Comparison of 2025 DKA Guidelines to Previous Guidelines
I cannot provide a comparison between 2025 and previous DKA guidelines because no 2025-specific DKA management guideline exists in the provided evidence. The evidence contains guidelines from other clinical areas (CKD, hypertension, ACS, ADPKD, diabetes in pregnancy) but not a dedicated 2025 DKA guideline update.
What the Evidence Shows
Current DKA Management Standards (Based on Available Guidelines)
The most recent DKA-specific guidance comes from the American Diabetes Association and American College of Physicians, as summarized in the Praxis Medical Insights documents 1, 2, 3:
Fluid Resuscitation - Key Change:
- Balanced electrolyte solutions (Ringer's lactate or Plasma-Lyte) are now recommended as first-line therapy over 0.9% saline at 15-20 mL/kg/hour initially 3
- This represents a fundamental shift from traditional normal saline protocols 3
- Switch to 5% dextrose with 0.45-0.75% saline when glucose reaches 250 mg/dL 3
- Avoid osmolality changes exceeding 3 mOsm/kg/hour to prevent cerebral edema 3
Insulin Administration - Expanded Options:
- Subcutaneous rapid-acting insulin analogs are now considered equally effective and safer than IV insulin for uncomplicated mild-to-moderate DKA when combined with aggressive fluid management 3
- For severe/complicated DKA: IV bolus 0.1-0.15 units/kg, then continuous infusion at 0.1 units/kg/hour 3
- Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound 2, 3
Monitoring - Improved Accuracy:
- Direct blood β-hydroxybutyrate measurement is now the standard for monitoring DKA resolution, replacing nitroprusside methods 3
- Blood ketone monitoring provides more accurate assessment than urine ketones 3
Bicarbonate Therapy - More Conservative:
- Bicarbonate is recommended against for pH >6.9-7.0 3
- Consider only if pH <6.9: give 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h 3
SGLT2 Inhibitor Awareness - New Consideration:
- Discontinue SGLT2 inhibitors immediately if patient was on them 2
- Hold SGLT2 inhibitors 3-4 days before any planned procedure 2, 3
- This reflects recognition of SGLT2 inhibitor-associated euglycemic DKA 4, 5
Resolution Criteria (Unchanged)
All four criteria must be met 1, 2, 3:
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
- Anion gap ≤12 mEq/L
Critical Pitfalls to Avoid
- Never stop insulin when glucose normalizes if ketoacidosis persists 3
- Continue insulin infusion until all metabolic parameters resolve, adding dextrose to prevent hypoglycemia 3
- Delay insulin if initial potassium <3.3 mEq/L to avoid arrhythmias and cardiac arrest 3
Evidence Gaps Identified
Recent research highlights substantial gaps in DKA management evidence 6:
- Scant evidence for prophylactic electrolyte administration
- Limited data on enteral intake timing
- Insufficient evidence for adjunctive therapies (thiamine, bicarbonate)
- Gaps in patient-centered and healthcare service outcomes even for well-studied interventions
To answer your specific question about 2025 guideline changes, you would need access to an actual 2025 DKA-specific guideline document, which is not present in the provided evidence.