From the Guidelines
Starvation and alcoholic ketoacidosis should be managed with intravenous fluids, glucose administration, and electrolyte replacement, with thiamine supplementation in alcoholic ketoacidosis, as these interventions can significantly improve morbidity, mortality, and quality of life outcomes. The pathophysiology of these conditions involves depleted glycogen stores, leading to increased lipolysis and ketone body production, with alcohol metabolism in alcoholic ketoacidosis further promoting ketogenesis and inhibiting gluconeogenesis 1. Key differences between starvation ketosis and alcoholic ketoacidosis include plasma glucose concentrations, which can range from mildly elevated to hypoglycemic, and serum bicarbonate concentrations, which are usually not lower than 18 mEq/l in starvation ketosis 1. Some important considerations in the management of these conditions include:
- Intravenous fluids, such as normal saline, to address dehydration and promote ketone clearance
- Glucose administration, such as D5W or D5NS, to provide a carbohydrate source and reduce ketone production
- Electrolyte replacement, particularly potassium, magnesium, and phosphate, to address deficiencies and prevent complications
- Thiamine supplementation, 100mg IV, in alcoholic ketoacidosis to prevent Wernicke's encephalopathy
- Insulin therapy, which is rarely needed unless blood glucose is significantly elevated 1. Prompt recognition and treatment of starvation and alcoholic ketoacidosis are essential to prevent complications, such as respiratory failure, cardiac arrhythmias, and cerebral edema, and to restore normal metabolic function, ultimately improving patient outcomes.
From the Research
Starvation and Alcoholic Ketoacidosis
- Starvation ketoacidosis (SKA) is a rare cause of ketoacidosis, which can be exacerbated by stress, resulting in severe acidosis 2.
- SKA can be easily missed in patients with an unexplained metabolic acidosis, and it is essential to recognize its link with psychiatric disease and alcohol dependence 3.
- Alcoholic ketoacidosis (AKA) is defined by metabolic acidosis and ketosis in a patient with alcohol use, and it requires targeted therapies, including fluid resuscitation, glucose and vitamin supplementation, and electrolyte repletion 4.
- The management of SKA and AKA involves similar approaches, such as intravenous fluids, thiamine, and electrolyte replacement, highlighting the importance of awareness and knowledge of these conditions 2, 3, 4.
- In patients with alcohol use disorder, thiamine supplementation is crucial, and the "banana bag" approach may not be sufficient to optimize thiamine delivery to the central nervous system 5.
Key Considerations
- SKA and AKA can coexist, and it is essential to manage them accordingly, with thiamine prior to carbohydrate replacement in all at-risk patients 3.
- Patients with SKA and AKA often present with dehydration, electrolyte imbalances, and metabolic acidosis, requiring prompt investigation, diagnosis, and management to avoid life-threatening complications 2, 3, 6, 4.
- Health professionals should be aware of the potential risks associated with strict ketogenic diets, especially in breast-feeding mothers, and discuss these risks with patients who plan to breast-feed and lose weight following pregnancy 6.