What is euglycemic diabetic ketoacidosis (DKA)?

From the Guidelines

Euglycemic diabetic ketoacidosis (DKA) is a serious condition that requires prompt treatment with IV fluids, insulin therapy, and electrolyte replacement, despite the patient having normal or only mildly elevated blood glucose levels. This condition is characterized by the presence of ketoacidosis, dehydration, and potentially life-threatening complications, such as coma, and therefore requires individualized treatment based on a careful clinical and laboratory assessment 1. The management goals for euglycemic DKA include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis.

Some key points to consider in the treatment of euglycemic DKA include:

• Starting an IV insulin infusion at 0.1 units/kg/hour while simultaneously administering IV fluids, such as normal saline at 15-20 mL/kg in the first hour, then 250-500 mL/hour
• Replacing potassium, phosphate, and magnesium as needed based on laboratory values
• Considering the use of dextrose-containing fluids to prevent hypoglycemia while continuing insulin therapy to clear ketones
• Identifying and treating any underlying causes of DKA, such as sepsis, myocardial infarction, or stroke
• Temporarily discontinuing SGLT2 inhibitors, such as empagliflozin, dapagliflozin, or canagliflozin, during acute illness or when unable to maintain adequate oral intake

The pathophysiology of euglycemic DKA involves continued ketogenesis due to insulin deficiency and glucagon excess, while blood glucose remains relatively normal due to increased urinary glucose excretion or decreased carbohydrate intake/absorption 1. Close monitoring of both glucose and ketone levels is essential during treatment to prevent complications and ensure optimal outcomes.

From the Research

Definition and Characteristics of Euglycemic Diabetic Ketoacidosis (DKA)

• Euglycemic DKA is a rare complication of diabetes mellitus (DM) characterized by metabolic acidosis, ketosis, and blood glucose levels < 250 mg/dL 2, 3, 4, 5, 6.
• It is a life-threatening emergency that may occur in patients with both type 1 and type 2 DM 4, 6.
• The condition is often associated with a relative or absolute carbohydrate deficit, resulting in ketosis while maintaining near-normal glucose levels 3, 6.

Causes and Risk Factors

• The prevalence of euglycemic DKA is increasing with the popularity of ketogenic (low-carbohydrate) diets 2.
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors can precipitate euglycemic DKA, particularly in patients with lower mass index and decreased glycogen store 3, 5.
• Other causes associated with euglycemic DKA include pregnancy, decreased caloric intake, heavy alcohol use, insulin use prior to hospital admission, cocaine abuse, pancreatitis, sepsis, chronic liver disease, and liver cirrhosis 4, 6.

Diagnosis and Treatment

• Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones 6.
• The diagnostic workup includes arterial blood gas for metabolic acidosis, serum ketones, and exclusion of other causes of high anion gap metabolic acidosis 6.
• Treatment includes rapid correction of dehydration, correction of electrolyte abnormalities, and use of insulin drip until the anion gap and bicarbonate levels normalize 4, 6.
• Dextrose-containing fluids should accompany intravenous insulin to correct metabolic acidosis, ketonemia, and to avoid hypoglycemia 6.