What is the first line treatment for Diabetic Ketoacidosis (DKA)?

From the Guidelines

The first line treatment for diabetic ketoacidosis (DKA) is aggressive fluid resuscitation with intravenous normal saline (0.9% NaCl), typically starting with 15-20 mL/kg or 1-1.5 L in the first hour for adults, followed by continuous infusion, as recommended by the most recent guidelines 1. This approach should be accompanied by intravenous regular insulin, given as an initial bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hour. Key aspects of DKA management include:

• Potassium replacement is essential once levels fall below 5.3 mEq/L, aiming to maintain serum potassium between 4-5 mEq/L 1.
• Blood glucose should be monitored hourly, and when it reaches approximately 200-250 mg/dL, the IV fluids should be changed to dextrose-containing solutions (D5W or D5 1/2NS) while continuing insulin to clear ketones.
• Frequent monitoring of electrolytes, especially potassium, phosphate, and magnesium, is crucial.
• The underlying cause of DKA must be identified and treated simultaneously. This approach addresses the three main pathophysiological issues in DKA: dehydration, insulin deficiency, and electrolyte imbalances, as outlined in recent guidelines 1. Fluid resuscitation improves tissue perfusion and renal function, while insulin stops ketogenesis and promotes glucose utilization. Treatment should continue until ketoacidosis resolves, indicated by normalized anion gap, bicarbonate >18 mEq/L, and pH >7.3, in line with the recommendations from the highest quality and most recent study 1.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.

The first line treatment for Diabetic Ketoacidosis (DKA) is intravenous administration of insulin, as it is a life-threatening emergency that requires immediate medical attention.

• The treatment should be done under medical supervision.
• Intravenous insulin is used to lower blood glucose levels and treat DKA 2.

From the Research

DKA First Line Treatment

• The first line treatment for Diabetic Ketoacidosis (DKA) involves fluid and electrolyte replacement, insulin therapy, and treatment of precipitating causes 3.
• Fluid therapy aims to lower muscle venous Pco2, ensuring effective removal of hydrogen ions by bicarbonate buffer in muscle and diminishing the binding of hydrogen ions to intracellular proteins in vital organs 4.
• Insulin administration should be done cautiously, as it may cause hypokalemia and cardiac arrhythmias in patients with relatively low plasma potassium levels 4.
• Potassium chloride should be administered intravenously to bring the plasma potassium level close to 4mmol/L before insulin administration in such cases 4.
• Sodium bicarbonate administration should be individualized, considered in adult patients with moderately severe acidemia (pH<7.20 and plasma bicarbonate level < 12mmol/L) who are at risk for worsening acidemia, particularly if hemodynamically unstable 4.
• Sodium bicarbonate should not be administered to children with DKA, except if acidemia is very severe and hemodynamic instability is refractory to saline administration 4.

Key Considerations

• The risk for cerebral edema, a common cause of mortality and morbidity, especially in children with DKA, may be minimized by avoiding a bolus of insulin, excessive saline resuscitation, and a decrease in effective plasma osmolality early in treatment 4.
• Treatment protocols for DKA may vary across institutions, highlighting the need for standardized protocols based on current evidence-based best practices 5.
• Patient education programs focusing on adherence to insulin and self-care guidelines during illness, as well as improved access to medical providers, can help reduce future episodes of DKA 6.