What are the diagnostic criteria for euglycemic diabetic ketoacidosis (DKA)?

From the Guidelines

Euglycemic diabetic ketoacidosis (euDKA) is diagnosed when a patient presents with ketoacidosis but has relatively normal blood glucose levels, typically less than 250 mg/dL (13.9 mmol/L). The diagnostic criteria for euDKA include:

• Blood pH less than 7.3
• Serum bicarbonate less than 18 mEq/L
• Presence of ketonemia or ketonuria
• Anion gap greater than 10 mEq/L All while maintaining blood glucose levels below the typical threshold for traditional DKA 1. This condition is most commonly seen in patients taking SGLT2 inhibitors, during pregnancy, after excessive alcohol consumption, or during periods of starvation. Key points to consider in the diagnosis and management of euDKA include:
• Monitoring of electrolytes, glucose, and acid-base status until ketoacidosis resolves
• Discontinuation of SGLT2 inhibitors if euDKA is diagnosed and not restarting until the underlying cause is identified and addressed
• Management following similar principles to traditional DKA, including intravenous fluids, insulin therapy, and electrolyte replacement, though glucose administration is often required earlier to prevent hypoglycemia while continuing insulin to clear ketones 1. It's essential to note that the normal glucose levels in euDKA can delay diagnosis, as clinicians may not immediately suspect DKA. The provided evidence from the studies 1 supports the diagnostic criteria and management principles for euDKA.

From the Research

Diagnostic Criteria for Euglycemic DKA

The diagnostic criteria for euglycemic diabetic ketoacidosis (DKA) include:

• Increased anion gap metabolic acidosis
• Ketonemia or ketonuria
• Normal blood glucose levels, typically defined as less than 200 mg/dL 2 or less than 11 mmol/L 3
• Blood pH and blood or urine ketones should be checked in ill patients with diabetes regardless of blood glucose levels 2

Key Considerations

• Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones 3
• The diagnostic workup includes arterial blood gas for metabolic acidosis, serum ketones, and exclusion of other causes of high anion gap metabolic acidosis 3
• Treatment of euglycemic DKA is based on the same principles as for DKA, with correction of dehydration, electrolytes deficit, and insulin replacement 3

Comparison with Traditional DKA

• Traditional DKA is characterized by hyperglycemia, ketonemia, and metabolic acidosis, with a serum glucose level greater than 250 mg per dL 4
• Euglycemic DKA, on the other hand, presents with normal or near-normal blood glucose levels, making it a more challenging diagnosis 2, 3

Importance of Early Recognition

• Early recognition and treatment of euglycemic DKA are crucial to prevent complications and improve outcomes 2, 3
• Physicians should be aware of the diagnostic criteria and consider euglycemic DKA in the differential diagnosis of patients with diabetes mellitus, even if their blood glucose levels are normal 2, 3