From the Guidelines
The management of diabetic ketoacidosis (DKA) has evolved to prioritize individualized treatment, with a focus on restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalances, as outlined in the 2024 standards of care in diabetes 1. The goals of DKA management include:
- Restoration of circulatory volume and tissue perfusion
- Resolution of ketoacidosis
- Correction of electrolyte imbalance and acidosis
- Treatment of any underlying cause of DKA, such as sepsis, myocardial infarction, or stroke Recent studies have shown that 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. In critically ill and mentally obtunded individuals with DKA, continuous intravenous insulin is the standard of care, while individuals with uncomplicated DKA may be treated with subcutaneous rapid-acting insulin analogs in the emergency department or step-down units 1. The use of bicarbonate in people with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1. Key considerations in DKA management include:
- Individualization of treatment based on careful clinical and laboratory assessment
- Aggressive fluid management
- Frequent point-of-care blood glucose monitoring
- Treatment of any concurrent infections
- Appropriate follow-up to avoid recurrent DKA Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2-4 hours before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
From the Research
New Developments in DKA Management
- The management of diabetic ketoacidosis (DKA) has evolved to include more tailored approaches, considering special patient factors and comorbidities such as pregnancy, renal disease, and congestive heart failure 2.
- Recent studies emphasize the importance of addressing unique circumstances and providing an approach to managing complex patients with specific conditions and co-morbidities 2.
- The use of sodium-glucose cotransporter-2 (SGLT2) inhibitors has been identified as a potential precipitating cause for DKA, and clinicians should be aware of this when managing patients with diabetes 3.
Updates in Treatment Approaches
- The mainstays of DKA treatment remain fluid repletion and insulin administration, with careful monitoring of glucose concentrations, vital signs, and electrolytes 4, 5.
- Restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event are crucial for optimal management 5, 3.
- Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA, as well as patient education programs focusing on adherence to insulin and self-care guidelines during illness 3.
Future Directions
- Future episodes of DKA can be reduced through patient education programs, improved access to medical providers, and new approaches such as extended availability of phone services, use of telemedicine, and utilization of public campaigns 3.
- Continued research and updates in guidelines are necessary to address knowledge gaps and controversies in DKA management, including optimal fluid resuscitation, rate and type of insulin therapy, and potassium and bicarbonate replacement 2.