What treatment is appropriate for a patient with diabetic ketoacidosis (DKA) presenting with hyperglycemia, metabolic acidosis, and an increased anion gap?

From the Guidelines

Intravenous insulin is the most appropriate treatment for this patient's anion gap abnormality, as it directly addresses the underlying pathophysiology of diabetic ketoacidosis (DKA) by suppressing ketogenesis in the liver and promoting glucose uptake in peripheral tissues. The patient's presentation with hyperglycemia (glucose 487 mg/dL), metabolic acidosis (bicarbonate 13 mEq/L), an elevated anion gap (25 mEq/L), and ketonuria is consistent with DKA.

Key Considerations

• The standard approach involves an IV insulin bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hour, as recommended by recent guidelines 1.
• This should be accompanied by appropriate fluid resuscitation with normal saline initially, and potassium replacement as needed.
• Sodium bicarbonate is generally not recommended in DKA unless pH is severely low (<7.0), as stated in multiple studies 1.
• The resolution of ketoacidosis requires insulin to stop ketone production, which will gradually correct the anion gap as ketoacids are metabolized and cleared from the circulation.

Management Goals

• Restoration of circulatory volume and tissue perfusion
• Resolution of hyperglycemia
• Correction of electrolyte imbalance and ketosis
• Treatment of any underlying cause of DKA, such as sepsis, as emphasized in recent guidelines 1.

Important Notes

• The use of bicarbonate in patients with DKA has been shown to make no difference in resolution of acidosis or time to discharge, and its use is generally not recommended 1.
• Phosphate replacement may be indicated in patients with cardiac dysfunction, anemia, or respiratory depression, and in those with serum phosphate concentration < 1.0 mg/dl, as noted in previous studies 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. With DKA, blood and urine tests show large amounts of glucose and ketones.

The patient has hyperglycemia and diabetic ketoacidosis (DKA), as indicated by the high serum glucose level, presence of ketones in the urine, and anion gap of 25 mEq/L.

• The appropriate treatment for the anion gap abnormality is Intravenous insulin 2 2.
• Intravenous insulin will help to lower the blood glucose level and resolve the ketoacidosis.
• It is essential to monitor the patient's potassium levels closely when administering intravenous insulin, as it can cause hypokalemia 2.

From the Research

Treatment of Anion Gap Abnormality

The patient's laboratory results show an anion gap of 25 mEq/L, which is indicative of an anion gap metabolic acidosis. The treatment of this condition is crucial to improve patient outcomes.

• The mainstays of treatment for diabetic ketoacidosis (DKA), which is characterized by an anion gap metabolic acidosis, include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 3.
• Intravenous insulin is a key component of treatment for DKA, as it helps to reduce glucose levels and promote the clearance of ketones 3, 4.
• Normal saline fluid bolus is often used for initial volume replacement in DKA patients, but recent studies suggest that large volumes of normal saline may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 5.
• Crystalloid bolus with D5 one-half normal saline and intravenous sodium bicarbonate are not typically recommended as first-line treatments for anion gap metabolic acidosis in DKA patients 3, 4.

Appropriate Treatment

Based on the evidence, the most appropriate treatment for the anion gap abnormality in this patient is:

• Intravenous insulin, as it is a key component of treatment for DKA and helps to reduce glucose levels and promote the clearance of ketones 3, 4.
• Normal saline fluid bolus, but with caution and careful monitoring to avoid large volumes and potential complications such as hyperchloremic metabolic acidosis 5.