What to give to a diabetic patient with a history of Diabetic Ketoacidosis (DKA) / Hyperosmolar Hyperglycemic State (HHS) who is still experiencing nausea and vomiting?

Management of Persistent Nausea and Vomiting in Diabetic Patients with DKA/HHS History

In a diabetic patient with prior DKA/HHS who presents with persistent nausea and vomiting, you must immediately seek medical attention and evaluate for recurrent hyperglycemic crisis rather than simply treating the symptoms, as nausea and vomiting are cardinal features of both DKA and HHS and signal potential metabolic decompensation. 1

Immediate Assessment Required

Do not give antiemetics without first ruling out active DKA/HHS. The presence of nausea and vomiting in this population mandates urgent evaluation:

• Check blood glucose immediately - if >200 mg/dL (11.1 mmol/L), measure urine or blood ketones 1
• Assess ability to tolerate oral hydration - inability to keep fluids down is an absolute indication for emergency department evaluation 1
• Monitor mental status - any alteration requires immediate hospitalization 1
• Verify insulin administration - missed doses are a common precipitant 1

Clinical Decision Algorithm

If Patient CANNOT Tolerate Oral Hydration:

Immediate emergency department transfer is mandatory. 1 This patient requires:

• Intravenous fluid resuscitation 2
• Laboratory evaluation including glucose, electrolytes, anion gap, serum osmolality, ketones, and arterial blood gases 2
• Intensive care unit admission if HHS is suspected (develops over days with severe volume depletion) 1, 2

If Patient CAN Tolerate Oral Hydration AND Glucose <200 mg/dL:

Only in this scenario can symptomatic treatment be considered:

Metoclopramide is FDA-approved for diabetic gastroparesis and can relieve nausea/vomiting in diabetic patients. 3 However, critical caveats apply:

• Maximum duration: 12 weeks only - prolonged use causes irreversible tardive dyskinesia 3
• Higher risk in diabetic patients - diabetes itself increases tardive dyskinesia risk 3
• Contraindicated if gastroparesis suspected - per ACC guidelines, GLP-1 agonists should be avoided in gastroparesis history, and metoclopramide use requires careful consideration 1
• Insulin doses may need adjustment - metoclopramide affects gastric emptying 3

Critical Pitfalls to Avoid

Never assume "just nausea" in a diabetic with DKA/HHS history. Nausea and vomiting are presenting symptoms in both conditions:

• DKA presents with nausea, vomiting, and abdominal pain developing over hours to days 1
• HHS can present with nausea/vomiting in up to 25% of cases despite developing over days to weeks 2
• One-third of hyperglycemic emergencies have mixed DKA-HHS features 1

SGLT2 inhibitors are a specific concern. If the patient is on canagliflozin, empagliflozin, or dapagliflozin:

• These medications can precipitate DKA even with normal glucose levels (euglycemic DKA) 1, 4
• Patients should be educated that DKA symptoms (nausea, vomiting, weakness) can occur with glucose readings of 150-250 mg/dL 1
• History of DKA is a relative contraindication to SGLT2 inhibitor use 1

When Symptomatic Treatment Is Appropriate

Only after excluding active hyperglycemic crisis:

Metoclopramide 10 mg IV/IM can be given for acute symptom relief in diabetic gastroparesis 3, but:

• Ensure renal function is adequate (dose adjustment needed in kidney disease) 3
• Avoid if patient has depression history (can cause suicidal ideation) 3
• Monitor for dystonic reactions (occur within first 2 days, more common in patients <30 years) 3
• Do not use if patient takes MAOIs or other dopamine antagonists 3

Alternative approach: If nausea/vomiting is from a clear non-metabolic cause (e.g., viral gastroenteritis) and glucose/ketones are normal, standard antiemetics may be used, but maintain high suspicion and frequent glucose monitoring.

Monitoring During Illness

All diabetic patients with nausea/vomiting require:

• Blood glucose checks every 2-4 hours 2
• Ketone monitoring if glucose >200 mg/dL 1
• Continued insulin administration even if not eating 1
• Contact with diabetes care team for insulin dose adjustments 1
• Aggressive oral hydration with noncaloric fluids if tolerated 1

Red flags requiring immediate emergency evaluation:

• Inability to keep down fluids 1
• Glucose not improving with insulin 1
• Any mental status changes 1
• Kussmaul respirations (deep, rapid breathing) 1
• Persistent vomiting despite treatment 2