PRACTICE PARTNER
deceased in his rooming
house February 16, 2012,
after health-care workers
called the home concerned
about the man’s absence a
few days earlier. Post-mortem examination revealed
classic findings of diabetic ketoacidosis (DKA). There
was also terminal esophageal hemorrhage secondary to
Mallory-Weiss tears.
Discussion:
imminent, and when it did occur, it appears to have
been rapid.
Although neither the expert reviewer or the Committee found the care in this case to be lacking, it was felt
that this death represented an opportunity to educate
care providers of the need to consider DKA, even in
patients with T2DM, especially in those receiving
atypical antipsychotic agents.
Recommendations:
1. hysicians are reminded that in patients with
P
The deceased had multiple risk factors for T2DM inschizophrenia, particularly those on atypical anticluding a strong family history of T2DM, schizophrepsychotics, it is important to:
nia, and use of atypical anti-psychotic agents. He was
• Screen for, and diagnose diabetes mellitus;
modestly overweight at the time of
his diagnosis (i.e., maximum BMI
• reat the diabetes with oral agents
T
26 in the record, normal being 20- Have a low threshold to
+/- insulin to achieve adequate
25). The deceased refused diabetes
glycemic control, and monitor
involve an endocrinologist
therapy and had poorly controlled
and treat complications and other
diabetes in the year preceding his
cardiovascular risk factors;
in the care of diabetic
death despite ongoing warnings and
patients with severe mental • Discuss and document ongoing
encouragement from his physicians.
conversations with patients who
health disorders.
It is not clear from the records
are competent and who refuse
whether or not the decedent was
monitoring and/or therapy; and
specifically offered insulin therapy,
• ave a low threshold to involve an endocrinoloH
as opposed to oral hypoglycemic agents. However, the
gist in the care of diabetic pati ents with severe
decedent was aware of the use of insulin for the treatmental health disorders.
ment of some patients with diabetes, as his sibling was
being treated with insulin. Further, there are numer2. hysicians should be aware that atypical antipsyP
ous references in the medical records to the decedent
chotics have been associated with diabetic ketoacirefusing “all DM medications.”
dosis. This typically occurs early in therapy with the
antipsychotic agent.1
The decedent ultimately died from acute DKA. DKA
typically occurs in patients with T1DM who both
lack insulin and have a precipitating factor, usually
another acute illness. Atypical antipsychotics have
been associated with DKA in patients with T2DM. In
this case, however, the decedent had already been on
an antipsychotic for three years. His glycemic control
deteriorated with the switch to clozapine, in addition
to stopping his diabetes medications.
It is not clear what precipitated the deceased’s DKA,
or how he died from it. There was no opportunity for
physicians to intervene to treat the DKA and acute
event as there was no warning that an acute event was
3. atients who have very poor glycemic control
P
should be assessed for ketoacidosis even if they have
T2DM. While this is most relevant to those patients receiving an atypical antipsychotic, it should
be a consideration for any patient with T2DM who
appears unwell, especially in the setting of high capillary blood glucose readings.
References
1. Nihalani NO et al, Diabetic ketoacidosis among patients receiving
clozapine: a case series and review of socio-demographic risk factors.
Ann Clin Psychiatry, 2007; 19(2).
DIALOGUE • Issue 1, 2014
PRACTICE PARTNER
... Continued from page 30
35