Management of Hyperglycemia with Ketonuria

Initial Assessment and Management

The American Diabetes Association recommends that patients with a blood glucose level of 17.7 mmol/L and ketones of 0.3 mmol/L require immediate treatment to prevent progression to full diabetic ketoacidosis, which is a life-threatening condition 1, 2, 3
The American Association of Clinical Endocrinologists suggests that any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose, and patients with ketosis require continued urine or blood ketone monitoring 1, 4

The American Diabetes Association recommends regular insulin 0.1 units/kg/hour via intravenous infusion for non-severe cases, and subcutaneous insulin with an initial "priming" dose of 0.4-0.6 units/kg body weight for mild cases 5, 6, 7
The Endocrine Society suggests continuing insulin therapy until ketosis resolves, not just until blood glucose normalizes 5, 6
The American College of Physicians recommends beginning with isotonic saline to restore intravascular volume, and switching to 5% dextrose with 0.45-0.75% NaCl once blood glucose reaches 250 mg/dL to prevent hypoglycemia while continuing insulin therapy 5, 6, 7

The American Association of Clinical Endocrinologists recommends checking blood glucose every 1-2 hours until stable, and monitoring ketones to track resolution of ketosis 5, 6, 7
The American Diabetes Association suggests assessing electrolytes, especially potassium, every 2-4 hours initially, and monitoring acid-base status via venous pH and anion gap 5, 6, 7

The American Diabetes Association recommends continuing insulin therapy even after blood glucose normalizes to suppress ketogenesis in patients with type 1 diabetes or insulin-deficient type 2 diabetes 5, 6
The Endocrine Society suggests looking for and treating any underlying precipitating factors, such as infection, illness, or medication non-adherence 1, 2

The American College of Physicians defines resolution of DKA as glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, and venous pH ≥7.3 5
The American Diabetes Association recommends transitioning to a multiple-dose insulin regimen with combination of short/rapid-acting and intermediate/long-acting insulin when the patient can eat 5, 6

The American Association of Clinical Endocrinologists warns against stopping insulin therapy prematurely when glucose normalizes but ketosis persists, and avoiding rapid correction of glucose to prevent cerebral edema 5, 6, 7
The Endocrine Society recommends never delaying insulin therapy in patients with significant hyperglycemia and ketosis 1, 3