What is the next step in managing a 52-year-old man with empagliflozin (Jardiance)-induced euglycemic DKA who is receiving IV insulin, isotonic saline with potassium supplementation (1.5 g per pint) at 225 mL/h, D5W at 150 mL/h, and has pH 7.30, bicarbonate 18 mmol/L, glucose 10‑11 mmol/L, ketones 3 mmol/L, sodium 135 mmol/L, and potassium 3.9 mmol/L?

Management of Empagliflozin-Induced Euglycemic DKA with Improving Ketones

Continue the current IV insulin infusion, maintain D5W at 150 mL/h, and continue isotonic saline with potassium supplementation while monitoring ketones every 2–4 hours until β-hydroxybutyrate falls below 1.0 mmol/L and bicarbonate rises above 18 mmol/L. 1

Current Clinical Status Assessment

Your patient demonstrates partial resolution of euglycemic DKA:

• pH 7.30 (target ≥7.30 achieved) 1
• Bicarbonate 18 mmol/L (at the lower threshold for resolution) 2
• Ketones 3 mmol/L (still significantly elevated; normal <0.6 mmol/L) 1
• Glucose 10–11 mmol/L (180–198 mg/dL, appropriate range during DKA treatment) 1
• Sodium 135 mmol/L (normal) 1
• Potassium 3.9 mmol/L (acceptable but suboptimal; target 4.0–5.0 mmol/L) 1

The patient has NOT met full DKA resolution criteria, which require ALL of the following: glucose <200 mg/dL (11.1 mmol/L), bicarbonate ≥18 mmol/L, pH >7.30, AND anion gap ≤12 mmol/L. 1 Most critically, ketones remain elevated at 3 mmol/L when they should be <1.0 mmol/L for safe transition. 1

Immediate Management Steps

Continue Insulin Infusion Without Reduction

• Do not reduce or stop the IV insulin infusion despite normalized glucose; insulin is required to suppress ongoing ketogenesis and clear circulating ketones, not merely to control glucose. 1, 3, 4
• The current glucose of 10–11 mmol/L is ideal during DKA treatment—it allows continued insulin administration while preventing hypoglycemia. 1
• Ketonemia typically takes longer to clear than hyperglycemia; premature insulin discontinuation is the most common cause of recurrent DKA. 2, 1

Maintain Dextrose-Containing Fluids

• Continue D5W at 150 mL/h to provide approximately 150–200 g of carbohydrate per 24 hours, which suppresses starvation ketosis and allows safe continuation of insulin. 1
• This dextrose infusion prevents hypoglycemia while insulin clears ketones—a critical principle in euglycemic DKA management. 1, 3, 4

Optimize Potassium Replacement

• Increase potassium supplementation to achieve a target of 4.0–5.0 mmol/L (current 3.9 mmol/L is borderline low). 1
• Add 20–30 mEq/L potassium to the isotonic saline, using a mixture of 2/3 potassium chloride (or acetate) and 1/3 potassium phosphate. 1
• Monitor potassium every 2–4 hours because insulin drives potassium intracellularly; severe hypokalemia (<2.5 mEq/L) increases mortality. 1

Continue Isotonic Saline with Electrolyte Monitoring

• Maintain isotonic saline at 225 mL/h with the enhanced potassium supplementation described above. 1
• Total fluid replacement should approximate 1.5 times the 24-hour maintenance requirement. 1

Monitoring Protocol

Laboratory Frequency

• Check ketones (β-hydroxybutyrate preferred), glucose, electrolytes, venous pH, bicarbonate, and anion gap every 2–4 hours until all resolution criteria are met. 1
• Direct measurement of β-hydroxybutyrate in blood is superior to urine ketones, which lag behind serum clearance and can falsely suggest worsening ketosis as β-hydroxybutyrate converts to acetoacetate. 2

Target Resolution Criteria

The patient can transition to subcutaneous insulin only when ALL of the following are achieved simultaneously:

• Glucose <200 mg/dL (11.1 mmol/L) ✓ (already met)
• Bicarbonate ≥18 mmol/L ✓ (borderline; recheck)
• pH >7.30 ✓ (already met)
• Anion gap ≤12 mmol/L (calculate and verify) 1
• Ketones <1.0 mmol/L ✗ (current 3 mmol/L; NOT met) 1
• Patient able to tolerate oral intake 1

Special Considerations for SGLT2 Inhibitor-Induced Euglycemic DKA

Prolonged Ketogenesis Risk

• Empagliflozin has a half-life of 12–14 hours, but persistent euglycemic DKA has been reported 7–12 days after the last dose due to continued renal glucose wasting and glucosuria. 5
• Your patient's persistent glucosuria (likely present given SGLT2 inhibitor mechanism) perpetuates ketogenesis even with normal glucose levels. 5
• Recurrent euglycemic DKA can occur until 2 weeks after SGLT2 inhibitor discontinuation, particularly in patients with decreased oral intake, infection, or recent surgery. 5

Monitoring for Recurrence

• Even after initial resolution, continue monitoring for recurrent ketoacidosis by checking urine ketones and glucose daily for 7–14 days after empagliflozin discontinuation. 5
• Persistent glucosuria (4+) with ketonuria (4+) despite serum glucose below the renal threshold confirms ongoing SGLT2 inhibitor effect and risk of recurrent DKA. 5

Transition to Subcutaneous Insulin (When Criteria Met)

Timing and Overlap Protocol

• Only after ketones fall below 1.0 mmol/L and all other resolution criteria are met, administer a long-acting basal insulin (glargine or detemir) 2–4 hours before stopping the IV insulin infusion. 1
• Continue the IV insulin infusion for an additional 1–2 hours after the subcutaneous basal dose to ensure adequate absorption and prevent rebound ketoacidosis. 1
• Calculate the basal insulin dose as approximately 50% of the total 24-hour IV insulin amount given as a single daily injection. 1
• Divide the remaining 50% equally among three meals as rapid-acting prandial insulin. 1

Critical Pitfalls to Avoid

• Never stop IV insulin when glucose normalizes—this is the most common error leading to recurrent DKA; insulin must continue until ketones clear. 1
• Never discontinue IV insulin without 2–4 hour basal insulin overlap—abrupt cessation causes rebound hyperglycemia and ketoacidosis. 1
• Never reduce insulin infusion rate based on glucose alone—ketone clearance, not glucose, determines insulin duration. 1
• Do not rely on urine ketones alone—they lag behind serum ketone clearance and can be misleading during treatment. 2

Discharge Planning (For Future Reference)

Once DKA fully resolves and the patient transitions to subcutaneous insulin:

• Permanently discontinue empagliflozin—SGLT2 inhibitors are contraindicated after euglycemic DKA. 3, 4, 6
• Provide structured diabetes education covering insulin administration, glucose monitoring, hypoglycemia recognition/treatment, and sick-day management. 7
• Ensure the patient has insulin supplies, blood glucose meter and strips, and urine ketone strips at discharge. 7
• Schedule follow-up with an endocrinologist within 1–2 weeks. 7