What is the treatment of ketosis?

Treatment of Ketosis

The treatment of ketosis requires insulin therapy to rapidly correct hyperglycemia and metabolic derangement, followed by initiation of metformin once acidosis is resolved. 1

Types of Ketosis and Initial Assessment

• Ketosis can present in different forms, ranging from mild ketosis to diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS) 1
• Initial assessment should include plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, and arterial blood gases 2
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring ketosis, as the nitroprusside method only measures acetoacetic acid and acetone 2

Treatment Algorithm for Ketosis

For Mild Ketosis (Without Acidosis)

• Begin metformin therapy if no acidosis or significant ketosis is present 1
• Monitor blood glucose levels regularly to ensure adequate glycemic control 1

For Ketosis/Ketoacidosis

1. Insulin Therapy

   • Administer subcutaneous or intravenous insulin to rapidly correct hyperglycemia 1
   • For intravenous administration: Give an initial bolus of regular insulin at 0.15 units/kg body weight, followed by continuous infusion at 0.1 unit/kg/hour 1
   • Target glucose decline of 50-75 mg/dl per hour 1
   • If glucose does not fall by 50 mg/dl in the first hour, double the insulin infusion rate 1

2. Fluid Therapy

   • Begin with isotonic saline at 15-20 ml/kg/hour during the first hour to restore circulatory volume 2
   • Continue fluid replacement to correct estimated deficits within 24 hours 2

3. Electrolyte Management

   • Monitor potassium levels closely as total body potassium deficits are common 2
   • Once renal function is assured and serum potassium is known, add 20-40 mEq/L potassium to the infusion when levels fall below 5.5 mEq/L 2
   • Bicarbonate therapy is generally not recommended for patients with pH >7.0 2

4. Transition to Oral Therapy

   • Once ketoacidosis is resolved, initiate metformin while continuing subcutaneous insulin therapy 1
   • For successful transition from intravenous to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent rebound hyperglycemia 2

Special Considerations

For Children and Adolescents

• Initial treatment must address hyperglycemia and associated metabolic derangements regardless of ultimate diabetes type 1
• For youth with ketosis/ketoacidosis, use subcutaneous or intravenous insulin until acidosis resolves 1
• Once acidosis is resolved, metformin should be initiated while subcutaneous insulin therapy is continued 1
• Follow the management algorithm in Figure 14.1 for new-onset diabetes in youth with overweight or obesity 1

For Severe Presentations (HHS)

• In individuals with severe hyperglycemia (≥600 mg/dL), assess for hyperglycemic hyperosmolar nonketotic syndrome 1
• More aggressive fluid resuscitation may be required due to greater dehydration 3
• Monitor for signs of cerebral edema during treatment 3

Identifying and Treating Precipitating Factors

• Common precipitating factors include:
  • Infection (most common) 4
  • Omitting insulin or taking less than prescribed 5
  • Significant dietary changes 5
  • Fever, infection, or other significant stressful situations 5
• Obtain bacterial cultures if infection is suspected and administer appropriate antibiotics 2
• Address any underlying medical conditions that may have triggered the ketosis 4

Monitoring and Resolution Parameters

• Monitor blood glucose every 2-4 hours during treatment 1
• DKA resolution requires: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 2
• Continue monitoring for potential complications such as hypoglycemia, hypokalemia, and cerebral edema 2, 5

Prevention of Recurrence

• Provide education on recognition of early symptoms of ketosis 5
• Ensure proper insulin administration and dosing 5
• Regular blood glucose monitoring, especially during illness 5
• Develop a sick-day management plan 2

Potential Complications to Watch For

• Hypoglycemia from excessive insulin administration 5
• Hypokalemia due to insulin therapy and fluid shifts 2
• Cerebral edema, particularly in pediatric patients 2
• Hyperchloremic metabolic acidosis from excessive saline administration 3

Remember that early recognition and prompt treatment of ketosis are essential to prevent progression to more severe metabolic derangements and to reduce morbidity and mortality associated with these conditions 6.