What are the medications and doses used in the management of Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis: Medications and Dosing

The standard treatment for diabetic ketoacidosis (DKA) includes intravenous fluids (0.9% NaCl at 1-1.5 L in first hour), continuous IV regular insulin (0.1 U/kg/hour without bolus), and electrolyte replacement, with subcutaneous insulin initiated 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia. 1

Initial Fluid Therapy

• Begin with isotonic saline (0.9% NaCl) at 1-1.5 L in the first hour 1
• Continue fluid resuscitation based on hemodynamic status
• Consider balanced solutions which may lead to faster DKA resolution 2

Insulin Therapy

Severe DKA (pH <7.00, bicarbonate <10 mEq/L, altered mental status)

• Continuous IV regular insulin at 0.1 U/kg/hour without bolus 1
• Titrate to achieve glucose reduction of 50-75 mg/dL/hour
• Continue until resolution of ketoacidosis (bicarbonate ≥18 mEq/L, venous pH >7.3) 1

Mild to Moderate DKA (pH 7.00-7.30, bicarbonate 10-18 mEq/L)

• May be treated with subcutaneous rapid-acting insulin analogs in appropriate settings 3
• If using subcutaneous approach, ensure adequate fluid replacement and frequent glucose monitoring 3

Electrolyte Replacement

• Potassium: Start replacement when serum levels <5.3 mEq/L and patient is producing urine
• Monitor electrolytes (especially potassium) hourly during initial treatment 1
• Replace phosphate and magnesium as needed based on laboratory values

Transition to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before discontinuing IV insulin 3
• Consider adding low-dose basal insulin analog during IV insulin infusion to prevent rebound hyperglycemia 3

Monitoring Parameters

• Vital signs, mental status: Hourly
• Blood glucose: Every 1-2 hours
• Electrolytes, pH, anion gap: Every 2-4 hours until stable 1
• Monitor for resolution criteria:
  • Glucose <200 mg/dL
  • Serum bicarbonate ≥18 mEq/L
  • Venous pH >7.3 1

Special Considerations

Bicarbonate Therapy

• Generally not recommended for most DKA patients 3
• Consider only if pH <6.9 or in severe acidosis with hemodynamic instability 2

Cerebral Edema Prevention

• Avoid rapid correction of hyperglycemia
• Maintain glucose reduction rate at 50-75 mg/dL/hour 2
• Monitor for headache, altered mental status, or focal neurological signs

Mild DKA Alternative Approach

• Subcutaneous insulin may be an effective alternative for mild to moderate DKA with fewer hypoglycemic events compared to IV insulin 4
• This approach may be safer and more cost-effective in appropriate settings 3

Pitfalls to Avoid

• Premature discontinuation of IV insulin before resolution of ketoacidosis
• Insufficient timing or dosing of subcutaneous insulin before stopping IV insulin
• Inadequate fluid replacement
• Failure to identify and treat the precipitating cause of DKA
• Neglecting potassium replacement, which can lead to life-threatening arrhythmias

The management of DKA requires careful clinical evaluation, correction of metabolic abnormalities, and identification/treatment of precipitating conditions. Continuous monitoring and adjustment of therapy based on clinical and laboratory parameters are essential for successful outcomes and prevention of complications.