What is the treatment for diabetic ketoacidosis (DKA)?

From the Guidelines

The treatment for diabetic ketoacidosis (DKA) requires immediate hospitalization and focuses on three main interventions: fluid replacement, insulin therapy, and electrolyte correction, as recommended by the most recent guidelines 1.

Key Interventions

• Fluid replacement: Initially, intravenous fluids (typically 0.9% saline) are administered at 15-20 mL/kg/hr for the first hour, then adjusted based on hydration status to restore circulatory volume and improve kidney perfusion.
• Insulin therapy: Regular insulin is given as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hour until blood glucose reaches 200-250 mg/dL, at which point dextrose is added to prevent hypoglycemia while continuing insulin to clear ketones, as supported by recent studies 1.
• Electrolyte correction: Potassium replacement is crucial, typically starting when levels fall below 5.3 mEq/L, with 20-30 mEq/L added to IV fluids if kidney function is adequate.

Additional Considerations

• Bicarbonate therapy is generally not recommended for DKA treatment, as several studies have shown that it makes no difference in the resolution of acidosis or time to discharge 1.
• Frequent monitoring of vital signs, glucose levels (hourly), electrolytes (every 2-4 hours), and mental status is essential throughout treatment.
• The underlying cause of DKA must also be identified and addressed, whether it's infection, medication non-compliance, or new-onset diabetes.
• 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 1.

Treatment Approach

The aggressive treatment approach is necessary because DKA represents a severe metabolic derangement that can be life-threatening if not corrected promptly. Individualization of treatment based on a careful clinical and laboratory assessment is needed, considering the variability in the presentation of DKA and hyperosmolar hyperglycemic states 1.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.

The treatment for Diabetic Ketoacidosis (DKA) is not explicitly stated in the provided drug labels, but it is mentioned that DKA is a life-threatening emergency that requires immediate medical assistance.

• Key points to consider in treating DKA include:
  • Insulin administration
  • Fluid replacement
  • Electrolyte management However, the exact treatment protocol is not provided in the given text. It is crucial to consult a healthcare professional for proper diagnosis and treatment of DKA 2.

From the Research

Treatment Overview

The treatment for diabetic ketoacidosis (DKA) involves several key components, including:

• Administering intravenous fluids to restore hydration and electrolyte balance 3, 4
• Insulin therapy to reduce glucose levels and resolve ketoacidosis 5, 3, 6
• Monitoring glucose and electrolyte levels to prevent complications such as hypoglycemia and hypokalemia 5, 3, 7
• Preventing cerebral edema by avoiding rapid overcorrection of hyperglycemia 3, 7

Insulin Therapy

Insulin therapy is a crucial component of DKA treatment, with several studies recommending the use of low-dose insulin administered as a continuous intravenous infusion 5, 6 or hourly intramuscular injections 6. The use of subcutaneous insulin glargine along with continuous regular IV insulin has also been shown to be effective in resolving DKA and reducing hospital stays 3.

Fluid Resuscitation

Isotonic normal saline is commonly used for initial fluid resuscitation, although balanced solutions have been shown to result in faster DKA resolution 3. The use of hypotonic versus isotonic saline, with or without colloids, is a topic of debate, with some studies suggesting that hydration should be initiated before insulin therapy 4.

Electrolyte Replacement

DKA frequently involves multiple electrolyte abnormalities, including hypokalemia, hypophosphatemia, and hypomagnesemia, making regular monitoring essential for DKA management 3. Potassium phosphate was given to 47 of the 52 patients in one study, highlighting the importance of electrolyte replacement 5.

Nutrition and Airway Management

Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay 3. For impending respiratory failure, intubation and mechanical ventilation are recommended, with monitoring and management of acid-base and fluid status 3.

Use of Sodium Bicarbonate

The use of sodium bicarbonate is generally discouraged due to the potential for worsening ketosis, hypokalemia, and risk of cerebral edema 3, 4. However, IV sodium bicarbonate may be considered in certain situations, such as when the serum pH falls below 6.9 or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L 3.