What is the management of vomiting in Diabetic Ketoacidosis (DKA)?

From the Guidelines

Management of vomiting in diabetic ketoacidosis (DKA) requires prompt antiemetic therapy alongside addressing the underlying metabolic derangements, with ondansetron as the preferred first-line antiemetic, typically administered at 4-8 mg IV every 8 hours as needed 1. The goal of managing vomiting in DKA is to prevent dehydration, electrolyte imbalances, and further metabolic complications.

• Addressing the underlying DKA with insulin therapy, aggressive fluid resuscitation, and electrolyte replacement is crucial for resolving the vomiting.
• Typically, 0.9% normal saline should be infused at 15-20 mL/kg/hr initially (approximately 1-1.5 L in the first hour), followed by 250-500 mL/hr depending on hydration status, as recommended by recent guidelines 1.
• Potassium replacement is essential once levels fall below 5.3 mEq/L to prevent hypokalemia and cardiac arrhythmias.
• Nasogastric tube placement may be necessary in cases of severe, persistent vomiting or altered mental status to prevent aspiration.
• Vomiting in DKA results from ketone-induced stimulation of the chemoreceptor trigger zone and gastric stasis due to autonomic neuropathy, making antiemetic therapy an important adjunct to metabolic correction.
• The use of bicarbonate in people with DKA has been shown to make no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1.
• Recent studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1.
• For further treatment information, it is recommended to refer to recent in-depth reviews 1.

From the FDA Drug Label

If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately. The management of vomiting in Diabetic Ketoacidosis (DKA) is to obtain medical assistance immediately.

• Key symptoms of DKA that may lead to vomiting include:
  • Nausea
  • Vomiting
  • Stomach pain
  • Dehydration
  • Loss of consciousness
• Treatment requires immediate medical attention to prevent severe complications or death 2

From the Research

Management of Vomiting in Diabetic Ketoacidosis (DKA)

• Vomiting is a common symptom of DKA, along with nausea, abdominal pain, weight loss, severe fatigue, dyspnea, and preceding febrile illness 3
• The management of DKA requires careful replacement of fluid and electrolyte deficits, intravenous administration of insulin, and close monitoring of clinical and biochemical parameters directed towards timely detection of complications, including hypokalemia, hypoglycemia and cerebral edema 4
• Treatment involves fluid and electrolyte replacement, insulin, treatment of precipitating causes, and close monitoring to adjust therapy and identify complications 3
• Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states 5
• Management of DKA requires reversing metabolic derangements, correcting volume depletion, electrolyte imbalances and acidosis while concurrently treating the precipitating illness 6

Key Considerations

• Factors precipitating the episode of DKA should be identified and rectified 4
• Special patient factors and comorbidities should receive more careful attention and consideration, such as pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and site of care 6
• Guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, and treatment approaches may need to be tailored to individual patient needs 6

Treatment Approaches

• Fluid resuscitation, insulin regimen, and electrolyte replacement are crucial components of DKA management 7
• The use of sodium-glucose cotransporter-2 inhibitors modestly increases the risk of DKA and euglycemic DKA 3
• Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA 5