What is the treatment for acidosis with normal glucose levels?

Treatment of Acidosis with Normal Glucose Levels

The treatment of acidosis with normal glucose levels requires immediate identification of the underlying cause, with insulin therapy initiated for euglycemic diabetic ketoacidosis (EuDKA) and supportive care directed at the specific etiology, while avoiding routine sodium bicarbonate administration. 1, 2

Initial Diagnostic Approach

The critical first step is distinguishing between different causes of acidosis with normal glucose:

• Check serum and urine ketones immediately to differentiate ketotic from non-ketotic acidosis 1
• Calculate the anion gap (normal <12 mEq/L) to categorize the acidosis type 1, 3
• Obtain arterial blood gas to assess pH and severity (pH <7.3 indicates severe acidosis requiring urgent intervention) 1
• Review medication history specifically for SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) and metformin, which are common culprits of EuDKA and lactic acidosis 4, 5

High Anion Gap Acidosis with Normal Glucose

Euglycemic Diabetic Ketoacidosis (EuDKA)

If ketones are elevated (serum β-hydroxybutyrate >3 mmol/L or urine ketones ≥80 μmol/L) with normal glucose, treat as EuDKA with insulin plus dextrose: 4, 5

• Initiate intravenous insulin infusion at 0.1 U/kg/hour to suppress ketogenesis 1, 2
• Simultaneously administer dextrose 5% in water (D5W) intravenously to prevent hypoglycemia while continuing insulin 4, 5
• Discontinue SGLT2 inhibitors permanently if they are the precipitant 4, 5
• Provide aggressive fluid resuscitation with isotonic saline at 15-20 mL/kg/hour initially 1
• Monitor potassium closely and replace to maintain levels between 4-5 mEq/L, as insulin drives potassium intracellularly 1

Lactic Acidosis

If lactate is elevated (>4 mmol/L) without significant ketones, focus on improving tissue perfusion rather than administering bicarbonate: 3, 6

• Identify and treat the underlying cause (sepsis, shock, tissue hypoperfusion, metformin accumulation in renal failure) 3, 5
• Discontinue metformin immediately if present, especially with renal dysfunction 5
• Optimize hemodynamics with fluid resuscitation and vasopressors if needed 6
• Consider hemodialysis for refractory acidosis (pH <7.1) unresponsive to supportive measures, particularly when complicated by acute kidney injury 5

Normal Anion Gap (Hyperchloremic) Acidosis

• Assess for gastrointestinal bicarbonate losses (diarrhea, fistulas, ureterosigmoidostomy) 3
• Evaluate for renal tubular acidosis if no obvious GI losses 3
• Treatment is supportive with oral or intravenous bicarbonate replacement only if pH <7.2 and symptomatic 7

Bicarbonate Administration: When and How

Sodium bicarbonate should NOT be routinely administered for organic acidoses (ketoacidosis, lactic acidosis) as it does not improve outcomes and may worsen intracellular acidosis: 1, 3, 6

However, bicarbonate may be considered in specific circumstances:

• Severe acidemia (pH <7.0-7.1) with hemodynamic instability 7
• Hyperchloremic acidosis from bicarbonate losses 3
• Dosing when indicated: 2-5 mEq/kg over 4-8 hours, monitoring arterial pH and avoiding overcorrection (target pH ~7.2, not full normalization) 7

Critical Pitfall

Bicarbonate administration in ketoacidosis or lactic acidosis can paradoxically worsen intracellular acidosis, cause hypocalcemia, and produce hyperosmolality without improving mortality. 6 The only effective treatment for organic acidosis is cessation of acid production through treating the underlying cause. 3, 6

Special Populations

Youth with Type 2 Diabetes

In pediatric patients with ketosis/ketoacidosis and normal or near-normal glucose, initiate subcutaneous or intravenous insulin immediately, then add metformin once acidosis resolves: 1

• Start with insulin therapy regardless of glucose level if ketoacidosis is present 1
• Once pH >7.3 and bicarbonate >15 mEq/L, transition to subcutaneous insulin and initiate metformin 1

Monitoring During Treatment

• Check arterial or venous blood gases every 2-4 hours until pH >7.3 1
• Monitor serum electrolytes (particularly potassium) every 2-4 hours 1
• Track anion gap closure as a marker of acidosis resolution 1
• Measure blood glucose hourly when administering insulin, maintaining target 150-200 mg/dL during acute treatment 2

Transition and Follow-up

• Once acidosis resolves (pH >7.3, bicarbonate >18 mEq/L, anion gap <12), transition from IV to subcutaneous insulin with 2-4 hour overlap 2
• For patients on insulin and metformin meeting glucose targets, taper insulin by 10-30% every few days over 2-6 weeks 1, 2
• Schedule follow-up within 1-2 weeks to reassess glycemic control and adjust therapy 2