Recurrent DKA, Insulin Omission, and Cannabis Use
Leah is 16 years and 6 months old with type 1 diabetes for 6 years on an insulin pump. A1c has risen from 8.1% to 10.9% over 9 months. She has had two DKA admissions in 4 months, both with ketones and vomiting. She is 168 cm, 52 kg, BMI 18.4; weight down 3 kg from a year ago. Alone, she admits she sometimes skips boluses to lose weight and uses cannabis 'a few times a week' at parties; she says her parents 'would kill her' if they knew. She denies suicidal ideation but reports feeling 'burned out' and checking glucose 1-2 times a day. She asks you to keep the cannabis use confidential.
1. How do you approach confidentiality and safety with Leah?
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Do not promise absolute confidentiality. Explain that insulin omission causing recurrent DKA and frequent cannabis use are safety issues that may require parental involvement, and that you will work with her on how and when to disclose rather than going behind her back. Distinguish what must be shared from what can remain private. Assess immediate risk: current glucose and ketones, vomiting, ability to keep fluids down, suicidal ideation, and whether she can safely go home. If she is in DKA or cannot maintain intake, arrange emergency care.
Use a nonjudgmental, motivational approach. Ask what makes bolusing hard, what she hopes cannabis does for her, and what she fears about her parents' reaction. Screen for depression, anxiety, and disordered eating. Explain that recurrent DKA is life-threatening and that cannabis use has been associated with more DKA and with hyperemesis. Negotiate a shared plan: involve her parents in safety planning, arrange behavioral health follow-up, and set concrete goals such as checking glucose before meals and ketones when ill.
2. What is the differential for her recurrent DKA and weight loss, and what evaluation is indicated?
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Intentional insulin omission for weight control is the leading concern, but the differential includes pump malfunction or site absorption problems, missed boluses from burnout, infection, gastroenteritis, cannabis hyperemesis, gastroparesis, celiac disease, thyroid disease, adrenal insufficiency, and an eating disorder. Depression and family conflict can drive both omission and poor follow-up. Weight loss of 3 kg with a BMI of 18.4 warrants formal screening for disordered eating rather than reassurance.
Review pump downloads, glucose meter or CGM data, and ketone logs. Obtain HbA1c, comprehensive metabolic panel, CBC, TSH, and celiac serology; consider cortisol testing only if there are suggestive features. Screen with a validated diabetes eating disorder tool such as the DEPS-R and with a depression screen. Ask directly about self-induced vomiting, laxative use, and insulin manipulation. Assess frequency of glucose checks and whether she has a sick-day plan. If DKA is present, treat it emergently and evaluate afterward.
3. What management plan should you recommend, and how do you engage the family without driving her away?
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Build a multidisciplinary plan: diabetes education and self-management support, pump and CGM review, behavioral health, and nutrition. Set small, measurable goals, such as checking glucose at least before meals and bedtime, checking ketones when glucose exceeds 250 mg/dL, and keeping a sick-day supply kit. Consider a CGM with alarms and share data with a trusted adult only with a negotiated plan. Address insulin omission explicitly and nonpunctuationally; shame tends to worsen secrecy.
Involve her parents with her knowledge, focusing on safety and support rather than punishment. Explain that recurrent DKA can be fatal and that cannabis use may worsen glycemic control and increase DKA risk. Recommend cannabis cessation or reduction and offer substance-use counseling. Screen for depression and disordered eating, and refer to a specialized eating disorder program if indicated. Schedule frequent follow-up, coordinate with the diabetes team, and provide clear emergency instructions. If she cannot engage in safety planning or continues to omit insulin with recurrent DKA, escalate the level of care.