What is the treatment for acute Diabetic Ketoacidosis (DKA)?

From the Guidelines

The treatment for acute Diabetic Ketoacidosis (DKA) should prioritize restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis, with individualization of treatment based on a careful clinical and laboratory assessment 1. The management of DKA involves several key components, including:

• Restoration of circulatory volume and tissue perfusion through aggressive fluid management
• Resolution of ketoacidosis through insulin therapy
• Correction of electrolyte imbalance and acidosis
• Treatment of any underlying cause of DKA, such as sepsis, myocardial infarction, or stroke In critically ill and mentally obtunded individuals with DKA, continuous intravenous insulin is the standard of care 1. However, recent studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1. For individuals with uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used in the emergency department or step-down units, provided that adequate fluid replacement, frequent POC blood glucose monitoring, treatment of any concurrent infections, and appropriate follow-up are ensured 1. It is also important to note that the use of bicarbonate in people with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1. Overall, the goal of treatment is to address the underlying pathophysiology of DKA, correcting dehydration, suppressing ketogenesis through insulin administration, and carefully managing electrolyte imbalances that result from osmotic diuresis and acidosis.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.

The treatment for acute Diabetic Ketoacidosis (DKA) is not explicitly stated in the provided drug labels. However, it is mentioned that DKA can result from prolonged hyperglycemia and that medical assistance should be obtained immediately if symptoms occur.

• Key points about DKA include:
  • It is a life-threatening emergency
  • Symptoms include drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath
  • Heavy breathing and rapid pulse are more severe symptoms
  • If uncorrected, DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death
  • Medical assistance should be obtained immediately if symptoms occur 2

From the Research

Treatment for Acute Diabetic Ketoacidosis (DKA)

The treatment for acute DKA involves several key components, including:

• Fluid resuscitation to restore volume status
• Insulin therapy to reduce glucose levels and resolve ketoacidosis
• Electrolyte replacement to manage abnormalities such as hypokalemia, hypophosphatemia, and hypomagnesemia
• Monitoring for complications such as cerebral edema and respiratory failure

Fluid Resuscitation

The choice of fluid for resuscitation is important, with studies suggesting that:

• Balanced crystalloids, such as lactated Ringer's solution or Plasma-Lyte A solution, may be preferred over 0.9% saline due to their ability to resolve DKA faster and reduce the risk of hyperchloremic metabolic acidosis 3, 4, 5
• Isotonic normal saline may still be used, but large volumes should be avoided due to the risk of undesirable outcomes such as hyperchloremic metabolic acidosis 5

Insulin Therapy

Insulin therapy is a critical component of DKA management, with guidelines recommending:

• Continuous intravenous (IV) insulin for DKA management after fluid status has been restored and potassium levels have been achieved 6
• Subcutaneous (SQ) insulin may be started only after the resolution of metabolic acidosis 6
• The use of SQ insulin glargine along with continuous regular IV insulin may result in faster DKA resolution and shorter hospital stays compared to continuous IV insulin alone 6

Electrolyte Replacement and Monitoring

Electrolyte replacement is essential to manage abnormalities such as hypokalemia, hypophosphatemia, and hypomagnesemia, with regular monitoring necessary to guide therapy 6, 7

• The use of sodium bicarbonate may be considered in certain situations, such as severe acidosis or during intubation, but its use is generally discouraged due to the potential for worsening ketosis, hypokalemia, and risk of cerebral edema 6