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Licensed Unlicensed Requires Authentication Published by De Gruyter November 12, 2021

Ketoacidosis in new-onset type 1 diabetes: did the severity increase during the COVID-19 pandemic?

  • Teresa A. Botelho ORCID logo EMAIL logo , Joana M. N. Santos ORCID logo , Crisbety M. S. Pinho , Ana Isabel B. R. Martins , Adriana I. S. Formiga , Joana Serra-Caetano , Rita C. F. Cardoso , Isabel C. A. D. Dinis and Alice S. R. Mirante



Since the beginning of the COVID-19 pandemic, there has been a consistent decrease in the number of admissions to the emergency department, leading to a delay in the diagnosis of several pathologies. The time from onset of symptoms to the diagnosis of Type 1 diabetes is highly variable. This treatment delay can lead to the appearance of ketoacidosis.


Retrospective study of inaugural Type 1 diabetes cases, from March 2016 to March 2021. The pandemic group was considered between March 2020 to March 2021, and the remaining period was considered as pre-pandemic. Clinical variables were analysed: duration of symptoms, weight loss and value of ketonemia and glycated haemoglobin on admission. The mean differences were considered statistically significant at p<0.05.


103 inaugural episodes of Type 1 diabetes were registered. The pandemic group had a lower mean age when compared to pre-pandemic group, and 51.7% of the episodes had ketoacidosis with a higher relative risk of ketoacidosis and severe ketoacidosis, when compared the pandemic with pre-pandemic group, there was a longer symptom evolution time (34 vs. 20 days), greater weight loss occurred (9.5% vs. 6.3%), the pH and HCO3 values were lower (7.30 vs. 7.36 and 16.43 vs. 20.71 mmol/L respectively) and ketonemia was higher (5.9 vs. 2.3 mmol/L).


The COVID-19 pandemic caused a delay in the diagnosis of Type 1 diabetes, greater length of disease, greater weight loss, higher ketonemia and lower pH and HCO3 . There was greater ketoacidosis relative risk in pandemic group when compared to pre-pandemic group.

Corresponding author: Teresa A. Botelho, Master in Medicine, Medical Doctor Avenida, R. Dr. Afonso Romão, 3000-602 Coimbra, Portugal; and Hospital Pediátrico de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, E-mail:

The work was carried out without external funding. There is no conflict of interest, including financial interests, relationships and/or affiliations relevant to the subject matter or materials included in this manuscript.

  1. Research funding: None declared. No funding has been involved.

  2. Author contributions: All authors have participated in the drafting of the manuscript and have read and approved its final version. T.B, J.S, C.P. A.I.M and A.F performed the research. T.B, J.S and A.M designed the research study. T.B and J.S analyzed the data. J.S.C, R.C, I.D and A.M revising it critically. T.B wrote the paper. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: All authors state no conflict of interest.

  4. Informed consent: Not applicable.

  5. Ethical approval: Our study was evaluated and approved by the research Ethics Committee of the Centro Hospitalar e Universitário de Coimbra – Nº 167/CES, Proc. Nº OBS.SF.39/2021. The ethical recommendations established by the Declaration of Helsinki of the World Medical Association were followed.


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Received: 2021-07-02
Accepted: 2021-10-25
Published Online: 2021-11-12
Published in Print: 2022-01-27

© 2021 Walter de Gruyter GmbH, Berlin/Boston

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