Management of DKA with Improved Blood Sugars but Elevated Beta-Hydroxybutyrate
The next step in managing a diabetic ketoacidosis patient with improved blood sugars but serum beta-hydroxybutyrate of 2.1 mmol/L is to start insulin glargine (option b) while continuing the IV insulin infusion until ketosis resolves completely.
Understanding DKA Resolution Criteria
According to the American Diabetes Association guidelines, DKA is not considered resolved until three key parameters are met:
- Blood glucose less than 200 mg/dL
- Serum bicarbonate greater than or equal to 18 mEq/L
- Venous pH greater than 7.3 1
Additionally, research evidence indicates that plasma beta-hydroxybutyrate (BOHB) levels should be less than 1.5 mmol/L to define resolution of DKA 2. With a current BOHB of 2.1 mmol/L, the patient still has ongoing ketosis despite improved blood glucose levels.
Proper Transition from IV to Subcutaneous Insulin
A common pitfall in DKA management is the premature termination of intravenous insulin therapy 3. The correct approach involves:
- Continue IV insulin infusion until ketosis resolves (BOHB <1.5 mmol/L)
- Start long-acting insulin (insulin glargine) before discontinuing IV insulin
- Overlap IV and subcutaneous insulin to prevent recurrence of ketosis
The Joint British Diabetes Societies guideline specifically recommends that if a patient is already taking long-acting insulin analogues such as insulin glargine, they should be continued at usual doses during DKA treatment 4.
Why Other Options Are Incorrect
Option A (discontinue IV insulin): This would be dangerous as ketosis is still present (BOHB 2.1 mmol/L). Premature termination of IV insulin is a common management error 3.
Option C (start empagliflozin): SGLT-2 inhibitors like empagliflozin are contraindicated in DKA as they can actually precipitate or worsen ketoacidosis by increasing ketone formation 5.
Option D (discontinue potassium): Potassium management should be based on serum potassium levels, not ketone levels. Discontinuing potassium without knowing the current potassium level could lead to dangerous hypokalemia during insulin therapy 1.
Monitoring During Transition
During the transition from IV to subcutaneous insulin:
- Continue monitoring blood glucose hourly
- Check BOHB levels every 2-4 hours until <1.5 mmol/L
- Monitor electrolytes, especially potassium
- Ensure adequate fluid status is maintained
Preventing Recurrence
After resolution of DKA:
- Identify and address the precipitating cause
- Provide education on diabetes self-management
- Ensure proper sick-day management protocols
- Schedule outpatient follow-up within 1-2 weeks 1
Remember that the duration of action differs between IV and subcutaneous insulin, which is why overlap is necessary to prevent recurrence of ketosis 6. The long-acting insulin should be administered 1-2 hours before discontinuing the IV insulin infusion.