Severe hypoglycemia and diabetic ketoacidosis in adults with type 1 diabetes: results from the T1D Exchange clinic registry
Abstract
Context Few studies have assessed factors associated with severe hypoglycemia (SH) and diabetic ketoacidosis (DKA) in adults with type 1 diabetes (T1D). Objective Our objective was to determine frequency of and factors associated with the occurrence of SH and DKA in adults with T1D. Design and setting We conducted a cross-sectional analysis from the T1D Exchange clinic registry at 70 U.S. endocrinology centers. Patients Analysis included 7012 participants in the T1D Exchange clinic registry aged 26 to 93 years old with T1D for ≥2 years. Results Higher frequencies of SH and DKA were associated with lower socioeconomic status (P 7.5% (>58 mmol/mol). DKA frequency increased with higher HbA1c levels (P Conclusions SH and DKA are more common in those with lower socioeconomic status. DKA, most common in those with HbA1c ≥10.0% (≥86 mmol/mol), should be largely preventable. In contrast, SH, most frequent with diabetes ≥40 years duration, cannot be abolished given the limitation of current therapies. To reduce SH in adults with longstanding diabetes, consideration should be given to modifying HbA1c goals, particularly in patients with very low HbA1c levels.
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Integration of continuous glucose monitoring (CGM) into the treatment plan soon after diagnosis improves glycemic outcomes, decreases hypoglycemic events, and improves quality of life for individuals with type 1 diabetes.
“Integration of continuous glucose monitoring (CGM) into the treatment plan soon after diagnosis improves glycemic outcomes, decreases hypoglycemic events, and improves quality of life for individuals with type 1 diabetes (18-23).”
From 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2025 (2025) · cites this paper as [21]
Some studies have shown that rates of hypoglycemia have not declined even with more widespread use of insulin analogs and CGM, while other studies have shown benefit with these therapeutic advances.
“Several studies have shown that rates of hypoglycemia have not declined, even with more widespread use of insulin analogs and CGM, while other studies have shown benefit with these therapeutic advances (41).”
Risks for hypoglycemia, particularly level 3 hypoglycemia, include longer duration of diabetes, older age, history of recent level 3 hypoglycemia, alcohol ingestion, exercise, lower education levels, lower household incomes, chronic kidney disease, and IAH.
“Risks for hypoglycemia, particularly level 3 hypoglycemia, include longer duration of diabetes, older age, history of recent level 3 hypoglycemia, alcohol ingestion, exercise, lower education levels, lower household incomes (41), chronic kidney disease, and IAH (103-105).”
In the Type 1 Diabetes Exchange Clinic Registry, the risk of level 3 hypoglycemia was increased not only in those whose HbA1c was below 7.0% (53 mmol/mol), but also in people with an HbA1c above 7.5% (58 mmol/mol).
“However, in the Type 1 Diabetes Exchange Clinic Registry, the risk of level 3 hypoglycemia was increased not only in those whose HbA 1c was below 7.0% (53 mmol/mol), but also in people with an HbA 1c above 7.5% (58 mmol/mol) (41).”
The U.S. Type 1 Diabetes Exchange Clinic Network reported that 4.8% of participants (age 26 to 93 years) had been hospitalized for DKA in the prior year.
“The U.S. Type 1 Diabetes Exchange Clinic Network reported that 4.8% of participants (age 26 to 93 years) had been hospitalized for DKA in the prior year (41).”
More recent studies have not found a higher risk of DKA in those using insulin pumps.
“However, more recent studies have not found this to be the case (41,210,215).”
Some known risk factors for DKA are nonmodifiable, such as low socioeconomic status, younger age, female sex, and ethnicity.
“Some known risk factors are nonmodifiable, such as low socioeconomic status, younger age, female sex, and ethnicity (41,210)”
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References 20 · Cited by 338
- Authors
- Weinstock, R. S., Xing, D., Maahs, D. M., Michels, A., Rickels, M. R., Peters, A. L., Bergenstal, R. M., Harris, B., DuBose, S. N., Miller, K. M., Beck, R. W., & for the T1D Exchange Clinic Network
- Affiliations
- SUNY Upstate Medical University (US)
- Jaeb Center for Health Research (US)
- University of Pennsylvania (US)
- University of Southern California (US)
- Stanford University (US)
- Corresponding author
- Miller, Kellee M.
- ORCID
- Venue
- The Journal of Clinical Endocrinology & Metabolism
- Publisher
- The Endocrine Society
- Published
- 2013-08
- Volume
- 98
- Issue
- 8
- Pages
- 3411-3419
- ISSN
- 0021-972X (ISSN-L)
- 1945-7197
- OpenAlex
- W2066245509
- Cited by
- 338
- References
- 20
- Citations by year
- 2026: 13 · 2025: 17 · 2024: 24 · 2023: 16 · 2022: 24 · 2021: 44 · 2020: 21 · 2019: 37 · 2018: 34 · 2017: 30 · 2016: 28 · 2015: 35 · 2014: 14 · 2013: 1
- FWCI
- 20.45
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Endocrinology & Metabolism (publishedVersion)
- PubMed (publishedVersion)
- RWTH Publications (RWTH Aachen) (submittedVersion)
- Funders
- American Diabetes Association
- Park Nicollet Foundation
- Eli Lilly and Company
- GlaxoSmithKline
- Sanofi
- Leona M. and Harry B. Helmsley Charitable Trust
- Halozyme
- Dexcom
- ResMed
- Novo Nordisk
- National Institutes of Health
- Abbott Diabetes Care
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Diabetes and associated disorders
- Keywords
- severe hypoglycemia, diabetic ketoacidosis, type 1 diabetes, adults, socioeconomic status, diabetes duration, HbA1c, glycemic control, risk factors
- MeSH terms
- Adult, Aged, Aged, 80 and over, Cross-Sectional Studies, Diabetes Mellitus, Type 1, Female, Glycated Hemoglobin, Humans, Hypoglycemia, Male, Middle Aged, Registries, Diabetic Ketoacidosis
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