Diabetic ketoacidosis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Medical Therapy
The United States (US) and United Kingdom (UK) follow slightly different guidelines for the management of diabetic ketoacidosis but the basic principles are same.
Basic principles
The basic principles of diabetic ketoacidosis treatment (DKA) are:
- Rapid restoration of adequate circulation and perfusion with intravenous fluids.
- Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate.
- Insulin to reverse ketosis and lower glucose levels.
- Careful monitoring to detect and treat complications.
US guidelines
The American Diabetes Association (ADA) recommends the following therapy for diabetic ketoacidosis (DKA):
Fluid therapy
- Initial fluid therapy is aimed towards expansion of the intravascular, interstitial, and intracellular volume, all of which are reduced in hyperglycemic crises.
- Fluid restoration also leads to increased renal perfusion and improves renal function.
- The following options may be used for fluid restoration:
- Isotonic saline (0.9% NaCl) is infused at a rate of 15–20 ml/kg/h or 1–1.5 L during the first hour. It may also be infused at a rate of 250-500 ml/h if serum sodium is low.
- Subsequent choice for fluid replacement depends on hemodynamics, the volume status of the body (signs and symptoms of dehydration), serum electrolyte levels, and urinary output.
- Half normal saline (0.45% NaCl ) infused at 250–500 ml/h is beneficial if the corrected serum sodium is normal or increased.
- Successful progress with fluid replacement is judged by, blood pressure monitoring, measurement of fluid input/output, laboratory values, and clinical examination.
- Fluid replacement usually leads to successful treatment of volume deficit within the first 24 hours.
- In patients with renal or cardiac compromise, monitoring of serum osmolality and frequent assessment of cardiac, renal, and mental status must be performed during fluid resuscitation to avoid iatrogenic fluid overload.
- Aggressive rehydration with subsequent resolution of the hyperosmolar state has been shown to be linked to a better response to low dose insulin.
- Once the plasma glucose is ∼ 200 mg/dl, 5% dextrose should be added to replacement fluids to allow continued insulin administration.
Insulin therapy
- Insulin therapy helps control hyperglycemia, hyperkalemia and ketosis.
- The following routes and rates of insulin administration may be used:
- An initial intravenous dose of regular insulin (0.1 units/kg) followed by the infusion of 0.1 units/kg/h insulin .
- The initial bolus of insulin may be skipped, if patients receive an hourly insulin infusion of 0.14 units/kg body weight (equivalent to 10 units/h in a 70 kg patient).
- Intravenous route is preferred because of rapid onset of action, although subcutaneous route can also be used.
- Low-dose insulin infusion protocols decrease plasma glucose concentration at a rate of 50–75 mg/dl/h.
- If plasma glucose does not decrease by 50–75 mg from the initial value in the first hour, the insulin infusion should be increased every hour until a steady glucose decline is achieved.
- When the blood glucose level reaches 200 mg/dl, the rate of insulin infusion should be changed to 0.02 units/kg/h - 0.05 units/kg/h and dextrose may be added to the IV fluids.
Contraindicated medications
Diabetic ketoacidosis is considered an absolute contraindication to the use of the following medications:
- Glipizide
- Glyburide
- Glyburide and Metformin
- Linagliptin and Metformin hydrochloride
- Repaglinide
- Saxagliptin hydrochloride and Metformin hydrochloride