What defines resolution of Diabetic Ketoacidosis (DKA) according to 2025 guidelines?

Resolution of Diabetic Ketoacidosis According to 2025 Guidelines

According to the 2025 American Diabetes Association guidelines, DKA is considered resolved when ALL three biochemical criteria are met: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, and venous pH >7.3. 1

Core Resolution Parameters

The 2025 standards require simultaneous achievement of all three criteria 1:

• Glucose <200 mg/dL 1
• Serum bicarbonate ≥18 mEq/L 1
• Venous pH >7.3 1

Additionally, an anion gap ≤12 mEq/L is considered a relevant parameter for confirming resolution 1

Critical Monitoring During Treatment

Blood should be drawn every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH until DKA resolves 1

Venous pH (typically 0.03 units lower than arterial pH) and anion gap can be followed to monitor resolution of acidosis 1

Important Considerations About Ketone Clearance

Ketonemia typically takes longer to clear than hyperglycemia, which is why you must continue insulin therapy even after glucose normalizes 1, 2

Direct measurement of β-hydroxybutyrate (β-OHB) in blood is the preferred method for monitoring DKA 1

Common pitfall to avoid: The nitroprusside method only measures acetoacetic acid and acetone, NOT β-OHB, and should not be used as an indicator of treatment response 1, 2

Post-Resolution Management Algorithm

Once all three resolution criteria are met 1:

1. If patient is NPO: Continue intravenous insulin and fluid replacement, supplement with subcutaneous regular insulin every 4 hours as needed 1

2. When patient can eat: Start a multiple-dose schedule using combination of short/rapid-acting and intermediate/long-acting insulin 1

3. Critical timing: Continue intravenous insulin infusion for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels 1

4. Basal insulin must be administered 2-4 hours BEFORE stopping IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 3

Target Glucose During Treatment

Target glucose between 150-200 mg/dL until DKA resolution parameters are met 1

When serum glucose reaches 250 mg/dL during treatment, add dextrose 5% to IV fluids while continuing insulin therapy 1

Most Common Error Leading to DKA Recurrence

Do not stop IV insulin without prior basal insulin administration—this is the single most common error leading to DKA recurrence 3