Can a patient with diabetic ketoacidosis (DKA) take their home antihypertensive medications, such as angiotensin-converting enzyme (ACE) inhibitors or beta-blockers?

Management of Home Antihypertensive Medications in DKA

Patients in DKA should generally hold their home blood pressure medications, particularly ACE inhibitors, ARBs, and diuretics, until they are hemodynamically stable, adequately rehydrated, and have resolving metabolic acidosis.

Rationale for Holding Antihypertensive Medications

DKA causes severe volume depletion, electrolyte disturbances, and metabolic acidosis that fundamentally alter the risk-benefit profile of blood pressure medications 1, 2, 3:

• Volume depletion is universal in DKA, with patients typically experiencing 5-10% total body water loss from osmotic diuresis, requiring aggressive fluid resuscitation as the cornerstone of initial management 1, 2
• ACE inhibitors and ARBs increase risk of acute kidney injury and hyperkalemia in the setting of volume depletion and renal hypoperfusion, which are defining features of DKA 4
• Diuretics worsen dehydration and can precipitate further electrolyte abnormalities (hypokalemia or hyperkalemia) in patients who already have significant potassium shifts from insulin deficiency and acidosis 4, 1

Specific Medication Classes

ACE Inhibitors and ARBs

• Hold during acute DKA due to risk of acute kidney injury in volume-depleted states 4, 5
• The KDIGO guidelines specifically recommend avoiding nephrotoxic agents when acute renal failure risk is elevated, and DKA represents exactly this scenario 5
• Monitor serum creatinine and potassium closely, as these agents can cause dangerous hyperkalemia when combined with the potassium shifts inherent to DKA 4

Beta-Blockers

• Generally hold during acute DKA, though the evidence is less definitive than for RAAS blockers 4, 6
• Beta-blockers can mask hypoglycemic symptoms during insulin therapy and may impair the counter-regulatory response to hypoglycemia 6
• In post-MI patients where beta-blockers provide mortality benefit, the decision requires careful individualization once the patient is stabilized 4, 6

Diuretics

• Absolutely hold during acute DKA as they exacerbate volume depletion and electrolyte disturbances 1, 2
• Thiazide and loop diuretics can worsen hypokalemia or cause dangerous hyperkalemia depending on the type, compounding the already complex potassium management in DKA 4

When to Resume Antihypertensive Medications

Restart home blood pressure medications only after:

• Metabolic acidosis is resolving (pH >7.3, bicarbonate >15 mEq/L) and the patient is transitioning from IV to subcutaneous insulin 1, 2
• Volume status is restored and the patient is tolerating oral intake without ongoing losses 1
• Renal function is stable or improving, with monitoring of creatinine and eGFR before restarting ACE inhibitors or ARBs 5, 7
• Electrolytes are normalized, particularly potassium levels are in safe range (typically 3.5-5.5 mEq/L) before restarting RAAS blockers 4

Monitoring After Restart

• Recheck renal function within 2-4 weeks after restarting ACE inhibitors or ARBs to ensure eGFR remains stable 5, 7
• Monitor potassium levels closely within the first week of restarting RAAS blockers, as the combination of recovering renal function and these medications can cause delayed hyperkalemia 4

Common Pitfalls to Avoid

• Do not continue home antihypertensives reflexively during DKA admission—the acute metabolic derangement changes the risk profile entirely 1, 2
• Do not restart medications before adequate rehydration—volume status must be restored first to prevent acute kidney injury 5, 7
• Do not assume blood pressure medications are needed acutely—many patients will have normal or even elevated blood pressure once volume resuscitated, and chronic hypertension management can wait until metabolic stability is achieved 4