Do you start an insulin drip in euglycemic diabetic ketoacidosis (DKA)?

Management of Euglycemic Diabetic Ketoacidosis

Yes, an insulin drip should be started in euglycemic diabetic ketoacidosis (euDKA), as continuous intravenous insulin is the standard of care for DKA regardless of blood glucose levels. 1

Understanding Euglycemic DKA

Euglycemic DKA is characterized by:

• Metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L)
• Elevated ketones in blood or urine
• Blood glucose <250 mg/dL (unlike traditional DKA which typically presents with higher glucose levels)

Treatment Algorithm for Euglycemic DKA

Initial Management

1. Fluid Resuscitation

   • Begin with isotonic fluids (normal saline) to restore circulatory volume and tissue perfusion
   • Once volume status is restored, continue fluid replacement

2. Insulin Therapy

   • Start continuous intravenous insulin infusion at 0.1 units/kg/hour 1
   • Since blood glucose is already <250 mg/dL, add dextrose-containing fluids (5% dextrose with 0.45% normal saline) to prevent hypoglycemia while continuing insulin therapy 2
   • Continue insulin infusion until ketoacidosis resolves, even if blood glucose is normal or low

3. Electrolyte Management

   • Monitor potassium levels closely and replace as needed
   • Check electrolytes every 2-4 hours during treatment 1

Monitoring and Adjustment

• Check blood glucose hourly
• Monitor serum electrolytes, blood urea nitrogen, creatinine, and venous pH every 2-4 hours 1
• Follow anion gap to track resolution of ketoacidosis
• Measure beta-hydroxybutyrate (β-OHB) in blood when available (preferred method for monitoring DKA) 1

Transition to Subcutaneous Insulin

• Continue IV insulin until ketoacidosis resolves (criteria: serum bicarbonate ≥18 mEq/L, venous pH ≥7.3, and anion gap normalized) 1
• Administer basal insulin 2-4 hours before stopping the IV insulin infusion to prevent recurrence of ketoacidosis 1
• Recent studies show that administering a low dose of basal insulin analog alongside IV insulin may prevent rebound hyperglycemia without increased hypoglycemia risk 1

Important Considerations and Pitfalls

Common Pitfalls

1. Stopping insulin too early: The insulin infusion should continue until ketoacidosis resolves, even if blood glucose is normal or low. Ketonemia typically takes longer to clear than hyperglycemia 1.

2. Inadequate monitoring: Regular monitoring of electrolytes, acid-base status, and ketones is essential, as relying solely on blood glucose can lead to premature discontinuation of therapy 1.

3. Missing the diagnosis: Normal blood glucose levels can mask the underlying ketoacidosis, leading to delayed treatment. Always check for ketones in diabetic patients with unexplained acidosis, regardless of glucose levels 3.

Special Considerations

• SGLT2 inhibitors are a common cause of euglycemic DKA and should be discontinued at least 3-4 days before any surgical procedure 1
• Patients with euglycemic DKA due to SGLT2 inhibitors should be advised to avoid these medications in the future 2
• There are currently no separate guidelines specifically for euglycemic DKA management; treatment follows standard DKA protocols with the addition of dextrose-containing fluids 2

Remember that despite normal glucose levels, euglycemic DKA is a serious medical emergency requiring prompt treatment with insulin to resolve ketoacidosis and correct metabolic acidosis.