What is the treatment for euglycemic ketoacidosis?

From the Guidelines

The treatment for euglycemic ketoacidosis involves immediate administration of intravenous insulin and fluids, despite normal blood glucose levels, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalance and acidosis, as recommended by the most recent guidelines 1.

Key Components of Treatment

• Start with an IV insulin infusion at 0.05-0.1 units/kg/hour while simultaneously providing IV dextrose (D5W or D10W) to maintain blood glucose between 150-200 mg/dL.
• Administer isotonic fluids (normal saline) at 15-20 mL/kg in the first hour, then adjust based on hydration status, as individualization of treatment is crucial 1.
• Electrolyte replacement, particularly potassium, is crucial as levels may drop with insulin therapy; aim to maintain serum potassium between 4-5 mEq/L.
• Identify and treat the underlying cause, which may include SGLT2 inhibitor use, pregnancy, alcohol consumption, starvation, or acute illness.
• Monitor blood glucose, electrolytes, and ketones every 1-2 hours initially.

Transition to Subcutaneous Insulin

• Continue insulin infusion until ketoacidosis resolves (anion gap normalizes and ketones clear), then transition to subcutaneous insulin, with administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
• Recent studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1.

Important Considerations

• There is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA 1.
• The use of bicarbonate in people with DKA made no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1.

From the FDA Drug Label

Animals presenting with severe ketoacidosis, anorexia, lethargy, and/or vomiting should be stabilized with short-acting insulin and appropriate supportive therapy until their condition is stabilized The treatment for euglycemic ketoacidosis involves stabilization with short-acting insulin and appropriate supportive therapy. Key points to consider include:

• Short-acting insulin: should be used to stabilize the condition
• Supportive therapy: is necessary until the condition is stabilized 2

From the Research

Treatment for Euglycemic Ketoacidosis

The treatment for euglycemic ketoacidosis typically involves:

• Intravenous insulin to reduce ketone production and improve glucose uptake by cells 3
• Dextrose-containing fluids to provide a source of glucose and help correct acidosis 3
• Potassium replacement to prevent hypokalemia, which can occur due to increased potassium loss in the urine 3
• Monitoring of anion gap and ketones to guide insulin and fluid management 4
• Slower transition to subcutaneous insulin to prevent relapse 4

Management Considerations

Management of euglycemic ketoacidosis requires careful consideration of several factors, including:

• The need for timely diagnosis and treatment to improve clinical outcomes 4
• The importance of considering euglycemic ketoacidosis in patients taking SGLT2 inhibitors, even in the absence of significant hyperglycemia 3, 5
• The potential for SGLT2 inhibitors to promote lipolysis and ketogenesis while maintaining euglycemia, particularly during periods of carbohydrate deficiency, volume depletion, and upregulation of counter-regulatory stress hormones 5
• The need for a multidisciplinary approach to develop guidelines for withholding and restarting SGLT2 inhibitors after an episode of euglycemic ketoacidosis 6

Patient Care

Patient care for euglycemic ketoacidosis involves:

• Close monitoring of serum pH, bicarbonate levels, and ketones to assess the severity of the condition and guide treatment 4
• Recognition of the signs and symptoms of euglycemic ketoacidosis, including metabolic acidosis, ketonemia, and euglycemia, to enable timely diagnosis and treatment 7
• Consideration of patient-specific factors, such as concomitant therapies and underlying medical conditions, when developing treatment plans 6