What precipitates diabetic ketoacidosis among Sudanese patients?

During the study period, 44 patients were diagnosed to have DKA (23 men, 21 women; mean age 39±11 years); 29 patients (65.9%) had type 2 diabetes and 15 (34.1%) had type 1. The mean duration of diabetes was 11.2±4 years. The majority of the patients were on insulin therapy (26 patients, 59.2%). Table 1 shows that the two major precipitating factors in our study were poor compliance with therapy, and infections (of which malaria was the most common). Twenty-one patients (47.7%) had had one or more episode of DKA during the last two years and with the same precipitating factors. The general features of our patients include a relatively young age, poor diabetes care and non-compliance with therapy. Gender seems to play no role in determining the occurrence of DKA. The relatively young age of our patients is inconsistent with the epidemiological profile of the disease. The symptoms of poor glycaemic control such as polyuria and polydipsia may be present for several days but the metabolic alterations typical of DKA usually evolve within a short time thereafter. Occasionally the DKA occurs more acutely with no prior clues nor symptoms. Our study shows a marked delay in the diagnosis of DKA. The patients used to ignore the symptoms of poor glycaemia and the nonspecific early features of DKA. Poor compliance with diabetes treatment is a serious problem in the Sudan, being the most common precipitating factor for DKA.1 Some diabetic patients, even those with type 1 diabetes, refuse insulin therapy and insist on unsuitable oral regimens. They may perceive insulin introduction as a major crisis mainly due to losing complete control of their body by yielding it to the treatment.2 The poor socio-economic state of the majority of the patients renders them unable to afford the high costs of insulin and also tablets. The patients, therefore, tend to reduce or even stop their therapy, leaving themselves open to DKA. The potency of insulin is also questioned by some patients who are not able to afford a refrigerator and they may lose the motivation for optimal control. The lack of health education relevant to diabetes (in the context of absent or poor diabetes care in our country) adversely affects diabetes control. Some newly diagnosed patients soon stop their antidiabetic therapy once classical symptoms of diabetes (such as polyuria or polydipsia) have disappeared, thinking that their diabetes is cured! High consumption of sugar and soft drinks is a common dietary habit in our society. We go through a lot in order to convince our patients that sugar is not the only source of calories. Personality and social and domestic factors may underlie the poor compliance with diabetes therapy as well as depression, anxiety and simple forgetfulness. A role for psychological counselling among the care teams is likely to be beneficial. Infections are the second cause of precipitation of DKA (after poor compliance). Malaria is the most common infection in precipitating DKA and is often accompanied by vomiting and dehydration. The role of infection is worsened by the tendency of patients (and even some doctors) to self-treat any febrile illness as malaria and this might result in missing early signs of DKA. Also some misconceptions further worsen the adverse role of infections. Through fear of hypoglycaemia, many patients tend to stop their antidiabetic therapy once nausea and vomiting and loss of appetite (as common features of infections) occur. This malpractice occurs irrespective of the result on blood glucose. Things are made worse when such patients consume large amounts of sugar-rich fluids to counteract a presumed hypoglycaemia (and also as a social habit for any ill person). The prevention of DKA should remain the main objective (but, of course, good curative care is required when the condition arises). Implementation of a comprehensive education programme is the most important step in preventing DKA. This programme is expected to correct patients' misconceptions and malpractices relevant to diabetes care. The concerned authorities should ensure the availability of insulin (and also oral tablets) free of charge or at low prices. The introduction of clinical guidelines and algorithms may positively influence the management of DKA. In addition to correcting the errors and inconsistencies among the treating doctors, these guidelines should be designed to identify the cases of poor compliance and to solve their problems.