What is the management of starvation ketosis?

Management of Starvation Ketosis

The primary treatment for starvation ketosis is providing 150-200g of carbohydrates daily (45-50g every 3-4 hours) along with adequate fluid intake to prevent dehydration. 1

Pathophysiology and Recognition

Starvation ketosis occurs when inadequate carbohydrate intake leads to depleted glycogen stores, resulting in increased fat breakdown and ketone body production. This can progress to starvation ketoacidosis if prolonged, characterized by:

• Metabolic acidosis with increased anion gap
• Elevated ketone bodies in blood and urine
• Normal or low blood glucose (unlike diabetic ketoacidosis)
• Symptoms may include nausea, vomiting, abdominal pain, and fatigue

Management Algorithm

1. Carbohydrate Replacement

• Provide 45-50g of carbohydrates every 3-4 hours (150-200g daily) 1
• Options for carbohydrate sources:
  • Regular meals with adequate carbohydrate content
  • Sugar-sweetened beverages, fruit juices, soups if solid food not tolerated
  • For patients unable to tolerate oral intake, consider glucose-containing intravenous fluids 2

2. Fluid Resuscitation

• Increase oral fluid intake with sodium-containing options (broth, sports drinks) 1
• For severe cases or inability to tolerate oral fluids:
  • Administer IV isotonic saline (0.9% NaCl) 1
  • Avoid prolonged starvation periods 2

3. Electrolyte Management

• Monitor and replace potassium, sodium, and phosphate as needed 1
• Pay particular attention to potassium levels, as refeeding can cause shifts

4. Special Considerations

For Perioperative Patients:

• Adhere to recommended fasting guidelines and avoid prolonged starvation 2
• Consider glucose-containing IV fluids during unavoidable prolonged fasting 2
• For patients on SGLT2 inhibitors, these should be omitted the day before and day of procedure 2

For Pregnant Women:

• Monitor for starvation ketosis, especially in those with hyperglycemia or weight loss during treatment 2
• Fingerstick blood ketone testing is more accurate than urine ketone testing 2
• Ensure adequate energy intake to prevent starvation ketosis while managing gestational diabetes 2

For Patients on Ketogenic Diets:

• Patients following ketogenic diets are at higher risk for developing starvation ketoacidosis if fasting is prolonged 3
• This risk is particularly elevated in those with diabetes mellitus 3

Monitoring and Resolution

• Check blood glucose and ketones every 1-2 hours until resolution 1
• Consider hospital admission if:
  • pH < 7.0
  • Patient is obtunded or unable to tolerate oral intake
  • Significant electrolyte abnormalities present

Pitfalls and Caveats

• In patients with alcohol use disorder, consider concurrent alcoholic ketoacidosis and administer thiamine before carbohydrate replacement to prevent Wernicke's encephalopathy 4
• Patients with psychiatric illness may be at higher risk due to poor oral intake and inability to provide accurate history 4
• Refeeding syndrome is a risk in severely malnourished patients; start nutrition cautiously with close electrolyte monitoring 5
• When managing patients on very low-energy diets (such as pre-bariatric surgery diets), be vigilant for development of ketosis 2

Starvation ketosis is generally reversible with appropriate carbohydrate intake and hydration, but can progress to life-threatening ketoacidosis if not properly managed.