What is the management of euglycemic diabetic ketoacidosis (DKA)?

From the Guidelines

Euglycemic diabetic ketoacidosis (DKA) should be managed similarly to traditional DKA, with some important modifications, prioritizing the correction of metabolic acidosis and ketosis over glucose levels, as recommended by the most recent guidelines 1.

Management Approach

The management of euglycemic DKA involves:

• Starting with intravenous fluids using isotonic saline at 15-20 mL/kg/hr for the first hour, then adjusting to 250-500 mL/hr based on hydration status.
• Administering regular insulin as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr, as this regimen has been shown to effectively decrease plasma glucose concentration and clear ketones 1.
• Early administration of dextrose-containing fluids (D5W or D10W) is necessary even though blood glucose levels are not severely elevated (<250 mg/dL), to prevent hypoglycemia while continuing insulin therapy to clear ketones.
• Monitoring electrolytes every 2-4 hours, particularly potassium, and replacing as needed, as hypokalemia can occur due to insulin therapy and fluid replacement.
• Checking blood glucose hourly and ketones every 2-4 hours to assess the resolution of ketoacidosis.
• Continuing insulin infusion until anion gap normalizes and ketosis resolves, even if glucose levels are normal or low, as insulin is needed to suppress ketogenesis and correct metabolic acidosis.
• Investigating and treating the underlying cause, which often includes SGLT2 inhibitor use, pregnancy, reduced carbohydrate intake, alcohol consumption, or acute illness.
• Transitioning to subcutaneous insulin before discontinuing the infusion, to prevent recurrence of ketoacidosis and rebound hyperglycemia, as recommended by recent guidelines 1.

Key Considerations

• The use of bicarbonate in patients with DKA has been shown to make no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1.
• Phosphate replacement may be indicated in patients with cardiac dysfunction, anemia, or respiratory depression, and in those with serum phosphate concentration < 1.0 mg/dl, to avoid cardiac and skeletal muscle weakness and respiratory depression due to hypophosphatemia 1.
• Cerebral edema is a rare but potentially fatal complication of DKA, and prevention measures such as gradual replacement of sodium and water deficits and the addition of dextrose to the hydrating solution once blood glucose reaches 250 mg/dl may help decrease the risk 1.

From the Research

Management of Euglycemic Diabetic Ketoacidosis (DKA)

The management of euglycemic DKA involves several key components, including:

• Correction of dehydration and electrolyte deficits 2, 3, 4
• Insulin replacement therapy, which may seem counterintuitive in the setting of normal glucose levels, but is essential for treating the ketoacidosis 5, 4
• Use of dextrose-containing fluids to accompany intravenous insulin and prevent hypoglycemia 4
• Identification and treatment of precipitating causes, such as infection or other underlying medical conditions 2, 3
• Close monitoring to adjust therapy and identify potential complications, such as cerebral edema or other electrolyte imbalances 2, 3

Diagnostic Considerations

Euglycemic DKA can be challenging to diagnose, as the absence of hyperglycemia may lead to delayed recognition and treatment 5, 4, 6. The diagnostic workup should include:

• Arterial blood gas analysis to assess for metabolic acidosis 4
• Serum ketone measurements to confirm the presence of ketoacidosis 5, 4
• Exclusion of other causes of high anion gap metabolic acidosis 4
• Consideration of the patient's medical history, including the use of sodium-glucose cotransporter-2 inhibitors, which may increase the risk of euglycemic DKA 5, 3, 6

Treatment Principles

The treatment of euglycemic DKA is based on the same principles as hyperglycemic DKA, with a focus on:

• Correcting dehydration and electrolyte deficits 2, 3, 4
• Providing insulin replacement therapy to treat the ketoacidosis 5, 4
• Preventing hypoglycemia through the use of dextrose-containing fluids 4
• Identifying and treating underlying precipitating causes 2, 3
• Close monitoring to adjust therapy and prevent complications 2, 3