Case series / case reportindependent cross-checkabstract checked★ key study I-INS-108 in-depth review

Stopping insulin is the main cause of ketoacidosis in an urban US hospital

Diabetes in urban African-Americans. I. Cessation of insulin therapy is the major precipitating cause of diabetic ketoacidosis.

Overview

Musey VC et al.. Diabetes Care 1995 · PMID 7497857 · DOI 10.2337/diacare.18.4.483

Two out of three ketoacidosis episodes in people with known diabetes followed stopping insulin.

Does the study support the specific claim? No · Methodological quality: low

Study explained simply

What did the researchers want to find out?: Find the causes of DKA.
How was the study done?: Interviews and records of consecutive patients.
How many people, animals or samples were studied?: 56 DKA episodes.
What was actually found?: Stopping insulin caused 67% of episodes in known diabetes.
How large was the observed effect?: 67% (95% CI about 52-79%).
What do the results mean in everyday life?: Stopping insulin, even when not eating, can lead to ketoacidosis.
What are the study's limitations?: Small, old, single centre.
What does it say about Elawady's specific claim?: Contradicts advice to treat or prevent DKA without insulin.
Do the results apply to Germany and Europe?: Mechanism universal; social reasons vary.
What can explicitly not be concluded from this study?: Cannot give population rates.

What precipitates DKA in a large urban hospital?

Study design: Case series / case report – Consecutive case series with structured interviews (3 months, one urban hospital)
Population: Consecutive patients with moderate-to-severe DKA
Country: USA (Atlanta)
Period: 3-month period (early 1990s)
Sample size: 56 episodes (42 in known diabetes)
Inclusion and exclusion criteria: Glucose >13.9 mmol/l, bicarbonate <15 mmol/l, pH <7.35

Results: 75% of episodes in known diabetes; stopping insulin caused 67% of these. Reasons: lack of money for insulin or transport 50%, lack of appetite 21%, behavioural/psychological 14%, not knowing sick-day management 14%. Only 28% recalled instruction on dose adjustment and 35% on sick-day management.
Absolute risks: Not applicable
Authors' conclusion: DKA occurred most often in patients who stopped insulin; up to two-thirds of episodes may be preventable.

67% (Wilson 95% CI about 52-79%; stats/C-INS-08_insulin_omission_and_fluids.py).

Directly shows that stopping insulin precipitates DKA; 'lack of appetite' (not eating) was a reason people stopped insulin.

Directly applicable; same biology and clinical standards in Europe.

Replicated finding (I-INS-109).

Multidimensional assessment
Multidimensional assessment
Authenticity of the source	verified
Methodological quality	low
Risk of bias	some concerns
Precision of results	low
Directness	direct
Reproducibility	replicated
Consistency with the overall evidence	consistent
Regional transferability	moderate
Adequacy of the interpretation (by the archive)	not applicable