What is the prognosis for patients with euglycemic diabetic ketoacidosis (euDKA)?

Prognosis of Euglycemic Diabetic Ketoacidosis (euDKA)

Patients with euglycemic diabetic ketoacidosis generally have a favorable prognosis when promptly diagnosed and appropriately treated, though they face a higher risk of hypoglycemia during treatment compared to those with hyperglycemic DKA.

Understanding Euglycemic DKA

Euglycemic DKA is characterized by:

• Metabolic acidosis and ketosis with blood glucose levels <250 mg/dL 1
• The same underlying pathophysiology as traditional DKA but without marked hyperglycemia
• Increasing recognition since the introduction of SGLT2 inhibitors 1, 2

Clinical Outcomes and Prognosis Factors

Mortality and Morbidity

• When properly identified and treated, mortality rates are similar to traditional DKA
• The primary risk factor affecting prognosis is delayed diagnosis due to the absence of significant hyperglycemia 3
• Prompt treatment leads to resolution of metabolic derangements in most cases 4

Treatment Duration and Response

• Patients with euDKA typically require shorter insulin infusion times compared to hyperglycemic DKA (13.5 vs 19.4 hours) 2
• Time to normalization of bicarbonate levels is similar between euDKA and hyperglycemic DKA 2

Complications and Risks

Treatment-Related Complications

• Hypoglycemia risk is significantly higher during treatment of euDKA:
  • 18.2% of euDKA patients experience hypoglycemia (<70 mg/dL) while on insulin infusion versus 4.8% in hyperglycemic DKA 2
• Hypokalemia occurs in approximately 27.3% of euDKA patients during treatment 2

Recurrence Risk

• Recurrence depends on addressing underlying causes:
  • For SGLT2 inhibitor-induced cases: discontinuation of the medication
  • For other causes: management of precipitating factors such as poor oral intake, alcohol use, or pregnancy 1, 3

Management Considerations Affecting Prognosis

Diagnostic Challenges

• Delayed diagnosis is the most significant factor negatively affecting prognosis 3
• Euglycemic DKA should be considered in any diabetic patient with:
  • Unexplained metabolic acidosis despite normal or mildly elevated glucose
  • Risk factors such as SGLT2 inhibitor use, pregnancy, reduced caloric intake, or alcohol use 1

Treatment Modifications

• Treatment follows the same principles as traditional DKA but requires:
  • Earlier administration of dextrose-containing fluids
  • Careful insulin dosing to avoid hypoglycemia 3
  • Close monitoring of electrolytes, particularly potassium 4

Discharge Planning and Follow-up

• A structured discharge plan is essential for all DKA patients, including those with euDKA 4
• Follow-up within 1-2 weeks after discharge is recommended to:
  • Ensure resolution of metabolic abnormalities
  • Adjust medications as needed
  • Address precipitating factors to prevent recurrence 4

Pitfalls to Avoid

1. Delayed diagnosis due to lack of significant hyperglycemia
2. Inadequate dextrose administration during insulin therapy
3. Failure to identify and address the underlying cause
4. Insufficient monitoring for hypoglycemia during treatment
5. Inadequate follow-up after discharge

By understanding these aspects of euDKA management and prognosis, clinicians can optimize outcomes and reduce complications in this unique subset of DKA patients.