From the Guidelines
Diabetic ketoacidosis (DKA) treatment should prioritize intravenous fluids, insulin therapy, and electrolyte replacement, with a focus on individualized care based on careful clinical and laboratory assessment, as recommended by the most recent guidelines 1.
DKA Symptoms
DKA symptoms include excessive thirst, frequent urination, nausea, vomiting, abdominal pain, weakness, fatigue, confusion, fruity-scented breath, and rapid breathing. If DKA is suspected, emergency medical care should be sought immediately as it can be life-threatening.
Treatment Approach
Treatment involves hospital admission for:
- Intravenous fluids (typically normal saline at 15-20 mL/kg in the first hour)
- Insulin therapy (usually an IV insulin infusion at 0.1 units/kg/hour)
- Electrolyte replacement (particularly potassium, as levels drop with treatment) Blood glucose, electrolytes, and pH are monitored frequently, with insulin doses adjusted to gradually lower blood glucose by 50-70 mg/dL per hour.
Key Considerations
- The underlying cause, often infection or missed insulin doses, must be identified and addressed.
- Once the acidosis resolves and the patient can eat, they transition to subcutaneous insulin.
- DKA occurs when insulin deficiency prevents cells from using glucose for energy, forcing the body to break down fat for fuel, which produces ketones that acidify the blood.
- Prevention involves regular insulin administration, blood sugar monitoring, and seeking prompt medical attention during illness.
- Recent studies have shown that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1.
- There is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA 1.
Transition to Subcutaneous Insulin
Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
Use of Bicarbonate
Several studies have shown that the use of bicarbonate in people with DKA made no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1.
Individualized Care
Individualization of treatment based on a careful clinical and laboratory assessment is needed, considering factors such as dehydration, coma, and underlying causes of DKA 1.
From the FDA Drug Label
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. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. 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. Eating significantly more than your meal plan suggests. Developing a fever, infection, or other significant stressful situation. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency)
DKA Symptoms:
- Drowsy feeling
- Flushed face
- Thirst
- Loss of appetite
- Fruity odor on the breath
- Heavy breathing
- Rapid pulse
- Nausea
- Vomiting
- Stomach pain
- Dehydration
- Loss of consciousness
DKA Treatment:
- Obtain medical assistance immediately
- Treatment typically involves administering insulin and fluids to help lower blood glucose levels and replace lost fluids
- In severe cases, hospitalization may be necessary to closely monitor and manage the condition 2 2
From the Research
DKA Symptoms
- Polyuria and polydipsia are the most common symptoms of DKA, followed by nausea, vomiting, abdominal pain, weight loss, severe fatigue, dyspnea, and preceding febrile illness 3
- Other symptoms may include:
- Hyperglycemia (blood glucose greater than 250 mg/dL)
- Metabolic acidosis (pH less than 7.3, serum bicarbonate less than 18 mEq/L, anion gap greater than 10 mEq/L)
- Elevated serum or urine ketones
DKA Treatment
- Treatment involves fluid and electrolyte replacement, insulin, treatment of precipitating causes, and close monitoring to adjust therapy and identify complications 3
- Fluid resuscitation is a cornerstone of DKA management, with traditional guidelines recommending isotonic normal saline (NS) for initial volume replacement 4
- However, recent studies suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis, and balanced crystalloids such as lactated Ringers may be a better option 4
- Insulin therapy is titrated against the change in blood glucose concentration, and potassium is administered as required 5, 6
- Bicarbonate is employed in extreme acidosis, but its administration may contribute to the development of hypokalemia, CSF acidosis, and tissue hypoxia 6
DKA Management Considerations
- Special patient factors and comorbidities should receive more careful attention and consideration, such as pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, and use of sodium-glucose cotransporter-2 (SGLT2) inhibitors 7
- Guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, and institutions may develop their own protocols for internal use or do not routinely use any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal outcomes 7
- Prevention strategies include identifying diabetes before DKA develops, educating patients to manage high-risk situations, and ensuring uninterrupted access to therapies for diabetes 3