What is the treatment for Euglycemic Diabetic Ketoacidosis (DKA)?

From the Guidelines

The treatment for Euglycemic Diabetic Ketoacidosis (DKA) should follow the same principles as traditional DKA management, with careful attention to glucose levels, and the most recent guidelines from 2024 should be prioritized 1.

Key Principles of Treatment

The initial treatment includes:

• Intravenous fluids, typically 0.9% normal saline at 15-20 mL/kg/hr for the first hour, then 250-500 mL/hr
• Intravenous insulin, with regular insulin 0.1 units/kg/hr after an optional bolus of 0.1 units/kg
• Electrolyte replacement, particularly potassium Unlike traditional DKA, dextrose infusion should be started earlier, typically when glucose levels fall below 200-250 mg/dL, to prevent hypoglycemia while continuing insulin therapy to clear ketones.

Monitoring and Underlying Cause Identification

Patients require frequent monitoring of:

• Electrolytes
• Glucose
• Anion gap every 2-4 hours The underlying cause, often SGLT2 inhibitor use, should be identified and addressed. SGLT2 inhibitors should be discontinued immediately.

Insulin Therapy and Transition

Insulin infusion should continue until the anion gap normalizes and ketosis resolves, even if glucose levels are normal. Once the patient improves, transition to subcutaneous insulin can occur, with basal insulin administered 2–4 h prior to stopping intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.

Important Considerations

Euglycemic DKA requires vigilance because the absence of significant hyperglycemia may delay diagnosis and treatment, while the metabolic derangements remain just as dangerous as traditional DKA. The use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1.

From the Research

Treatment Overview

• The treatment for Euglycemic Diabetic Ketoacidosis (DKA) includes replacement of fluid and electrolytes lost through osmotic diuresis 2.
• Insulin is required to reverse ketoacid production by the liver, with low-dose therapy recommended 2, 3.
• Serum glucose must be monitored closely to avoid hypoglycemia, and dextrose should be added to the infusion once the serum glucose falls to 250 mg per dl 2.

Key Components of Treatment

• Aggressive treatment with intravenous fluids and insulin drip as per the protocol for the blood glucose levels until the anion gap normalizes, and the metabolic acidosis reverses 4.
• Correction of metabolic derangements and discontinuation of Sodium-Glucose Transporter-2 Inhibitors (SGLT2i) if applicable 5.
• Monitoring of blood pH, blood or urine ketones, and serum potassium levels to avoid hypokalemia and cardiac arrhythmia 2, 6.

Considerations and Challenges

• Euglycemic DKA can be challenging to diagnose due to the absence of significant hyperglycemia, and a high clinical suspicion is warranted 4, 5.
• The risk of hypoglycemia is increased in euglycemic DKA patients, and treatment strategies should aim to minimize this adverse event 6.
• The etiologies of euglycemia, such as insulin use prior to arrival, poor oral intake with baseline insulin use, and SGLT2 inhibitor use, should be considered when managing euglycemic DKA patients 6.