What is the treatment for diabetic ketoacidosis (DKA)?

From the Guidelines

The treatment for diabetic ketoacidosis (DKA) involves immediate hospitalization with a multi-faceted approach, prioritizing restoration of circulatory volume, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis, as outlined in the most recent guidelines 1.

Key Components of DKA Treatment

• Initial management includes intravenous fluid resuscitation to restore circulatory volume and improve tissue perfusion.
• Insulin therapy is crucial, with continuous intravenous insulin being the standard of care for critically ill patients, and subcutaneous rapid-acting analogs considered for mild or moderate DKA when combined with aggressive fluid management.
• Electrolyte replacement, particularly potassium, is vital as levels often drop with insulin therapy.
• Bicarbonate therapy is generally not recommended unless there is severe acidosis.

Approach to Insulin Therapy

• Continuous intravenous insulin is the standard of care for critically ill and mentally obtunded individuals with DKA or hyperosmolar hyperglycemia 1.
• 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.
• For uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used in the emergency department or step-down units, provided there is adequate fluid replacement, frequent monitoring, and appropriate follow-up.

Monitoring and Underlying Cause Identification

• Frequent monitoring of vital signs, glucose levels, electrolytes, and acid-base status is essential throughout treatment.
• The underlying cause of DKA must be identified and addressed, whether it's infection, medication non-compliance, or newly diagnosed diabetes.
• This comprehensive approach aims to correct dehydration, reverse ketosis, and maintain electrolyte balance to prevent complications.

Evidence Basis

The recommendations are based on the most recent and highest quality study available, which emphasizes individualization of treatment based on careful clinical and laboratory assessment 1. Previous studies and guidelines, such as those from 2021 1, 2023 1, 2018 1, and 2004 1, support various aspects of DKA management but are superseded by the latest evidence.

From the Research

Treatment of Diabetic Ketoacidosis (DKA)

The treatment of DKA involves several key components, including:

• Restoration of circulating volume and electrolyte replacement 2
• Correction of insulin deficiency to resolve metabolic acidosis and ketosis 2, 3, 4
• Reduction of risk of cerebral edema 2
• Avoidance of other complications of therapy, such as hypoglycemia, hypokalemia, hyperkalemia, and hyperchloremic acidosis 2, 3, 4
• Identification and treatment of precipitating events 2

Protocol for DKA Management

The protocol for DKA management may vary depending on the institution and the patient's specific needs. However, some common elements include:

• Administration of intravenous fluids to replace extracellular fluids 3, 5
• Use of low-dose intravenous insulin to correct metabolic acidosis and ketosis 3, 4
• Replacement of potassium and other electrolytes as needed 2, 3, 4
• Monitoring of serum glucose, electrolytes, and acid-base status 2, 3, 4
• Administration of bicarbonate in some cases, although its use is not routine 3, 5

Alternative Management Protocols

Alternative management protocols have been developed for use in resource-limited settings or in patients who do not require intensive care. These protocols may involve:

• Use of subcutaneous rapid-acting insulin analogs 2
• Oral replacement of fluids and electrolytes 2
• Use of intermediate-acting insulin to transition to subcutaneous insulin therapy 2

Key Considerations

Key considerations in the treatment of DKA include:

• Prompt recognition and treatment of DKA to prevent complications and improve outcomes 5, 6
• Careful monitoring of serum glucose, electrolytes, and acid-base status to guide therapy 2, 3, 4
• Prevention of hypokalemia and other electrolyte imbalances 6
• Judicious use of bicarbonate and other therapies to avoid complications 6