What is the management of euglycaemic ketoacidosis?

Management of Euglycemic Diabetic Ketoacidosis

The management of euglycemic diabetic ketoacidosis (euDKA) follows the same principles as traditional DKA, with the critical addition of dextrose-containing fluids to prevent hypoglycemia during insulin therapy. 1, 2

Recognition and Diagnosis

• Euglycemic DKA is characterized by:

  • Blood glucose <250 mg/dL (often <200 mg/dL)
  • pH <7.3
  • Bicarbonate <15 mEq/L
  • Presence of ketones
  • Common in patients taking SGLT2 inhibitors 1

• Risk factors:

  • SGLT2 inhibitor use (most common trigger)
  • Reduced caloric intake
  • Acute illness
  • Surgery
  • Insulin reduction or discontinuation
  • Pregnancy
  • Alcohol consumption 1, 2, 3

Treatment Algorithm

1. Initial Management

• Discontinue SGLT2 inhibitor immediately 1
• Initiate IV fluids:
  • Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour
  • Critical difference from traditional DKA: Add dextrose-containing fluids early (D5W or D10W) even with normal glucose levels 4, 2

2. Insulin Therapy

• Administer IV regular insulin:
  • Initial bolus: 0.1 units/kg
  • Continuous infusion: 0.1 units/kg/hour 4
• Target glucose reduction: 50-75 mg/dL per hour
• Maintain blood glucose between 140-180 mg/dL 4
• Continue insulin infusion until acidosis resolves, regardless of glucose levels 5, 2

3. Electrolyte Management

• Monitor potassium, magnesium, and phosphate levels every 2-4 hours
• Replace electrolytes as needed:
  • Potassium: Add when serum level <5.2 mEq/L (if renal function adequate)
  • Bicarbonate: Generally not recommended unless pH <6.9 1, 4

4. Monitoring

• Check blood glucose hourly
• Monitor electrolytes, pH, bicarbonate, and anion gap every 2-4 hours
• Assess for resolution: pH >7.3, bicarbonate >15 mEq/L, and normal anion gap 4

5. Transition to Subcutaneous Insulin

• Once DKA resolves (pH >7.3, bicarbonate >15 mEq/L):
  • Administer basal insulin 2-4 hours before stopping IV insulin to prevent recurrence 1
  • Consider low-dose basal insulin analog in addition to IV insulin to prevent rebound hyperglycemia 1

Special Considerations

Perioperative Management

• Discontinue SGLT2 inhibitors 3-4 days before elective surgery 1, 6
• For emergency surgery in patients on SGLT2 inhibitors:
  • Monitor for euDKA even with normal glucose levels
  • Have low threshold for checking arterial blood gases and ketones 6

Prolonged Treatment Course

• EuDKA associated with SGLT2 inhibitors may require longer treatment due to the drug's half-life 5
• Continue monitoring for 24-48 hours after clinical resolution

Prevention

• Patient education about SGLT2 inhibitor risks
• Temporarily discontinue SGLT2 inhibitors during:
  • Acute illness
  • Reduced food intake
  • Surgical procedures
  • Excessive alcohol consumption 1
• Maintain at least low-dose insulin in patients requiring insulin who are also on SGLT2 inhibitors 1
• Consider blood or urine ketone monitoring in high-risk patients 1

Pitfalls to Avoid

• Delaying diagnosis due to normal or near-normal glucose levels
• Stopping insulin infusion prematurely when glucose normalizes
• Failing to provide dextrose-containing fluids alongside insulin
• Missing euDKA in patients with vague symptoms (nausea, malaise, abdominal pain) 7, 2