What is the initial management for Diabetic Ketoacidosis (DKA)?

From the Guidelines

The initial management of Diabetic Ketoacidosis (DKA) should focus on fluid resuscitation, insulin therapy, electrolyte replacement, and identifying/treating the underlying trigger, with the most recent guidelines from 2025 1 emphasizing the importance of individualization of treatment based on careful clinical and laboratory assessment. The management goals include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis.

• Begin with aggressive intravenous fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr for the first hour (typically 1-1.5 L in adults), then adjust to 250-500 mL/hr based on hemodynamic status.
• Start continuous intravenous insulin at 0.1 units/kg/hr after fluid initiation, as recommended by recent studies 1.
• Replace potassium when levels fall below 5.2 mEq/L, aiming to maintain levels between 4-5 mEq/L.
• Add dextrose (D5W or D10W) to IV fluids when glucose reaches 200-250 mg/dL while continuing insulin to clear ketones.
• Monitor electrolytes, glucose, and arterial pH every 2-4 hours.
• Investigate and treat precipitating factors such as infection, medication non-compliance, or acute illness. The use of bicarbonate in people with DKA is generally not recommended, as several studies have shown that it made no difference in the resolution of acidosis or time to discharge 1. This approach addresses the fundamental pathophysiology of DKA: dehydration from osmotic diuresis, metabolic acidosis from ketone production, and the insulin deficiency that drives the entire process.
• Continue treatment until ketoacidosis resolves, indicated by normalized anion gap, bicarbonate >18 mEq/L, and pH >7.3.
• 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, as reported in recent studies 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 initial management for Diabetic Ketoacidosis (DKA) involves intravenous administration of insulin, with an initial dose of 0.5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL) 2.

• The goal is to achieve near normoglycemia, with blood glucose levels within the target range of 100 to 160 mg/dL.
• Intravenous insulin is used to manage DKA, with adjustments made as needed to maintain target blood glucose levels.

From the Research

Initial Management of Diabetic Ketoacidosis (DKA)

The initial management of DKA involves several key steps, including:

• Restoration of circulating volume and electrolyte replacement 3
• Correction of insulin deficiency to resolve metabolic acidosis and ketosis 3, 4
• Reduction of the risk of cerebral edema 3, 4
• Avoidance of other complications of therapy, such as hypoglycemia, hypokalemia, hyperkalemia, and hyperchloremic acidosis 3, 4
• Identification and treatment of precipitating events 3, 5

Fluid and Insulin Therapy

The mainstay of treatment for DKA is appropriate fluid and insulin therapy 6. This includes:

• Administration of intravenous fluids to restore optimal volume status 4, 6
• Use of low-dose intravenous insulin infusion 6
• Potassium replacement to address total body depletion 6
• Consideration of phosphate replacement if serum levels fall toward the lower limits of normal values 6

Monitoring and Adjustment

Close monitoring of the patient's biochemical, physical, and mental parameters is essential to allow for adjustments in therapy as necessary 3, 4, 6. This includes:

• Frequent monitoring of blood glucose, ketone, and electrolyte levels 3, 4
• Adjustment of insulin drip rate as needed 7
• Monitoring for signs of cerebral edema and other complications 4

Special Considerations

There are special populations that require unique consideration in the management of DKA, including:

• Patients with chronic kidney disease 5
• Pregnant patients 5
• Patients prescribed sodium-glucose cotransporter inhibitors 5
• Patients in resource-limited settings 5