From the Guidelines
The treatment of euglycemic diabetic ketoacidosis (euDKA) primarily involves intravenous fluids and insulin therapy, not GIK (glucose-insulin-potassium) infusion. Standard management includes IV normal saline to restore volume status, followed by IV insulin infusion at 0.05-0.1 units/kg/hour, as recommended by the most recent guidelines 1. Unlike typical DKA, euDKA requires concurrent dextrose administration (typically D5W or D10W) when starting insulin to maintain euglycemia while clearing ketones. Electrolyte replacement, particularly potassium, is essential as levels may drop with insulin therapy, and should be given in each liter of i.v. fluid as needed to keep serum K+ between 4 and 5 mmol/L 1. Addressing the underlying cause is crucial, especially discontinuing SGLT2 inhibitors if they triggered the condition. Frequent monitoring of glucose, electrolytes, and acid-base status guides therapy adjustments. This approach differs from GIK protocols, which are primarily used in other clinical scenarios like cardiac conditions. The rationale for this treatment is that insulin is needed to suppress ketogenesis and promote ketone clearance, while fluids help correct dehydration and electrolyte imbalances, even though blood glucose levels may be relatively normal. Some key points to consider in the management of euDKA include:
- Restoration of circulatory volume and tissue perfusion
- Resolution of hyperglycemia
- Correction of electrolyte imbalance and acidosis
- Treatment of any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke 1
- The use of bicarbonate should only be considered in specific situations, such as severe acidosis, and phosphate should not be given unless there is muscle weakness, respiratory compromise, or other specific indications 1.
From the Research
Treatment of Euglycemic Diabetic Ketoacidosis (EDKA)
- The treatment of EDKA involves correction of dehydration, electrolytes deficit, and insulin replacement, similar to the treatment of traditional diabetic ketoacidosis (DKA) 2, 3.
- Intravenous fluids, including dextrose-containing fluids, should accompany intravenous insulin to correct metabolic acidosis, ketonemia, and to avoid hypoglycemia 2, 4.
- The use of glucose-containing intravenous fluid can induce endogenous insulin secretion and stop ketogenesis in EDKA 4.
- Insulin therapy is titrated against the change in blood glucose concentration, and potassium is administered as required 5.
- The treatment of EDKA may also involve the use of bicarbonate in extreme acidosis, but its administration may contribute to the development of hypokalemia, CSF acidosis, and tissue hypoxia 5.
Key Components of EDKA Treatment
- Fluid administration
- Electrolyte control
- Glucose control with insulin
- Use of dextrose-containing intravenous fluids to avoid hypoglycemia
- Potassium administration as required
Considerations for EDKA Treatment
- High clinical suspicion is required to diagnose EDKA, as normal blood sugar levels can masquerade the underlying DKA 3.
- Blood pH and blood or urine ketones should be checked in ill patients with diabetes, regardless of blood glucose levels 3.
- The incidence of hypoglycemia is higher in patients with EDKA, and treatment strategies should aim to minimize this adverse event 6.