What is the recommended treatment for diabetic ketoacidosis (DKA) after fluid repletion?

From the Guidelines

The recommended treatment for diabetic ketoacidosis (DKA) after fluid repletion is intravenous insulin therapy, with a continuous infusion of regular insulin at a dose of 0.1 unit/kg/h, as stated in the most recent guidelines 1.

Key Considerations

• The initial treatment should focus on establishing adequate renal function and correcting hypovolemia, with the use of 0.9% NaCl or other crystalloid at a clinically appropriate rate aiming to replace 50% of the estimated fluid deficit in the first 8-12 hours 1.
• Insulin therapy should be started with a continuous infusion of regular insulin at a dose of 0.1 unit/kg/h, with blood glucose levels monitored hourly to achieve a decrease in glucose by 50-75 mg/dL per hour 1.
• Potassium replacement is crucial during insulin therapy to prevent hypokalemia, with potassium given in each liter of IV fluid as needed to keep serum potassium between 4 and 5 mmol/L 1.
• The goal is to keep glucose between 150 and 200 mg/dL until resolution, and to target glucose to between 200 and 250 mg/dL until resolution in moderate or severe DKA 1.
• Transition to subcutaneous insulin should occur only after metabolic abnormalities have resolved, with the first subcutaneous dose given 1-2 hours before discontinuing the insulin infusion to prevent rebound hyperglycemia.

Monitoring and Adjustments

• Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable 1.
• The underlying cause of DKA should be identified and treated simultaneously.
• Bicarbonate should only be considered if the pH remains below 6.9 after initial treatment, and phosphate and magnesium levels should be monitored and replaced as needed 1.

From the FDA Drug Label

The intravenous administration of Humulin R U-100 was tested in 21 patients with type 1 diabetes The patients' usual doses of insulin were temporarily held, and blood glucose concentrations were maintained at a range of 200 – 260 mg/dL for one to three hours during a run-in phase of intravenous Humulin R U-100 followed by a 6-hour assessment phase. During the assessment phase patients received intravenous Humulin R at an initial dose of 0. 5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL). During the study, 4 patients experienced diabetic ketoacidosis.

The recommended treatment for diabetic ketoacidosis (DKA) after fluid repletion is intravenous insulin.

• The initial dose is 0.5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL) 2.
• Intravenous insulin is effective in achieving near normoglycemia in patients with DKA.

From the Research

Treatment of Diabetic Ketoacidosis after Fluid Repletion

The treatment of diabetic ketoacidosis (DKA) after fluid repletion involves several key components, including:

• Correction of insulin deficiency to resolve metabolic acidosis and ketosis
• Reduction of risk of cerebral edema
• Avoidance of other complications of therapy, such as hypoglycemia, hypokalemia, hyperkalemia, and hyperchloremic acidosis
• Identification and treatment of precipitating events 3

Insulin Therapy

Insulin therapy is a crucial component of DKA treatment, and several studies have investigated the optimal insulin regimen.

• Low-dose intravenous insulin has been shown to be effective in treating DKA, with a continuous infusion rate of 4-10 units/hour or hourly intramuscular injections of 20 units initially, followed by 5 units/hour 4
• Another study compared high-dose insulin therapy with low-dose continuous intravenous insulin therapy and found that the low-dose regimen was as effective as the high-dose regimen in treating severe ketoacidosis 5
• A Brazilian study used a protocol that included subcutaneous rapid-acting insulin analog administered at 0.15 U/kg dose every 2-3 hours until resolution of metabolic acidosis, followed by intermediate-acting insulin at a dose of 0.6-1 U/kg/day 3

Electrolyte Replacement and Monitoring

Electrolyte replacement and monitoring are also critical components of DKA treatment.

• Potassium supplementation is essential to prevent hypokalemia, and potassium levels should be monitored closely during treatment 6, 5
• Other electrolytes, such as sodium and chloride, should also be monitored and replaced as needed

Other Considerations

Other considerations in the treatment of DKA include:

• Rehydration with intravenous fluids to correct dehydration and electrolyte imbalances
• Monitoring of glucose and electrolyte levels to adjust treatment as needed
• Identification and treatment of precipitating events, such as infection or non-compliance with insulin therapy 3, 7
• Patient education on how to adjust insulin during times of illness and how to monitor glucose and ketone levels 7