Does hyperglycemia with ketonuria but no diabetic ketoacidosis (DKA) warrant intravenous (IV) insulin infusion or is intermittent subcutaneous insulin adequate?

Management of Hyperglycemia with Ketonuria without Acidosis

Intermittent subcutaneous insulin is adequate for hyperglycemia with ketonuria but no acidosis, as intravenous insulin infusion should be reserved for patients with diabetic ketoacidosis (DKA) characterized by acidosis (pH <7.3, bicarbonate <15 mEq/L). 1

Diagnostic Considerations

• Hyperglycemia with ketonuria without acidosis does not meet the full diagnostic criteria for DKA, which requires blood glucose >250 mg/dL, venous pH <7.3, serum bicarbonate <15 mEq/L, and moderate ketonuria or ketonemia 1
• The absence of acidosis indicates a milder metabolic derangement that can be managed with less intensive insulin therapy 2
• Laboratory assessment should include venous blood gases, electrolytes, blood urea nitrogen, creatinine, and urine analysis to confirm the absence of acidosis 2

Treatment Approach

Insulin Therapy

• For patients with hyperglycemia and ketonuria without acidosis, subcutaneous insulin is the appropriate treatment modality 2
• Subcutaneous regular insulin can be administered every 4 hours in adult patients, using 5-unit increments for every 50 mg/dL increase in blood glucose above 150 mg/dL, up to 20 units for blood glucose of 300 mg/dL 2
• A multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin should be initiated once the patient is able to eat 2

Fluid Management

• Less aggressive fluid replacement is needed compared to DKA management, but adequate hydration should be maintained 2
• Oral rehydration is often sufficient if the patient can tolerate it; otherwise, intravenous fluids may be administered 2

Monitoring

• Blood glucose should be monitored every 2-4 hours until stable 3
• Electrolytes, particularly potassium, should be monitored and replaced as needed 2
• Urine ketones should be monitored, but be aware that the nitroprusside method does not measure β-hydroxybutyrate, the predominant ketone body in DKA 2, 1

When to Consider IV Insulin Infusion

Intravenous insulin infusion should be considered only if:

• The patient develops acidosis (pH <7.3, bicarbonate <15 mEq/L) 1
• There is progression to moderate-to-severe DKA 2
• The patient has severe hyperglycemia (blood glucose ≥600 mg/dL) with risk of hyperosmolar hyperglycemic state 2
• The patient is critically ill or has hemodynamic instability 2

Transitioning to Maintenance Therapy

• Once ketonuria resolves and blood glucose is controlled, transition to a maintenance insulin regimen with basal-bolus therapy 2, 3
• For patients with known diabetes, resume their previous regimen with adjustments as needed 2
• For newly diagnosed diabetes, initiate appropriate long-term management based on diabetes type 2

Common Pitfalls to Avoid

• Overtreatment with insulin leading to hypoglycemia 2
• Inadequate monitoring of electrolytes, particularly potassium 2
• Premature discontinuation of insulin therapy before resolution of ketonuria 4
• Relying solely on urine ketones for monitoring response to treatment (the nitroprusside method does not measure β-hydroxybutyrate) 1
• Failing to identify and treat the underlying precipitating cause of hyperglycemia and ketonuria 1

Special Considerations

• In pediatric patients with hyperglycemia and ketonuria, similar principles apply, but dosing should be adjusted based on weight 2
• In patients with type 2 diabetes, consider adding or resuming oral antidiabetic medications once the acute episode resolves 2
• For patients with recurrent episodes, education on sick-day management is essential 3