What are the symptoms and treatment of Diabetic Ketoacidosis (DKA) in diabetes?

Symptoms and Treatment of Diabetic Ketoacidosis (DKA) in Diabetes

DKA is characterized by polyuria, polydipsia, polyphagia, weight loss, vomiting, abdominal pain, dehydration, weakness, clouding of sensoria, and potentially coma, with the classic biochemical triad of hyperglycemia (>250 mg/dL), acidosis (pH <7.3), and ketonemia. 1

Clinical Presentation of DKA

Common Symptoms

• Polyuria (excessive urination)
• Polydipsia (excessive thirst)
• Polyphagia (excessive hunger)
• Weight loss
• Nausea and vomiting (occurs in up to 25% of patients)
• Abdominal pain (characteristic of DKA but not HHS)
• Severe fatigue
• Weakness
• Altered mental status (ranging from mild confusion to coma)

Physical Findings

• Poor skin turgor
• Kussmaul respirations (deep, rapid breathing)
• Tachycardia
• Hypotension
• Fruity odor on breath (from ketone production)
• Dehydration signs
• Hypothermia (if present, indicates poor prognosis) 1

Diagnostic Criteria

DKA is diagnosed by the presence of:

1. Hyperglycemia (blood glucose >250 mg/dL)
2. Metabolic acidosis (pH <7.3, serum bicarbonate <18 mEq/L)
3. Elevated serum or urine ketones 2

Note: Euglycemic DKA can occur, particularly in patients taking SGLT2 inhibitors, where blood glucose may be <200 mg/dL 2

Risk Factors and Precipitating Factors

Risk Factors

• Type 1 diabetes/absolute insulin deficiency
• Younger age
• Prior history of hyperglycemic crises
• Prior history of hypoglycemic crises
• Presence of other diabetes complications
• Presence of other chronic health conditions
• Behavioral health conditions
• Alcohol and/or substance use
• High A1C level
• Social determinants of health 1

Common Precipitating Factors

• Infection (most common)
• Missed insulin doses or inadequate insulin
• New-onset diabetes (especially type 1)
• Cerebrovascular accident
• Alcohol abuse
• Pancreatitis
• Myocardial infarction
• Trauma
• Medications (corticosteroids, thiazides, sympathomimetic agents) 1
• SGLT2 inhibitors (can increase risk of DKA, including euglycemic DKA) 1

Treatment of DKA

1. Fluid Replacement

• Initial fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hour
• Subsequent fluid choice based on hydration status and electrolytes 3

2. Insulin Therapy

• Begin insulin therapy 1-2 hours after starting fluid replacement
• Continuous intravenous insulin infusion at 0.1 U/kg/hour
• Avoid bolus intravenous insulin (especially in children)
• Goal: Reduce glucose by 50-100 mg/dL per hour 3
• Continue IV insulin until DKA resolves (bicarbonate ≥18 mEq/L, pH >7.3, anion gap normalized) 3

3. Electrolyte Replacement

• Potassium supplementation when levels are <5.5 mEq/L and renal function is adequate
• Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO4)
• Monitor potassium levels closely as insulin therapy can cause hypokalemia 3, 4
• Bicarbonate therapy only for patients with pH <6.9
• Phosphate replacement may be necessary in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 3

4. Monitoring

• Blood glucose every 1-2 hours
• Electrolytes, BUN, and creatinine every 2-4 hours
• Venous pH and anion gap every 2-4 hours
• Cardiac monitoring for T-wave changes indicating hypo/hyperkalemia 3

5. Treatment of Precipitating Factors

• Identify and treat underlying causes (infection, etc.)
• Additional tests to consider: amylase, lipase, hepatic transaminase levels, troponin, creatine kinase, blood and urine cultures, and chest radiography 2

6. Transition to Subcutaneous Insulin

• Once DKA resolves (blood glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, normalized anion gap)
• Continue IV insulin for 1-2 hours after first dose of subcutaneous insulin
• Patients with type 1 diabetes should continue with multiple dose insulin therapy or insulin pump therapy
• Patients with type 2 diabetes may be considered for metformin after resolution of ketosis 3

Special Considerations

Pregnant Patients

• Up to 2% of pregnancies with pregestational diabetes are complicated by DKA
• Pregnant individuals may present with euglycemic DKA (glucose <200 mg/dL)
• Diagnosis may be hindered by mixed acid-base disturbances, particularly with hyperemesis
• Pregnant individuals at risk for DKA should be counseled on signs and symptoms and seek immediate medical attention if concerned 1

SGLT2 Inhibitor Users

• Educate patients regarding symptoms of DKA (nausea, vomiting, abdominal pain, weakness)
• DKA can occur even with blood glucose in the 150-250 mg/dL range
• Instruct patients to seek urgent medical attention if experiencing DKA-like symptoms 1

Prevention Strategies

Patient Education

• Recognize early warning signs of DKA
• Sick day management protocols
• Never discontinue basal insulin even when not eating
• Measure urine or blood ketones when glucose exceeds 200 mg/dL or during illness
• Seek medical attention if unable to tolerate oral hydration, blood glucose doesn't improve with insulin, altered mental status develops, or signs of worsening illness occur 1, 3

Healthcare Provider Strategies

• Regular follow-up appointments
• Structured discharge planning after DKA episodes
• Address social determinants of health that may affect diabetes management
• Ensure uninterrupted access to insulin and diabetes supplies 3, 2

Complications of Untreated DKA

• Cerebral edema
• Coma
• Death 5

DKA remains a serious but largely preventable complication of diabetes that requires prompt recognition and treatment to reduce morbidity and mortality.