What is the treatment for euglycemic diabetic ketoacidosis (DKA)?

Treatment of Euglycemic Diabetic Ketoacidosis (EuDKA)

The treatment of euglycemic diabetic ketoacidosis follows the same principles as traditional DKA, with intravenous hydration, insulin therapy, and electrolyte replacement as the cornerstones of management, while maintaining vigilant monitoring of glucose levels to prevent hypoglycemia. 1, 2, 3

Diagnosis and Initial Assessment

• EuDKA is characterized by:

  • Blood glucose <250 mg/dL (distinguishing it from traditional DKA)
  • Arterial pH <7.3
  • Serum bicarbonate <15 mEq/L
  • Moderate ketonemia or ketonuria 1, 3

• Common precipitating factors to identify:

  • SGLT2 inhibitor use (significant risk factor)
  • Pregnancy
  • Decreased food intake or fasting
  • Infection
  • Discontinuation or inadequate insulin
  • Acute medical events 1, 2

Treatment Algorithm

1. Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl)
  • Initial rate: 500 mL/hour for first 2-3 liters to replace extracellular fluid deficit
  • Then transition to 0.45% saline with 5% glucose at 250 mL/hour 1, 4
• Important: Unlike traditional DKA, add glucose earlier in treatment to prevent hypoglycemia 5

2. Insulin Therapy

• Start low-dose intravenous (IV) insulin infusion
  • Initial bolus: 0.1 units/kg (optional)
  • Continuous infusion: 0.1 units/kg/hour
• Critical difference from traditional DKA: Add dextrose to IV fluids when glucose falls below 200-250 mg/dL to prevent hypoglycemia while continuing insulin to clear ketones 1, 5
• Continue insulin until ketoacidosis resolves (normalized anion gap, bicarbonate ≥18 mEq/L, venous pH >7.3) 1, 5

3. Electrolyte Management

• Potassium replacement:
  • Monitor levels every 2-3 hours during initial treatment
  • Begin replacement when serum potassium <5.2 mEq/L (even if initially normal)
  • Add 20-30 mEq potassium (as KCl or K-phosphate) per liter of IV fluid 1, 4
• Bicarbonate therapy:
  • Generally not recommended in most patients
  • Consider only in severe acidosis (pH <7.0) or if hemodynamic instability 1, 6

4. Monitoring Protocol

• Hourly monitoring:
  • Vital signs
  • Neurological status
  • Blood glucose
  • Fluid input/output 1
• Every 2-4 hours:
  • Electrolytes
  • BUN, creatinine
  • Venous pH 1

Transition to Subcutaneous Insulin

• Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia
• Check blood glucose 2 hours after IV insulin discontinuation
• Continue frequent monitoring (every 3-4 hours) for the first 24 hours after transition 1

Resolution Criteria

EuDKA is considered resolved when:

• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap normalized 1, 5

Special Considerations

• SGLT2 inhibitors: Discontinue these medications during acute illness and hold for at least 24-48 hours before any planned procedures 2, 3
• Pregnant patients: Require immediate attention due to risk of feto-maternal harm 1
• Cardiac patients: Require cardiac monitoring during treatment 1

Common Pitfalls to Avoid

1. Delayed diagnosis due to normal or near-normal glucose levels masking the underlying DKA 2, 3
2. Inadequate potassium replacement despite initially normal serum levels, which can lead to fatal cardiac arrhythmias 5
3. Premature discontinuation of insulin before ketoacidosis resolves, even if glucose normalizes 5
4. Failure to add dextrose to IV fluids when glucose levels approach 200-250 mg/dL 1, 5
5. Missing the underlying precipitating cause, which can lead to recurrence 5, 6

By following this structured approach to managing euglycemic DKA, you can effectively treat this potentially life-threatening condition while minimizing complications and improving outcomes.