Management of Euglycemic Diabetic Ketoacidosis

Discontinuation of Medications

Metformin must be stopped due to severe metabolic acidosis and risk of lactic acidosis, with bicarbonate of 8 and acute infection (osteomyelitis), in patients with multiple risk factors for metformin-associated lactic acidosis 1, 2
Metformin should be discontinued in patients at risk for lactic acidosis including those with acute kidney injury, hypoxia, or shock, although creatinine is 0.91 (eGFR likely >60) 1, 2, 3
Check serum lactate level to rule out concurrent lactic acidosis 1, 2

Start intravenous insulin infusion immediately targeting blood glucose 140-180 mg/dL (7.8-10 mmol/L) 4, 1
Continue DKA protocol until anion gap normalizes and bicarbonate >15 mEq/L, with monitoring for electrolyte abnormalities, particularly hypokalemia and hypernatremia 4, 1

Tight glycemic control is essential for successful osteomyelitis treatment, with target blood glucose 140-180 mg/dL during acute illness to balance infection control with hypoglycemia risk 5, 4, 1
Ensure appropriate intravenous antibiotics are continued for osteomyelitis, with duration of antibiotic therapy typically 4-6 weeks, requiring sustained glycemic control throughout treatment 5, 6

Once DKA resolves (anion gap normalized, bicarbonate >15, ketones cleared) and patient is clinically stable, initiate basal-bolus insulin regimen with long-acting basal insulin plus rapid-acting insulin before meals 4, 1
Starting total daily dose: 0.3-0.5 units/kg/day, given as 50% basal and 50% divided among meals 4, 1

Metformin can be cautiously restarted after hospital discharge once patient is clinically stable, eating normally, and infection is controlled, with baseline creatinine 0.91, and no dose adjustment needed if eGFR remains >60 mL/min/1.73m² 1, 2, 7
Consider adding a GLP-1 receptor agonist (liraglutide, semaglutide, or dulaglutide) for cardiovascular and glycemic benefits without DKA risk 7, 8
DPP-4 inhibitors (sitagliptin, linagliptin) are safe alternatives with neutral effect on heart failure risk 8, 1