Management of Euglycemic Diabetic Ketoacidosis in Patients with Type 2 Diabetes Mellitus

Introduction to Euglycemic Diabetic Ketoacidosis

The American Journal of Kidney Diseases recommends immediate hospital admission for patients with euglycemic diabetic ketoacidosis (euDKA) for intravenous fluid resuscitation, insulin therapy, and close monitoring of ketones and electrolytes 1.

The American Journal of Kidney Diseases states that a blood glucose level <10 mmol/L with elevated ketones indicates euDKA 1, 3.
The Journal of Clinical Oncology suggests that recent discontinuation of empagliflozin and gliclazide indicates acute illness management 1, 2.

The Journal of Clinical Oncology recommends volume resuscitation with intravenous normal saline to reverse volume depletion and improve tissue perfusion 1, 3.
The Journal of Clinical Oncology suggests initiating insulin therapy immediately, with a continuous insulin infusion at 0.1 units/kg/hour or subcutaneous insulin at 0.3-0.4 units/kg/day divided as basal-bolus regimen 3, 5.
The Journal of Clinical Oncology recommends monitoring ketones every 2-4 hours until they normalize (<0.6 mmol/L) 1, 3.
The Journal of Clinical Oncology suggests checking electrolytes (particularly potassium) every 2-4 hours and replacing as needed 3, 5.

The Journal of Clinical Oncology recommends IV insulin infusion (preferred for moderate-to-high ketones) starting at 0.1 units/kg/hour, continuing until ketones <0.6 mmol/L and anion gap closes 3, 5.
The Journal of Clinical Oncology suggests a subcutaneous basal-bolus regimen (if IV not feasible) with a total daily dose of 0.3-0.4 units/kg/day, with 50% as long-acting basal insulin and 50% divided as rapid-acting prandial insulin 3, 5.

The American Journal of Kidney Diseases recommends permanently stopping empagliflozin in patients who have developed euDKA 1, 2, 6.
The American Journal of Kidney Diseases suggests resuming gliclazide once the patient is eating and drinking normally, and symptoms have resolved 1.

The Journal of Clinical Oncology recommends checking ketones every 2-4 hours until <0.6 mmol/L 1, 3.
The Journal of Clinical Oncology suggests monitoring blood glucose every 1-2 hours during insulin infusion, then every 4-6 hours on subcutaneous insulin 3, 5.
The Journal of Clinical Oncology recommends checking electrolytes (especially potassium) every 2-4 hours initially, then every 6 hours once stable 3, 5.

The Journal of Clinical Oncology recommends transitioning off IV insulin when ketones <0.6 mmol/L for at least 6 hours, anion gap normalized, patient tolerating oral intake, and pH >7.3 if measured 3, 5.
The American Journal of Kidney Diseases suggests resuming gliclazide at the usual dose once the patient is eating normally, and considering alternative medications to empagliflozin 1, 7, 8.

The Diabetes/Metabolism Research and Reviews journal warns against assuming normal glucose excludes DKA, as euDKA is a recognized complication of SGLT2 inhibitors 4, 3.
The Journal of Clinical Oncology recommends continuing insulin (with dextrose supplementation) until ketones clear, as premature insulin cessation will perpetuate ketogenesis 3, 5.