What is the diagnosis for diabetic ketoacidosis (DKA) with euglycemia (normal glucose levels)?

From the Guidelines

Diagnosis of Euglycemic Diabetic Ketoacidosis (EDKA) The diagnosis for diabetic ketoacidosis (DKA) with euglycemia (normal glucose levels) is known as euglycemic diabetic ketoacidosis (EDKA) or normoglycemic ketoacidosis, which occurs when the body produces ketones at an alarming rate, despite having normal blood glucose levels, often due to a combination of factors such as insulin deficiency, dehydration, and increased counter-regulatory hormones.

• Key diagnostic criteria for DKA include blood glucose levels, venous pH, bicarbonate levels, and ketonuria or ketonemia, as outlined in the study by 1.
• However, in EDKA, the glucose levels may be normal, and the diagnosis should be based on the presence of ketonuria or ketonemia, metabolic acidosis, and anion gap, as well as clinical symptoms such as nausea, vomiting, and abdominal pain.
• Certain medications like sodium-glucose cotransporter 2 (SGLT2) inhibitors can contribute to the development of EDKA, as noted in the study by 1, which highlights the importance of awareness and counseling patients on potential triggers.
• The study by 1 emphasizes the need for individualized treatment based on careful clinical and laboratory assessment, and the importance of addressing underlying causes of DKA, such as sepsis or myocardial infarction.
• Measurement of beta-hydroxybutyrate (B-OHB) in the blood is the preferred method for monitoring DKA, as it is the strongest and most prevalent acid in DKA, and its levels can be used to assess the severity of the condition and the response to treatment, as discussed in the study by 1.

From the Research

Diagnosis of Diabetic Ketoacidosis (DKA) with Euglycemia

The diagnosis of diabetic ketoacidosis (DKA) with euglycemia, also known as euglycemic diabetic ketoacidosis (EDKA), is a challenging task due to the presence of normal blood glucose levels, which can masquerade the underlying DKA 2, 3, 4, 5, 6.

Key Diagnostic Criteria

The key diagnostic criteria for EDKA include:

• Increased anion gap metabolic acidosis
• Ketonemia or ketonuria
• Normal blood glucose levels, typically less than 200-250 mg/dL 2, 3, 4, 5, 6

Diagnostic Approach

The diagnostic approach for EDKA involves:

• High clinical suspicion, particularly in patients with a history of diabetes mellitus, regardless of blood glucose levels 2, 3, 4, 5, 6
• Laboratory assessment, including:
  • Arterial blood gas for metabolic acidosis
  • Serum ketones
  • Venous blood gas for serum pH, bicarbonate, and ketones 3, 6
• Exclusion of other causes of high anion gap metabolic acidosis 3, 6

Importance of Early Diagnosis

Early diagnosis and treatment of EDKA are crucial to prevent serious adverse outcomes, as the absence of marked hyperglycemia can delay diagnosis and treatment 2, 3, 4, 5, 6.

Common Causes and Associations

EDKA can occur in patients with type 1 or type 2 diabetes mellitus, and is associated with various factors, including:

• Sodium-glucose cotransporter-2 (SGLT2) inhibitors 3, 4, 5, 6
• Pregnancy
• Fasting or starvation
• Bariatric surgery
• Gastroparesis
• Insulin pump failure
• Cocaine intoxication
• Chronic liver disease
• Glycogen storage disease 3, 5, 6