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 hemodynamic monitoring (improvement in blood pressure), measurement of fluid input/output, laboratory values, and clinical examination.
- Fluid replacement should correct estimated deficits within the first 24 h.
- 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 correction of the hyperosmolar state has been shown to result in a more robust response to low-dose insulin therapy
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