Diabetic ketoacidosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

Diabetic ketoacidosis (DKA) is a medical emergency. The mainstay of therapy for DKA is medical therapy including intravenous insulin, fluids, potassium replacement and bicarbonate therapy in case of severe acidosis (pH <6.9). The basic principles guiding therapy include rapid restoration of adequate circulation and perfusion, insulin to reverse ketosis and lower glucose levels, and close monitoring to prevent and treat complications if they develop. There are minor differences in the management of DKA in U.S.A. and U.K. which are opinion based and depend on the healthcare setting.

Medical Therapy

The United States (US) and United Kingdom (UK) follow slightly different guidelines for the management of diabetic ketoacidosis (DKA) but the basic principles are same.

Basic principles

The basic principles of diabetic ketoacidosis treatment (DKA) are:

ADA guidelines

The American Diabetes Association (ADA) recommends the following therapy for diabetic ketoacidosis (DKA):[1][2][3]

Fluid therapy

Insulin therapy

Potassium replacement

  • Potassium replacement is started when the levels fall below the upper limit of normal (5.0-5.2 mEq/L).[8]
  • Goal is to maintain serum potassium levels within the normal range of 4–5 mEq/L.

Bicarbonate

Phosphate

Criteria for resolution

PLUS

Differences in management between US and UK

The following are differences in management of DKA between the US and UK:[1][11][15][16][17]

Region Treatment
Insulin Intravenous fluids Bicarbonate
United states
United Kingdom

Step-wise approach to management of diabetic ketoacidosis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DKA treatment protocol according to ADA guidelines
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fluids
 
 
 
 
 
 
 
 
Bicarbonate
 
 
 
 
 
 
Insulin
 
 
 
 
 
 
 
 
Potassium
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hydration status
 
 
 
 
 
 
pH greater than equal to 6.9
 
pH less than 6.9
 
 
0.1 u/kg/B.WT. as IV bolus
 
 
0.14 u/kg/B.WT/hr as continous IV infusion
 
K < 3.3 mEq/L
 
K = 3.3 - 5.2 mEq/L
 
 
K > 5.2 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe hypovolemia
 
Mild dehydration
 
Cardiogenic shock
 
 
 
 
 
 
 
 
 
 
 
0.1 u/kg/B.WT. as IV continous infusion
 
 
 
 
 
 
 
Hold insulin and give 20-30mEq/L of potassium until K+ > 3.3mEq/L
 
Give 20-30mEq/L in each liter of IV fluids to maintain serum K 4-5mEq/L
 
 
Do not give potassium but check serum potassium every 2 hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
0.9% Nacl (1L/hr) as IV infusion
 
Check corrected serum sodium
 
Hemodynamic monitoring and add pressors accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If serum glucose does not fall by 10 % within one hour of therapy then give 0.14 U/Kg as IV bolus and continue previous regimen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High serum Na (>145 mEq/L)
 
Normal serum Na (135-145 mEq/L)
 
Low serum Na (< 135 mEq/L)
 
 
 
 
 
 
 
 
 
 
 
 
When serum glucose drops to 200 mg/dl, reduce regular insulin to 0.02-0.05 U/Kg/hour, or give rapid-acting insulin at 0.1 U/kg SC every 2 hours, maintain serum glucose between 150 mg/dl to,200 mg/dl until resolution
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
0.45% NaCl (250-500 ml per hour depending on hydration status
 
 
 
 
0.9% NaCl (200-500 ml per hour) depending on hydration status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
When serum glucose decreases to 200 mg/dl, switch to 5% dextrose with 0.45% NaCl at 150-250 ml/hour
 
 
 
 
 
 
 
 
 

Contraindicated medications

Diabetic ketoacidosis is considered an absolute contraindication to the use of the following medications:

References

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  2. 2.0 2.1 2.2 2.3 "Diabetes Care".
  3. Nyenwe EA, Kitabchi AE (2011). "Evidence-based management of hyperglycemic emergencies in diabetes mellitus". Diabetes Res. Clin. Pract. 94 (3): 340–51. doi:10.1016/j.diabres.2011.09.012. PMID 21978840.
  4. 4.0 4.1 "Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician".
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  6. "Management of Diabetic Ketoacidosis - American Family Physician".
  7. 7.0 7.1 Gosmanov AR, Gosmanova EO, Dillard-Cannon E (2014). "Management of adult diabetic ketoacidosis". Diabetes Metab Syndr Obes. 7: 255–64. doi:10.2147/DMSO.S50516. PMC 4085289. PMID 25061324.
  8. Beigelman PM (1973). "Potassium in severe diabetic ketoacidosis". Am. J. Med. 54 (4): 419–20. PMID 4633105.
  9. Chua HR, Schneider A, Bellomo R (2011). "Bicarbonate in diabetic ketoacidosis - a systematic review". Ann Intensive Care. 1 (1): 23. doi:10.1186/2110-5820-1-23. PMC 3224469. PMID 21906367.
  10. Hale PJ, Crase J, Nattrass M (1984). "Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis". Br Med J (Clin Res Ed). 289 (6451): 1035–8. PMC 1443021. PMID 6091840.
  11. 11.0 11.1 Morris LR, Murphy MB, Kitabchi AE (1986). "Bicarbonate therapy in severe diabetic ketoacidosis". Ann. Intern. Med. 105 (6): 836–40. PMID 3096181.
  12. Munk P, Freedman MH, Levison H, Ehrlich RM (1974). "Effect of bicarbonate on oxygen transport in juvenile diabetic ketoacidosis". J. Pediatr. 84 (4): 510–4. PMID 4209917.
  13. Latif KA, Freire AX, Kitabchi AE, Umpierrez GE, Qureshi N (2002). "The use of alkali therapy in severe diabetic ketoacidosis". Diabetes Care. 25 (11): 2113–4. PMID 12401775.
  14. Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N (2001). "Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics". N. Engl. J. Med. 344 (4): 264–9. doi:10.1056/NEJM200101253440404. PMID 11172153.
  15. Fleming TN, Runge PE, Charles ST (1992). "Diode laser photocoagulation for prethreshold, posterior retinopathy of prematurity". Am. J. Ophthalmol. 114 (5): 589–92. PMID 1443021.
  16. Chua HR, Schneider A, Bellomo R (2011). "Bicarbonate in diabetic ketoacidosis - a systematic review". Ann Intensive Care. 1 (1): 23. doi:10.1186/2110-5820-1-23. PMC 3224469. PMID 21906367.
  17. Dhatariya KK, Vellanki P (2017). "Treatment of Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS): Novel Advances in the Management of Hyperglycemic Crises (UK Versus USA)". Curr. Diab. Rep. 17 (5): 33. doi:10.1007/s11892-017-0857-4. PMC 5375966. PMID 28364357.

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