What are the primary recommendations for managing Diabetic Ketoacidosis (DKA) based on the SCOPE DKA trial results?

Management of Diabetic Ketoacidosis Based on SCOPE DKA Trial Results

For mild to moderate diabetic ketoacidosis (DKA), subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are as effective as intravenous insulin, offering a potentially safer alternative with fewer hypoglycemic events. 1, 2, 3

Diagnosis and Initial Assessment

• Confirm DKA diagnosis with laboratory evaluation including plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, and complete blood count 4
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA, as it provides more accurate assessment of ketosis than urine ketone testing 1, 4
• Identify and treat any precipitating factors such as infection, myocardial infarction, stroke, or medication non-compliance 1

Fluid Therapy

• Begin aggressive fluid management with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion 1, 4
• For mild DKA, use 1.5 times the 24-hour maintenance requirements (approximately 5 mL/kg/hour) to accomplish smooth rehydration; do not exceed twice the maintenance requirement 5, 4
• Continue fluid replacement to correct estimated deficits within the first 24 hours 4

Insulin Therapy

• For mild to moderate DKA in stable patients, subcutaneous rapid-acting insulin analogs can be used instead of IV insulin 1, 2, 3
• If using IV insulin, administer an intravenous bolus of regular insulin at 0.1-0.15 U/kg body weight, followed by a continuous infusion at 0.1 U/kg/hour 4, 6
• If plasma glucose does not fall by 50 mg/dL from the initial value in the first hour, double the insulin infusion rate until a steady glucose decline between 50-75 mg/hour is achieved 4
• Do not discontinue insulin therapy prematurely when glucose levels fall below 200-250 mg/dL; instead, add dextrose to the hydrating solution while continuing insulin infusion to clear ketosis 1, 4

Electrolyte Management

• Begin potassium replacement after serum levels fall below 5.5 mEq/L, assuming adequate urine output 5, 4
• Add 20-30 mEq potassium (2/3 KCl and 1/3 KPO4) in each liter of infusion fluid to maintain serum potassium concentration within 4-5 mEq/L 5, 4
• If significant hypokalemia is present initially, delay insulin treatment until potassium concentration is restored to >3.3 mEq/L to avoid arrhythmias, cardiac arrest, and respiratory muscle weakness 5, 4
• Bicarbonate therapy is generally not recommended for DKA patients with pH >7.0 5, 1, 4
• For adult patients with pH <6.9, administer 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/hour 5, 4
• For patients with pH 6.9-7.0, administer 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/hour 5, 4
• Phosphate replacement is not routinely recommended but may be considered in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 5, 4

Monitoring During Treatment

• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 4
• Monitor fluid input/output, vital signs, and mental status regularly 4
• Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis 1, 4

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, 4
• When DKA is resolved and the patient can eat, transition to a multiple-dose regimen using a combination of short/rapid-acting and intermediate/long-acting insulin 4
• Administer basal insulin 2-4 hours before stopping the IV insulin infusion to prevent recurrence of ketoacidosis 1, 4
• For newly diagnosed patients, initiate a multidose regimen of short- and intermediate/long-acting insulin at approximately 0.5-1.0 units/kg/day 4

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 1
• Inadequate fluid resuscitation can worsen DKA 1
• Interruption of insulin infusion when glucose levels fall is a common cause of persistent or worsening ketoacidosis 1
• Failure to monitor and replace electrolytes, particularly potassium, can lead to serious complications 1, 4
• Overaggressive correction of glucose and osmolality may increase the risk of cerebral edema, particularly in pediatric patients 5, 4