What is the treatment for Diabetic Ketoacidosis (DKA)?

From the Guidelines

Diabetic ketoacidosis (DKA) treatment should prioritize individualization based on a careful clinical and laboratory assessment, with management goals including restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis, as recommended by the most recent guidelines 1.

Key Components of DKA Treatment

• Initial management includes intravenous fluid resuscitation with normal saline, adjusted based on hemodynamic status.
• Regular insulin therapy should be administered as an IV bolus followed by continuous infusion, with the dose adjusted based on blood glucose levels and the presence of ketosis.
• Electrolyte replacement, particularly potassium, is crucial to prevent hypokalemia and maintain levels between 4-5 mEq/L.
• Bicarbonate therapy is generally not recommended, except in cases of severe acidosis (pH < 6.9) 1.

Monitoring and Adjustments

• Frequent monitoring of vital signs, glucose levels (hourly), electrolytes (every 2-4 hours), and acid-base status is essential to adjust treatment as needed.
• The underlying cause of DKA must be identified and addressed, whether it's infection, medication non-compliance, or new-onset diabetes.

Transition to Subcutaneous Insulin

• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h prior to the intravenous insulin being stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.

Recent Guidelines and Recommendations

• The most recent guidelines from 2024 recommend individualization of treatment based on a careful clinical and laboratory assessment, with a focus on restoring circulatory volume and tissue perfusion, resolving ketoacidosis, and correcting electrolyte imbalance and acidosis 1.
• These guidelines also emphasize the importance of treating any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. Treatment of metabolic acidosis should, if possible, be superimposed on measures designed to control the basic cause of the acidosis - e.g., insulin in uncomplicated diabetes, blood volume restoration in shock.

DKA Treatment involves:

• Insulin administration to control hyperglycemia 2
• Addressing the underlying cause of the acidosis, such as administering insulin in uncomplicated diabetes 3
• Bicarbonate therapy may be indicated in severe cases of metabolic acidosis, including diabetic acidosis 3 It is crucial to obtain medical assistance immediately if symptoms of DKA occur.

From the Research

DKA Treatment Overview

• Diabetic ketoacidosis (DKA) can be effectively treated using low-dose intravenous insulin and isotonic saline to replace extracellular fluids, followed by glucose and potassium to replace intracellular fluids 4
• The treatment protocol may include:
  • Low-dose intravenous insulin
  • 2 to 3 liters of isotonic saline at 500 ml/hr
  • 2 to 4 L of 5% glucose in 0.45% saline with potassium chloride and/or potassium phosphate
  • Monitoring of serum glucose, potassium, bicarbonate, sodium, and chloride levels

Insulin Therapy

• The use of an initial insulin bolus in DKA treatment has been controversial, with some studies suggesting it may not be necessary 5
• A study comparing two protocols of intravenous insulin therapy found that both protocols were safe and had comparable efficiency, with no significant differences in outcomes such as time to recovery and complications 6
• However, another study found that an initial insulin bolus was associated with significantly more adverse effects, such as hypokalemia, without a corresponding benefit in time to resolution of DKA 7

Fluid Management

• Traditional guidelines recommend isotonic normal saline (NS) for initial volume replacement in DKA management, but recent studies suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 8
• A study found that large-volume resuscitation with isotonic NS was associated with prolonged ICU length of stay, increased time on insulin infusion, and higher rates of non-anion gap metabolic acidosis in patients with DKA 8
• The use of balanced crystalloids, such as lactated Ringers, may be a better option for initial resuscitation in DKA patients, as they may reduce the risk of complications related to hyperchloremia and improve clinical outcomes 8