What is the management of Euglycemic Diabetic Ketoacidosis (DKA)?

Management of Euglycemic Diabetic Ketoacidosis (DKA)

Euglycemic DKA should be treated with the same core principles as classic DKA, with the critical addition of dextrose-containing IV fluids from the start of treatment to maintain adequate glucose levels while administering insulin to resolve ketosis. 1

Definition and Diagnosis

Euglycemic DKA is characterized by:

• Blood glucose <200 mg/dL (unlike classic DKA with glucose >250 mg/dL)
• Arterial pH <7.3
• Serum bicarbonate <15 mEq/L
• Presence of ketosis/ketonemia 2

Common causes include:

• SGLT2 inhibitor use (most common modern cause)
• Pregnancy
• Reduced caloric intake
• Recent insulin use
• Heavy alcohol consumption
• Chronic liver disease 2

Treatment Protocol

1. Immediate Management

• Discontinue SGLT2 inhibitors if applicable 3
• Start IV fluids immediately:
  • Begin with dextrose-containing IV fluids (unlike classic DKA where 0.9% NaCl is used initially)
  • This is critical to provide glucose substrate while insulin is administered 1, 4

2. Insulin Administration

• Start IV insulin infusion at 0.1 units/kg/hour of regular insulin (no initial bolus needed) 4
• Continue insulin infusion until resolution of ketoacidosis, even if glucose levels are normal or low
• Add dextrose to IV fluids to maintain blood glucose between 150-200 mg/dL while continuing insulin to clear ketones 4, 1

3. Monitoring

• Check blood glucose hourly until stable
• Monitor electrolytes, renal function, and venous pH every 2-4 hours
• Monitor vital signs, neurological status, and fluid input/output hourly 4

4. Electrolyte Replacement

• Replace potassium as needed to maintain levels between 4-5 mEq/L
• Monitor for and correct other electrolyte abnormalities (sodium, chloride, phosphate) 4

5. Transition to Subcutaneous Insulin

• Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin infusion to prevent rebound hyperglycemia and recurrence of ketoacidosis
• Do not use correction insulin alone without basal insulin 4

Resolution Criteria

DKA is considered resolved when:

• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap normalized 4

Special Considerations for Euglycemic DKA

• SGLT2 inhibitor-associated euglycemic DKA may have a more prolonged course due to the long half-life of these medications 1
• Maintain glucose levels between 150-200 mg/dL during treatment to allow continued insulin administration for ketosis resolution 4, 1
• Consider ICU admission for close monitoring, especially if there is cardiovascular instability or altered mental status 5

Common Pitfalls

• Delayed diagnosis due to normal or near-normal glucose levels leading clinicians to overlook DKA 2
• Premature discontinuation of insulin when glucose normalizes before ketoacidosis resolves
• Inadequate dextrose administration leading to hypoglycemia during insulin treatment
• Failure to identify and treat the underlying cause (especially SGLT2 inhibitor use, reduced caloric intake, or pregnancy) 3, 2

Prevention of Recurrence

• Identify and address precipitating factors
• Provide education on diabetes self-management
• Review medication regimen, especially insulin administration
• Schedule follow-up appointment prior to discharge 4