What is the treatment approach for euglycemic Diabetic Ketoacidosis (DKA)?

From the Guidelines

The treatment approach for euglycemic diabetic ketoacidosis (DKA) should prioritize restoration of circulatory volume, resolution of ketoacidosis, and correction of electrolyte imbalance, with careful attention to glucose levels, as outlined in the most recent guidelines 1.

Key Components of Treatment

• Intravenous fluids, typically 0.9% normal saline, should be administered at 15-20 mL/kg/hr for the first hour, then adjusted based on hydration status.
• Regular insulin should be given as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr, with the possibility of using subcutaneous rapid-acting analogs in mild or moderate cases, as there is no significant difference in outcomes when combined with aggressive fluid management 1.
• Dextrose-containing fluids (D5W or D10W) may be started earlier, often simultaneously with insulin, to prevent hypoglycemia while continuing to clear ketones.
• Electrolyte replacement, particularly potassium, is crucial when levels fall below 5.3 mEq/L, aiming to maintain levels between 4-5 mEq/L.
• Bicarbonate therapy is generally not recommended unless pH is below 6.9, as several studies have shown it makes no difference in the resolution of acidosis or time to discharge 1.

Monitoring and Adjustment

• Glucose levels should be monitored hourly, electrolytes every 2-4 hours, and ketones assessed regularly.
• The underlying cause, such as SGLT2 inhibitors, should be temporarily discontinued.
• Insulin infusion should continue until the anion gap normalizes and ketoacidosis resolves, even if glucose levels are normal or low.
• Transition to subcutaneous insulin should only occur after ketosis resolves, with basal insulin administered 2-4 hours before stopping intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.

From the Research

Treatment Approach for Euglycemic Diabetic Ketoacidosis (DKA)

The treatment approach for euglycemic DKA involves several key components, including:

• Replacement of fluid and electrolytes lost through osmotic diuresis 2
• Insulin therapy to reverse ketoacid production by the liver 2
• Monitoring of serum glucose to avoid hypoglycemia, with dextrose added to the infusion once the serum glucose falls to 250 mg per dl 2
• Identification and treatment of precipitating causes to prevent increased morbidity and mortality 2

Fluid Replacement and Insulin Therapy

• Isotonic normal saline remains the standard for initial fluid resuscitation, though balanced solutions have been shown to have faster DKA resolution 3
• Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored and potassium levels have been achieved 3
• Subcutaneous (SQ) insulin is started only after the resolution of metabolic acidosis 3

Electrolyte Replacement and Monitoring

• DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia, and regular monitoring is essential for DKA management 3
• Electrolyte replacement is critical to prevent complications such as fatal cardiac arrhythmia 2

Special Considerations

• Euglycemic DKA may require a different approach to treatment, as the diagnosis may be missed in patients with a negative nitroprusside test for ketones or a nonanion gap metabolic acidosis 2
• The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of cerebral edema, but may be considered in certain situations 3