What is the algorithm for Diabetic Ketoacidosis (DKA) management?

From the Guidelines

The management of diabetic ketoacidosis (DKA) should prioritize a systematic approach focusing on fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying cause, with the most recent guidelines from 2025 1 emphasizing individualization of treatment based on careful clinical and laboratory assessment.

Key Components of DKA Management

• Begin with rapid assessment and stabilization, including securing airway if needed and establishing IV access.
• Start fluid resuscitation with 0.9% normal saline at 15-20 mL/kg/hr (typically 1-1.5 L) in the first hour, then adjust to 250-500 mL/hr based on hemodynamic status and hydration, as recommended by recent standards of care 1.
• After initial fluid bolus, initiate regular insulin as an IV bolus of 0.1 units/kg followed by continuous infusion at 0.1 units/kg/hr, with adjustments based on blood glucose monitoring, aiming for a decrease of 50-75 mg/dL per hour.
• When glucose reaches 200-250 mg/dL, reduce insulin rate to 0.02-0.05 units/kg/hr and add dextrose to IV fluids (D5W or D10W) to prevent hypoglycemia while continuing insulin to clear ketones.
• Replace potassium when levels are below 5.3 mEq/L, typically 20-30 mEq/L of IV fluids if renal function is adequate, and consider other electrolyte imbalances.
• The use of bicarbonate therapy is generally not recommended unless there is severe acidosis (pH < 6.9) or hemodynamic concerns, as supported by recent studies 1.

Transition to Subcutaneous Insulin

• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia, with recent evidence suggesting the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1.
• DKA resolves when glucose is < 200 mg/dL, bicarbonate ≥ 15 mEq/L, pH > 7.3, and anion gap normalizes, at which point transition to subcutaneous insulin can begin, with careful monitoring and adjustment of insulin doses as needed.

Addressing Underlying Causes

• Investigate and treat the precipitating cause of DKA, which may include infection, medication non-adherence, or new-onset diabetes, to prevent recurrence and improve patient outcomes, as emphasized in recent guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

DKA Management Algorithm

The management of Diabetic Ketoacidosis (DKA) involves several key steps, including:

• Diagnosis: A diagnosis of DKA requires a plasma glucose concentration above 250 mg per dL, a pH level less than 7.30, and a bicarbonate level of 18 mEq per L or less 2.
• Fluid replacement: Adequate fluid replacement is essential to treat dehydration and help the body replenish lost fluids 3, 4.
• Insulin therapy: Low-dose insulin therapy is recommended, with careful monitoring of potassium levels 3, 4.
• Electrolyte replacement: Potassium, phosphorous, and magnesium replacement may be necessary, depending on the patient's condition 3, 2, 4.
• Identification and treatment of underlying causes: Infections, new diagnosis of diabetes, and nonadherence to insulin therapy are common precipitating causes of DKA, and should be identified and treated promptly 5, 3, 2.
• Monitoring: Close monitoring of the patient's clinical and laboratory states is crucial to ensure proper management and prevent complications 5, 3, 6.

Treatment Protocol

A concise treatment protocol for DKA includes:

• Administering low-dose insulin therapy at frequent intervals 3, 4.
• Providing adequate potassium replacement from the time of first insulin therapy, with ECG monitoring 3.
• Replacing bicarbonate if the pH is less than 7.1 3.
• Administering broad-spectrum antibiotics if an infection is suspected 3.
• Implementing other supportive measures, such as fluid replacement and electrolyte management, as needed 3, 4, 6.

Prevention of Recurrence

To prevent recurrence of DKA, patient education programs focusing on adherence to insulin and self-care guidelines during illness are essential 5, 6. Additionally, improved access to medical providers and new approaches, such as extended availability of phone services and use of telemedicine, can provide further support for the prevention of DKA 5, 6.