How to manage non-hyperglycemic diabetic ketoacidosis (DKA) in type 1 diabetes?

Management of Non-Hyperglycemic DKA in Type 1 Diabetes

Non-hyperglycemic DKA (euglycemic DKA) in type 1 diabetes requires immediate insulin therapy with concurrent dextrose administration from the outset, aggressive fluid resuscitation, and careful electrolyte monitoring—never withhold insulin even when glucose is <200 mg/dL, as ketone clearance depends on insulin regardless of glucose levels. 1

Recognition and Initial Assessment

Euglycemic DKA presents with glucose <200 mg/dL (11.1 mmol/L) but maintains the metabolic acidosis and ketosis characteristic of DKA. 1 This occurs most commonly in:

• Pregnant individuals with type 1 diabetes (up to 2% of pregnancies) 1
• Patients on SGLT2 inhibitors 1
• Individuals who have maintained some carbohydrate intake during illness 1
• Those with prolonged fasting or very-low-carbohydrate diets 1

Obtain comprehensive laboratory evaluation including plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, and arterial blood gases. 2, 3

Fluid Resuscitation

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (1-1.5 liters in average adult) during the first hour to restore circulatory volume and tissue perfusion. 2, 3 Continue fluid replacement at 4-14 mL/kg/hour based on hemodynamic status and corrected serum sodium. 3

Monitor fluid input/output and hemodynamic parameters closely to assess progress. 2

Critical Insulin and Dextrose Management

This is where euglycemic DKA management differs fundamentally from typical DKA:

• Start continuous intravenous regular insulin at 0.1 U/kg/hour immediately after confirming potassium >3.3 mEq/L 2, 4
• Simultaneously add dextrose (D5W or D10W) to IV fluids from the beginning of insulin therapy 2, 3
• Target blood glucose of 100-180 mg/dL during treatment 5
• Continue insulin infusion until ketones clear completely, even if glucose remains in normal range 2, 3

The key principle: ketone clearance requires insulin, but hypoglycemia must be prevented by providing glucose. 1, 4 Never discontinue insulin prematurely, as ketosis may persist even after glucose normalization. 3

Electrolyte Management

Potassium replacement is critical despite potentially normal initial levels:

• Total body potassium is depleted in DKA despite acidosis-induced elevation of serum levels 2, 5, 3
• Once renal function is confirmed and potassium <5.5 mEq/L, add 20-40 mEq/L potassium to infusion 2, 3
• Use combination of 2/3 KCl and 1/3 KPO₄ 3
• Monitor potassium every 2-4 hours as levels will drop with insulin therapy and acidosis correction 2, 3

Bicarbonate therapy is not recommended as it does not improve outcomes in DKA management. 5, 3

Monitoring Protocol

• Check blood glucose every 1-2 hours until stable 2, 3
• Draw blood every 2-4 hours for serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 2, 3
• Monitor for signs of cerebral edema (rare but serious complication) 2
• Avoid rapid correction of osmolality (not exceeding 3 mOsm/kg/h) 2

Resolution Criteria and Transition

DKA is resolved when ALL of the following are met:

• Glucose <200 mg/dL 2, 3
• Serum bicarbonate ≥18 mEq/L 3
• Venous pH >7.3 3
• Anion gap ≤12 mEq/L 3

Transition to subcutaneous insulin:

• Administer basal insulin 2-4 hours before stopping IV insulin to prevent recurrence 2, 3
• Never stop IV insulin abruptly 3

Prevention of Recurrence

Individuals with type 1 diabetes must never stop basal insulin, even when not eating or during illness. 1 During acute illness:

• Continue insulin therapy (may require supplemental doses) 1
• Ingest 150-200 g carbohydrate daily (45-50 g every 3-4 hours) to prevent starvation ketosis 1
• Test blood glucose and urine/blood ketones frequently 1
• Maintain adequate fluid intake with sodium-containing fluids 1

Common Pitfalls to Avoid

• Never withhold insulin in euglycemic DKA—ketone clearance requires insulin regardless of glucose level 2, 3
• Never delay dextrose administration—start simultaneously with insulin in euglycemic presentations 2, 3
• Do not stop IV insulin before administering subcutaneous basal insulin 2, 3
• Avoid excessive fluid administration in patients with cardiac compromise or pleural effusions 2
• Do not assume DKA is resolved based on glucose normalization alone—check all resolution criteria 3