Is it okay to take home oral medication in Diabetic Ketoacidosis (DKA)?

From the Guidelines

No, it is not okay to take home oral medication when experiencing diabetic ketoacidosis (DKA). DKA is a serious, potentially life-threatening complication of diabetes that requires immediate emergency medical treatment in a hospital setting. During DKA, patients need intravenous insulin therapy, aggressive fluid replacement, and electrolyte management under close medical supervision 1. Oral medications like metformin, SGLT2 inhibitors, or oral insulin secretagogues are not appropriate for treating the acute crisis of DKA. These medications work too slowly and cannot address the severe metabolic derangements occurring during ketoacidosis. Additionally, many patients with DKA experience nausea, vomiting, and altered mental status, which makes oral medication administration unreliable or impossible.

The standard treatment protocol for DKA includes IV insulin infusion (typically starting at 0.1 units/kg/hour), IV fluids (often beginning with normal saline at 15-20 mL/kg in the first hour), potassium replacement as needed, and frequent monitoring of glucose, electrolytes, and acid-base status. Only after the acute crisis has resolved—when ketones are cleared, the anion gap has normalized, and the patient can eat and drink—should transition to subcutaneous insulin or other diabetes medications be considered. It's also important to note that SGLT2 inhibitors, which are oral medications, have been associated with an increased risk of diabetic ketoacidosis, particularly in patients with insulin deficiency 1.

Some key points to consider when managing DKA include:

• Intravenous insulin therapy is essential for treating DKA
• Aggressive fluid replacement and electrolyte management are critical
• Oral medications are not suitable for treating the acute crisis of DKA
• Patients with DKA require close medical supervision and monitoring
• SGLT2 inhibitors should be used with caution in patients with insulin deficiency due to the increased risk of diabetic ketoacidosis.

In terms of specific medications, metformin is generally considered a first-line medication for managing type 2 diabetes, but it should be omitted in the setting of severe illness, vomiting, or dehydration 1. SGLT2 inhibitors, on the other hand, have been associated with several potential risks, including increased risk of lower-limb amputation and fracture, and should be used with caution in certain patient populations 1.

From the FDA Drug Label

Limitations of Use: Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis JARDIANCE is not recommended for patients with type 1 diabetes or for the treatment of diabetic ketoacidosis. Ketoacidosis: Assess patients who present with signs and symptoms of metabolic acidosis for ketoacidosis, regardless of blood glucose level. If suspected, discontinue JARDIANCE, evaluate and treat promptly.

No, it is not ok to take home oral medication in DKA, as the medication is not indicated for the treatment of diabetic ketoacidosis.

• The medication should be discontinued if ketoacidosis is suspected.
• Patients on the medication may require monitoring and temporary discontinuation of therapy in clinical situations known to predispose to ketoacidosis 2 2.

From the Research

Management of Diabetic Ketoacidosis (DKA)

• DKA is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus 3.
• The management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event 4.
• Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA 4.

Oral Medication in DKA

• There is no direct evidence in the provided studies regarding the safety of taking home oral medication in DKA.
• However, studies suggest that certain oral medications, such as SGLT2 inhibitors, can increase the risk of metabolic acidosis, including euglycemic diabetic ketoacidosis 5.
• It is essential to note that DKA management typically involves intravenous fluids and insulin therapy, rather than oral medication 3, 6, 4, 7.

Patient Education and Prevention

• Patient education programs focusing on adherence to insulin and self-care guidelines during illness can help prevent recurrence of DKA 4, 7.
• Awareness of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors is crucial 4.
• Future episodes of DKA can be reduced through improved access to medical providers and new approaches such as extended availability of phone services, use of telemedicine, and utilization of public campaigns 4.