What is the treatment for diabetic ketoacidosis?

Treatment of Diabetic Ketoacidosis

For critically ill patients with DKA, initiate continuous intravenous regular insulin at 0.1 units/kg/hour combined with aggressive isotonic saline resuscitation at 15-20 mL/kg/hour, while carefully monitoring and replacing potassium to maintain levels between 4-5 mEq/L. 1, 2

Initial Assessment and Diagnosis

Confirm DKA with the following diagnostic criteria: 2

• Blood glucose >250 mg/dL
• Arterial pH <7.3
• Serum bicarbonate <15 mEq/L
• Presence of ketonemia or ketonuria

Obtain immediate laboratory evaluation including: 2

• Plasma glucose, BUN/creatinine, serum ketones
• Electrolytes with calculated anion gap and osmolality
• Arterial blood gases, complete blood count
• Urinalysis, urine ketones, ECG
• Bacterial cultures (blood, urine, throat) if infection suspected

Direct measurement of β-hydroxybutyrate in blood is the preferred monitoring method, as nitroprusside only detects acetoacetic acid and acetone. 2, 3

Fluid Resuscitation

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L) during the first hour. 2, 4 This aggressive initial fluid replacement is critical for restoring tissue perfusion and improving insulin sensitivity. 2

Subsequent fluid choice depends on: 2

• Hydration status
• Serum electrolyte levels
• Urine output

When serum glucose reaches 250 mg/dL, switch to 5% dextrose with 0.45-0.75% NaCl to prevent hypoglycemia while continuing insulin therapy. 2 This is a critical step—failure to add dextrose when glucose falls is a common cause of persistent or worsening ketoacidosis. 2

Insulin Therapy

For Moderate to Severe DKA (Critically Ill Patients)

Start continuous IV regular insulin infusion at 0.1 units/kg/hour. 2, 4 This is the standard of care for critically ill and mentally obtunded patients. 1, 2

If plasma glucose does not fall by 50 mg/dL in the first hour: 2

• Check hydration status
• If acceptable, double the insulin infusion rate hourly until achieving steady glucose decline of 50-75 mg/h

Continue insulin infusion until complete resolution of ketoacidosis (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L) regardless of glucose levels. 2 Premature termination of insulin therapy before complete resolution of ketosis is a common pitfall that leads to DKA recurrence. 2, 5

For Mild to Moderate Uncomplicated DKA

Subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are equally effective, safer, and more cost-effective than IV insulin in stable patients with mild-to-moderate DKA. 1, 2, 3 This approach requires: 1

• Adequate fluid replacement
• Frequent point-of-care glucose monitoring
• Treatment of concurrent infections
• Appropriate follow-up

Electrolyte Management

Potassium Replacement (Critical)

Despite often presenting with normal or elevated potassium, total body potassium depletion is universal in DKA, and insulin therapy will further lower serum levels. 2

Management algorithm: 2

• If K+ <3.3 mEq/L: Delay insulin therapy and aggressively replace potassium until ≥3.3 mEq/L to prevent life-threatening arrhythmias and respiratory muscle weakness
• If K+ 3.3-5.5 mEq/L: Add 20-30 mEq potassium per liter of IV fluid (use 2/3 KCl and 1/3 KPO₄) once adequate urine output confirmed
• If K+ >5.5 mEq/L: Withhold potassium initially but monitor closely, as levels will drop rapidly with insulin

Target serum potassium of 4-5 mEq/L throughout treatment. 2, 3

Bicarbonate (Generally NOT Recommended)

Bicarbonate administration is NOT recommended for DKA patients with pH >6.9-7.0. 1, 2 Studies show no difference in resolution of acidosis or time to discharge with bicarbonate use, and it may worsen ketosis, cause hypokalemia, and increase cerebral edema risk. 2

Monitoring During Treatment

Draw blood every 2-4 hours to measure: 2, 3

• Serum electrolytes, glucose, BUN, creatinine
• Osmolality and venous pH
• Anion gap

Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor acidosis resolution. 2, 3

Resolution Criteria

DKA is resolved when ALL of the following are met: 2, 3

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

Target glucose between 150-200 mg/dL until these resolution parameters are achieved. 2

Transition to Subcutaneous Insulin

Administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia. 1, 2, 3 This overlap period is essential—interruption of insulin infusion without adequate subcutaneous coverage is a common cause of treatment failure. 2, 5

When the patient can eat, start a multiple-dose schedule using combination of short/rapid-acting and intermediate/long-acting insulin. 2, 3

Treatment of Precipitating Causes

Identify and treat underlying causes: 2, 4

• Infection (most common)
• Myocardial infarction or stroke
• Insulin omission or inadequacy
• Pancreatitis, trauma
• Medications (especially SGLT2 inhibitors—must be discontinued 3-4 days before any planned surgery) 2

Administer appropriate antibiotics if infection suspected. 1

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete ketosis resolution leads to DKA recurrence 2, 3, 5
• Interrupting insulin infusion when glucose falls without adding dextrose causes persistent ketoacidosis 2
• Inadequate potassium monitoring and replacement can lead to life-threatening hypokalemia 2
• Stopping IV insulin without 2-4 hour overlap with subcutaneous basal insulin causes rebound hyperglycemia 1, 2
• Overly rapid correction of osmolality increases cerebral edema risk, particularly in children 2