What is the treatment for Diabetic Ketoacidosis (DKA)?

From the Guidelines

The treatment of diabetic ketoacidosis (DKA) should prioritize fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying cause, with the most recent guidelines from 2025 1 emphasizing the importance of individualized treatment based on careful clinical and laboratory assessment. The management goals include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis.

• Begin with aggressive intravenous fluid replacement using 0.9% normal saline at 15-20 mL/kg/hr for the first hour, then adjust to 250-500 mL/hr based on hydration status.
• Start insulin therapy with an IV insulin infusion at 0.1 units/kg/hr after initial fluid resuscitation, as recommended by recent studies 1.
• Do not give an insulin bolus as it increases hypoglycemia risk.
• Monitor blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour.
• When glucose reaches 200-250 mg/dL, add dextrose to IV fluids (D5 or D10) while continuing insulin to clear ketones.
• Replace potassium when levels are below 5.3 mEq/L and urine output is adequate, typically 20-30 mEq per liter of IV fluid.
• Address phosphate and magnesium deficiencies if severe.
• Monitor electrolytes, glucose, pH, and anion gap every 2-4 hours.
• Treat the precipitating cause, commonly infection, medication non-adherence, or new-onset diabetes.
• Transition to subcutaneous insulin when the patient is stable, has a normal anion gap, and can eat, with administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1. This approach works by correcting dehydration, suppressing ketogenesis through insulin administration, and addressing the metabolic derangements that characterize DKA, with recent studies supporting the use of subcutaneous rapid-acting insulin analogs in the emergency department or step-down units for individuals with uncomplicated DKA 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. Treatment of metabolic acidosis should, if possible, be superimposed on measures designed to control the basic cause of the acidosis - e.g., insulin in uncomplicated diabetes, blood volume restoration in shock. Vigorous bicarbonate therapy is required in any form of metabolic acidosis where a rapid increase in plasma total C02 content is crucial - e. g., cardiac arrest, circulatory insufficiency due to shock or severe dehydration, and in severe primary lactic acidosis or severe diabetic acidosis.

The treatment of Diabetic Ketoacidosis (DKA) involves:

• Insulin therapy to control hyperglycemia 2
• Bicarbonate therapy to treat metabolic acidosis, especially in severe cases 3 Key points to consider:
• Prompt medical attention is crucial in cases of DKA
• Insulin administration should be tailored to the individual's needs
• Bicarbonate therapy should be used judiciously, taking into account the patient's specific condition and the potential risks and benefits 3

From the Research

Treatment of Diabetic Ketoacidosis (DKA)

The treatment of DKA involves several key components, including:

• Fluid and electrolyte replacement: This is crucial to restore optimal volume status and reverse acidosis 4, 5, 6, 7, 8.
• Insulin therapy: Low-dose intravenous infusion is the accepted mode of insulin delivery for patients with DKA 4, 5, 7.
• Potassium replacement: This is almost always necessary due to total body depletion seen with the development of ketoacidosis 4, 5.
• Treatment of precipitating causes: Identifying and treating the underlying cause of DKA is essential for effective management 4, 6, 7, 8.
• Close monitoring: Regular monitoring of the patient's biochemical, physical, and mental parameters is necessary to adjust therapy as needed 4, 5, 6, 7, 8.

Controversies in DKA Treatment

There are some controversies in the treatment of DKA, including:

• The use of bicarbonate: Its administration is controversial and should be reserved for patients with severe metabolic acidosis (pH < 7.0-7.1) 4, 5.
• The use of phosphate: Replacement may be needed if serum levels fall toward the lower limits of normal values, but there is no strong evidence to support its routine use 4, 5.
• The choice of insulin regimen: Fixed weight-based insulin infusions are recommended, but the evidence is weak 5.

Prevention of DKA

Prevention of DKA is crucial, and strategies include:

• Patient education: Educating patients about diabetes, precipitating factors of DKA, and signs and symptoms of early metabolic decompensation 4, 6, 7, 8.
• Identifying diabetes before DKA develops: Early diagnosis and treatment of diabetes can prevent DKA 6, 7, 8.
• Ensuring uninterrupted access to therapies for diabetes: This can help prevent DKA by maintaining good glycemic control 6, 7.