From the Guidelines
Euglycemic diabetic ketoacidosis (DKA) typically does not present with normal beta-hydroxybutyrate levels. In euglycemic DKA, blood glucose levels may be normal or only mildly elevated (less than 250 mg/dL), but ketone production is still significant, resulting in elevated beta-hydroxybutyrate levels. Beta-hydroxybutyrate is the predominant ketone body produced during ketoacidosis and serves as a key diagnostic marker for DKA. Even in euglycemic DKA, beta-hydroxybutyrate levels are typically elevated above 3.0 mmol/L, which is consistent with ketoacidosis. The normal physiological range for beta-hydroxybutyrate is less than 0.6 mmol/L. Euglycemic DKA occurs when there is insulin deficiency sufficient to cause ketogenesis but with factors that prevent significant hyperglycemia, such as reduced carbohydrate intake, SGLT2 inhibitor use, pregnancy, or partial insulin treatment. These conditions allow for continued ketone production despite relatively normal glucose levels. If a patient presents with symptoms of DKA (nausea, vomiting, abdominal pain, fatigue) but has normal glucose levels, measuring beta-hydroxybutyrate is essential for diagnosis, as it will almost always be elevated in true euglycemic DKA, as stated in the most recent guidelines 1. Some key points to consider in the management of DKA include:
- Restoration of circulatory volume and tissue perfusion
- Resolution of hyperglycemia
- Correction of electrolyte imbalance and acidosis
- Treatment of any correctable underlying cause of DKA, such as sepsis or myocardial infarction
- Use of continuous intravenous insulin in critically ill patients, as recommended in the guidelines 1. It is also important to note that the use of bicarbonate in patients with DKA has been shown to make no difference in resolution of acidosis or time to discharge, and its use is generally not recommended 1. In terms of monitoring, direct measurement of beta-hydroxybutyrate in the blood is the preferred method for monitoring DKA, as stated in the guidelines 1. Overall, the management of euglycemic DKA requires careful clinical and laboratory assessment, as well as individualized treatment based on the patient's specific needs, as recommended in the guidelines 1.
From the Research
Euglycemic DKA and Beta Hydroxybutyrate Levels
- Euglycemic diabetic ketoacidosis (EDKA) is a condition where patients have normal blood glucose levels, but still experience diabetic ketoacidosis 2, 3, 4.
- In EDKA, patients can have elevated beta-hydroxybutyrate levels, which is a key indicator of ketosis 2, 5.
- The presence of ketonuria, an elevated anion gap, and elevated beta-hydroxybutyrate levels can be used to diagnose EDKA, even in the absence of hyperglycemia 2, 3.
- It is possible for patients with EDKA to have normal beta-hydroxybutyrate levels, but this is not typically the case 2, 5.
- Clinicians should be aware of the possibility of EDKA and check for ketosis in patients with diabetes, regardless of their blood glucose levels 3, 4.
Diagnostic Challenges
- EDKA can be masked by euglycemia, making it a diagnostic challenge 2, 3, 4.
- The absence of hyperglycemia can lead to a delay in diagnosis and treatment 4, 6.
- Clinicians should use a combination of clinical presentation, laboratory results, and medical history to diagnose EDKA 2, 3, 5.
- The use of sodium-glucose transporter type 2 (SGLT-2) inhibitors has been associated with an increased risk of EDKA 6.