PRACTICE PARTNER
Atypical antipsychotics linked with
DKA in patients with Type 2 diabetes
T
he Patient Safety Review Committee, a committee of the Chief Coroner of Ontario, is
reminding physicians of the need to consider
ketoacidosis, even in patients with Type 2 diabetes
mellitus, especially in those receiving atypical antipsychotic agents.
The deceased was a 47-year-old male with three
significant illnesses: schizophrenia,
panic disorder and Type 2 diabetes
mellitus (T2DM). After an incident
that resulted in criminal charges and
subsequent institutionalization in
2007, his schizophrenia was treated
with olanzepine. The T2DM was diagnosed in January 2009 and treated
with metformin 500 mg (two to
three times daily) and glyburide 2.5
mg (twice daily) over time.
In November 2009, the man lived in
a supportive housing-type environment with daily dispensing and monitoring of
medications. In November-December 2009, he was
re-admitted to hospital with panic disorder; clonazepam was started and the olanzepine was switched to
risperidone.
During this admission, the patient continued on his
diabetes medications and received further monitoring
and therapy for T2DM and its complications. This
included:
• ducation (he saw a dietitian November 2009, and
E
attended diabetes education in January 2010);
• onitoring for glycemic control – (this showed
M
suboptimal control with hemoglobin A1C 7.6%
(ideal<7%) on December 3, 2009);
• creening for complications (he had undetectable
S
urinary microalbumin levels and eyes screened in
February 2010); and
• reatment of additional cardiovascular risk factors
T
(he was started on rosuvastatin in December 2009
for hypercholesterolemia).
Reports from December 2009 indicate that he
blamed the symptoms of his panic attacks (i.e., abnormal pacing, panic, fear that he was having a heart
attack) on his diabetes medications.
He was readmitted to hospital from
May 11-June 28, 2010 with worsening psychosis. His risperidone was
switched to clozapine and he was
taking metformin and glyburide
with well-controlled DM (A1C
6.8%). An elevated insulin level
confirmed the diagnosis was Type 2
DM and not Type 1 DM.
After discharge from hospital in late
June 2010, the patient was again
living in the community and was
seen two to three times weekly by the nurse or social
worker. On September 27, 2010 he is noted to have
been assessed by a psychiatry resident.
Glycemic control deteriorated dramatically by
November 22, 2010 when his general practitioner
noted that his A1C was now 14.3% and plasma
glucose was 32 (normal random <11 mMol/L).
Electrolytes and anion gap were not mentioned. At
the time, the patient indicated that he had stopped
taking the diabetes medications because he was
following a better diet at home. His weight had
decreased to 75 kg.
Subsequent nurse and physician notes indicated
that the patient would not allow monitoring of his
diabetes laboratory values or take diabetes medication
despite many warnings and offers of assistance.
On February 13, 2012, the patient did not show up
for his medication check-up and was subsequently found
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DIALOGUE • Issue 1, 2014