Diabetic Ketoacidosis Management

Diagnosis and Assessment

Patients taking SGLT2 inhibitors should be evaluated for symptoms of euDKA, including nausea, vomiting, abdominal pain, generalized weakness or fatigue, rapid breathing or shortness of breath, and confusion or unusual behavior, when ketonuria is present with normal blood glucose levels, as recommended by the American College of Cardiology and the American Diabetes Association 1, 2
Immediate laboratory testing is recommended for patients with suspected euDKA, including serum beta-hydroxybutyrate (bOHB) levels, venous blood gas to assess for metabolic acidosis, serum electrolytes and anion gap calculation, complete blood count, and C-peptide level, as recommended by the American Diabetes Association 2
Blood ketone determinations should use specific measurement of bOHB, rather than nitroprusside reaction, for monitoring treatment of DKA, as recommended by the American Diabetes Association 2
A laboratory workup for euDKA should include venous blood gas to assess for acidosis, electrolytes, and anion gap, as recommended by the American Diabetes Association 2

Patients with euDKA should be treated with immediate hospital admission, IV fluids, IV insulin therapy, electrolyte monitoring and replacement as needed, and discontinuation of SGLT2 inhibitor, as recommended by the American College of Cardiology 3
Monitoring of blood glucose and ketones every 3-4 hours is recommended, with consideration of supplemental insulin doses if ketones persist despite treatment, as recommended by the American College of Cardiology 1
Identifying and addressing precipitating factors, such as recent low carbohydrate intake or fasting, reduced insulin dose, alcohol consumption, acute illness, or dehydration, is crucial in managing euDKA, as noted by the American College of Cardiology 3
Increasing carbohydrate intake and ensuring adequate hydration, as well as monitoring blood ketones until resolution, are essential for managing euDKA, according to the American Diabetes Association 2

Patient education is crucial for preventing euDKA, and should include teaching patients to recognize euDKA symptoms, avoiding prolonged fasting, avoiding ketogenic/very low carbohydrate diets, monitoring ketones during illness, and seeking medical attention when necessary, as recommended by the American College of Cardiology and Kidney International 4, 3
Patients with risk factors for euDKA, such as low C-peptide levels, or recent reduction in insulin dose >20%, should be considered for alternative therapy, as recommended by the American College of Cardiology 3

The following patients are at high risk for euDKA when starting SGLT2 inhibitors:

Patient Type	Risk Factor
Insulin-dependent type 2 diabetes patients	Reduced pancreatic reserve
Patients with late-onset type 1 diabetes	Insulin deficiency
Patients with low C-peptide levels	Insulin deficiency

Reducing insulin doses by >20% when initiating SGLT2 inhibitors should be avoided, as it may increase the risk of euDKA, as recommended by the American College of Cardiology and Kidney International 4, 3
C-peptide levels should be measured before starting SGLT2 inhibitors to assess insulin deficiency risk, and alternative therapies should be considered if C-peptide is significantly low, as recommended by Kidney International and the American College of Cardiology 4, 3