What is the treatment for Euglycemic Diabetic Ketoacidosis (DKA)?

Treatment of Euglycemic Diabetic Ketoacidosis (DKA)

Euglycemic DKA should be treated with the same protocol as traditional DKA, including IV fluid resuscitation, insulin therapy, and electrolyte replacement, despite normal blood glucose levels (<200 mg/dL). 1, 2

Definition and Diagnosis

Euglycemic DKA is characterized by:

• Metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L)
• Ketonemia or ketonuria
• Normal blood glucose levels (<200 mg/dL)

This condition presents a diagnostic challenge as the normal glucose levels can mask the underlying ketoacidosis, requiring high clinical suspicion 2.

Treatment Protocol

1. Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour
• Continue fluid replacement based on hemodynamic status
• Add dextrose (5-10%) to IV fluids when starting insulin therapy to prevent hypoglycemia, which is particularly important in euglycemic DKA 1

2. Insulin Therapy

• Administer regular insulin IV at 0.1 units/kg/hour (approximately 5-7 units/hour) after initial fluid resuscitation 1
• For moderate to severe DKA (pH <7.25), continuous IV regular insulin is recommended
• For mild DKA (pH 7.25-7.30), subcutaneous or intramuscular insulin every hour can be used (initial dose 0.4-0.6 U/kg, followed by 0.1 U/kg/h) 3, 1
• Continue insulin infusion until acidosis resolves (pH ≥7.3, bicarbonate ≥18 mEq/L) regardless of blood glucose levels 1

3. Electrolyte Replacement

• Potassium: Start replacement when serum potassium <5.2 mEq/L and patient is producing urine
  • Add 20-30 mEq potassium per liter of IV fluid
  • Monitor levels every 2-4 hours 1
• Bicarbonate: Generally not recommended except in cases of severe acidosis (pH <6.9) in adults 1

4. Monitoring

• Measure glucose, electrolytes, and venous pH every 2-4 hours
• Direct measurement of β-hydroxybutyrate in blood is preferred over the nitroprusside method to monitor ketosis resolution 1
• Venous pH and anion gap can be followed to monitor resolution of acidosis 3

Resolution Criteria

DKA is considered resolved when:

• Serum bicarbonate ≥18 mEq/L
• Venous pH ≥7.3
• Anion gap normalized 1

Transition to Subcutaneous Insulin

• Once DKA resolves, transition to a multiple-dose insulin regimen
• Continue IV insulin infusion for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels
• An abrupt discontinuation of IV insulin coupled with delayed onset of subcutaneous insulin can lead to poor glycemic control 3, 1

Special Considerations for Euglycemic DKA

1. Maintain glucose levels: Add dextrose to IV fluids earlier than in hyperglycemic DKA to prevent hypoglycemia while continuing insulin infusion to clear ketones 2

2. Identify and treat precipitating factors: Common causes of euglycemic DKA include:

   • SGLT-2 inhibitor use
   • Reduced carbohydrate intake or starvation
   • Insulin pump failure
   • Pregnancy
   • Infection 2, 4

3. Continue monitoring: Despite normal glucose levels, continue monitoring ketones until acidosis resolves 1

Common Pitfalls to Avoid

1. Diagnostic delay: Normal glucose levels may lead to missed or delayed diagnosis of DKA 2, 4

2. Premature insulin discontinuation: Continuing insulin therapy until ketosis resolves is essential, even if glucose levels are normal or low 1

3. Inadequate fluid resuscitation: Volume depletion must be corrected regardless of glucose levels 1

4. Failure to identify precipitating causes: Especially important to recognize SGLT-2 inhibitors as potential triggers 4

5. Discontinuing IV insulin too early: Ensure overlap between IV and subcutaneous insulin to prevent recurrence of ketosis 3, 1

Euglycemic DKA requires the same aggressive treatment approach as traditional DKA, with special attention to maintaining adequate glucose levels while clearing ketones with insulin therapy.