How can diabetic ketoacidosis (DKA) be prevented?

How to Prevent Diabetic Ketoacidosis (DKA)

The most critical prevention strategy is ensuring patients with type 1 diabetes never omit insulin, even during acute illness, and maintain continuous access to medical advice through 24-hour telephone availability or telemedicine services. 1, 2

Core Prevention Strategies During Acute Illness

Insulin Management

• Continue insulin therapy during all acute illnesses - this is the single most important intervention, as insulin omission is the most common preventable cause of DKA in established diabetes 1
• Supplemental insulin is often required during illness due to increased counter-regulatory hormones 1
• Never stop basal insulin, even if unable to eat 1

Monitoring Requirements

• Test blood glucose and ketones (blood or urine) frequently during any illness - this allows early detection before full DKA develops 1
• Direct measurement of β-hydroxybutyrate in blood is the preferred monitoring method 3
• Check for ketonuria or ketonemia whenever blood glucose exceeds 250 mg/dL 1

Fluid and Nutrition Management

• Increase fluid intake significantly to prevent dehydration - aim for sodium-containing fluids like broth, tomato juice, or sports drinks to maintain intravascular volume 1
• Consume 150-200 g of carbohydrate daily (45-50 g every 3-4 hours) to prevent starvation ketosis, even during illness 1
• If regular food is not tolerated, use liquid carbohydrates: sugar-sweetened soft drinks, juices, soups, or ice cream 1
• This carbohydrate intake is especially critical when blood glucose is <100 mg/dL during illness 1

High-Risk Populations Requiring Intensive Prevention

Recurrent DKA Patients

• Psychiatric evaluation and counseling is mandatory for all patients with recurrent DKA episodes, as these patients have higher rates of depression and intentional insulin omission 1
• Screen for eating disorders, particularly in adolescents with recurrent episodes 1
• Identify single-parent homes and underinsured patients who are at significantly higher risk 1
• Address financial barriers to insulin access immediately, as lack of resources is a leading cause of insulin omission 1, 2

Special Medication Considerations

• Discontinue SGLT2 inhibitors 3-4 days before any planned surgery to prevent euglycemic DKA 4
• Clinicians must maintain awareness that SGLT2 inhibitors can precipitate DKA even with normal glucose levels 2

Public Health and Education Interventions

Patient Education Programs

• Educate patients, family members, roommates, and caregivers about early signs and symptoms of DKA 1, 2
• Provide written sick-day management guidelines that specifically address insulin adjustment, fluid intake, and when to seek help 2, 5
• Focus education on adherence to insulin therapy and self-care during illness 2, 5

Healthcare System Interventions

• Establish 24-hour telephone availability and actively encourage patients to contact the healthcare team when blood glucose is high or ketones are present 1, 2
• Implement telemedicine services for remote monitoring and guidance 2
• Use public awareness campaigns to educate about signs and symptoms of untreated diabetes 1
• Ensure improved access to medical providers and follow-up care 2, 5

Critical Warning Signs Requiring Immediate Medical Contact

Patients should contact their healthcare provider immediately when experiencing:

• Persistent hyperglycemia (blood glucose >250 mg/dL) despite insulin 1
• Presence of ketones in blood or urine 1
• Nausea, vomiting, or inability to keep fluids down 1
• Any signs of infection (fever, dysuria, cough) 1, 2

Common Pitfalls to Avoid

• Never advise patients to reduce or stop insulin during illness - this is the most dangerous misconception and directly leads to DKA 1
• Do not wait for severe symptoms before seeking medical attention - early intervention prevents progression 1, 2
• Avoid inadequate fluid replacement during illness, as dehydration accelerates DKA development 1
• Do not ignore financial or psychological barriers to insulin adherence - these require active intervention 1, 2

The evidence consistently demonstrates that DKA is largely preventable through patient education, improved access to care, and systematic sick-day management protocols 2, 5, 6. Studies show that diabetes education programs and improved follow-up care significantly reduce DKA hospitalization rates 5.