What is the treatment approach for Diabetic Ketoacidosis (DKA) in a patient taking Wegovy (semaglutide)?

Treatment of Diabetic Ketoacidosis in Patients Taking Wegovy (Semaglutide)

The treatment of diabetic ketoacidosis (DKA) in patients taking Wegovy (semaglutide) follows standard DKA management protocols, with special attention to glucose monitoring and dextrose administration, as GLP-1 receptor agonists like Wegovy may mask hyperglycemia while ketosis persists. 1, 2

Initial Assessment and Management

• Perform comprehensive laboratory evaluation including plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes, osmolality, arterial blood gases, and complete blood count 3
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA, as the nitroprusside method only measures acetoacetic acid and acetone 1
• Consider the possibility of euglycemic DKA, which can occur in patients on GLP-1 receptor agonists like Wegovy (semaglutide) 2
• Identify and treat any precipitating factors such as infection, which occurs in 30-50% of DKA cases 4

Fluid Resuscitation

• Begin aggressive fluid management using isotonic saline (0.9% NaCl) at a rate of 15-20 mL/kg/hour for the first hour 3
• Continue fluid replacement to correct dehydration, with total fluid replacement approximately 1.5 times the 24-hour maintenance requirements 3
• When serum glucose reaches 250 mg/dL, change fluid to 5% dextrose with 0.45-0.75% NaCl while continuing insulin therapy 1
• For patients on Wegovy who present with euglycemic DKA (glucose <250 mg/dL with ketoacidosis), start D5 alongside 0.9% NaCl at the beginning of insulin treatment 1, 5

Insulin Therapy

• Administer continuous intravenous regular insulin infusion, starting with an IV bolus of regular insulin at 0.1 units/kg followed by continuous infusion at 0.1 units/kg/hour 3
• Continue insulin therapy until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L), even if glucose levels normalize quickly 1, 6
• Do not interrupt or discontinue intravenous insulin therapy when glucose levels fall, as this is a common cause of persistent or worsening ketoacidosis 1
• Target glucose between 150-200 mg/dL until DKA resolution parameters are met 1

Electrolyte Management

• Include 20-30 mEq/L potassium in the infusion once renal function is assured 3
• Monitor serum potassium closely as insulin therapy lowers serum potassium levels 3
• Ensure adequate potassium replacement to maintain serum K+ between 4-5 mmol/L 1

Monitoring During Treatment

• Check blood glucose every 2-4 hours 3
• Measure serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH every 2-4 hours until stable 1, 3
• Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis 1

Special Considerations for Patients on Wegovy (Semaglutide)

• Be aware that patients on GLP-1 receptor agonists like Wegovy may present with euglycemic DKA (glucose <250 mg/dL) 5, 2
• Ketonemia may persist longer in patients on medications that affect glucose metabolism like Wegovy, similar to what has been observed with SGLT-2 inhibitors 7, 2
• Consider more aggressive dextrose administration while maintaining insulin infusion to resolve ketosis in patients on Wegovy 1, 2

Resolution Parameters and Transition to Subcutaneous Insulin

• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1
• When DKA resolves and the patient can eat, start a multiple-dose insulin schedule using a combination of short/rapid-acting and intermediate/long-acting insulin 1, 3
• Administer basal insulin 2-4 hours before stopping the IV insulin infusion to prevent recurrence of ketoacidosis 3
• Continue intravenous insulin infusion for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels 1

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 6
• Interruption of insulin infusion when glucose levels fall is a common cause of persistent or worsening ketoacidosis 1, 6
• Failure to add dextrose when glucose falls below 250 mg/dL while continuing insulin therapy 1
• Inadequate monitoring of electrolytes, particularly potassium, during treatment 1, 6