Insulin and Glucagon Ratio in the Patho. Physiology Of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Non-Ketotic Diabetes

Abstract

Objective:To assess the role of insulin / glucagon ratio in pathophysiology of diabetic ketoacidosis and hyperosmolar hyperglycemic non-ketotic diabetes. Design: Case control, analytical study. Place and duration of study: Military Hospital, Rawalpindi from September 2003 to August 2004. Patients and methods The study included 7 patients with diabetic ketoacidosis, 3 patients with hyperosmolar hyperglycemic non-ketotic diabetes, 8 patients with uncontrolled type 1 diabetes mellitus and 12 patients with uncontrolled type 2 diabetes mellitus. Twenty non-diabetic persons having blood glucose level less than 6 mmol/L were selected as control group. Patient s detailed history was taken and general physical examination was done. Plasma samples of all the patients and control subjects were assayed for plasma glucose, glycosylated hemoglobin, plasma insulin and glucagon levels. Presence or absence of ketone bodies in urine was also determined. Results: Seven patients with diabetic ketoacidosis, 3 females and 4 males, were found to be hyperglycemic ( p<0.001 ), hypoinsulinemic ( p < 0.05) and hyperglucagonemic ( p < 0.001 ) as compared to control group. Three patients with hyperosmolar hyperglycemic non-ketotic diabetes, 1 male and 2 females, were hyperglycemic ( p < 0.001 ). Eight patients with uncontrolled type I diabetes mellitus, 6 males and 2 females, were having hyperglycemia (p< 0.001) along with hyperglucagonemia (p < 0.001). Twelve patients with uncontrolled type 2 diabetes mellitus, 6 males and 6 females, were found to be hyperglycemic ( p < 0.001 ) and hyperinsulinemic (p < 0.001) as compared to control group. The insulin / glucagon ratio was found to be 1 : 0.9 in diabetic ketoacidosis, 1: 0.15 in hyperosmolar hyperglycemic non-ketotic diabetes, 1: 0.24 in type 1 diabetics, 1: 0.08 in type 2 diabetics, and 1: 0.1 in the control group. Conclusion: It was concluded that if insulin / glucagon ratio in type 2 diabetics reduces to 1: 0.9 then these patients may develop ketoacidosis instead of hyperosmolar hyperglycemic non ketotic diabetes. Hence, it is the balance and interplay of insulin and glucagon which predicts the type of acute hyperglycemic emergencies (diabetic ketoacidosis and hyperosmolar hyperglycemic non-ketotic diabetes ) being observed in diabetic patients and not the type of diabetes mellitus.