DKA in Known Diabetes Mellitus with Blood Glucose Below 14 mmol/L
Diabetic ketoacidosis (DKA) does not always present with markedly elevated blood glucose. In patients with known diabetes mellitus, DKA can develop while glucose remains below 14 mmol/L — a pattern referred to as euglycaemic DKA. This variant requires a modified approach from the outset.
The patient has known diabetes mellitus and fulfils criteria for DKA, yet blood glucose is not particularly raised — it is below 14 mmol/L. Near-normal glycaemia does not exclude DKA. This presentation is seen in patients on a sodium-glucose cotransporter (SGLT) inhibitor, among other circumstances. Failure to recognise this variant risks undertreatment of the ketoacidosis.
Because blood glucose is already low, glucose replacement must be initiated immediately alongside fluid resuscitation and a fixed-rate intravenous insulin infusion. Where an SGLT inhibitor is in use, it should be stopped. Adjustment of the insulin rate may be required depending on glucose response during treatment.
- Reduce blood ketones by at least 0.5 mmol/L/hour
- Increase venous bicarbonate by 3.0 mmol/L/hour
- Reduce capillary blood glucose by 3.0 mmol/L/hour
- Maintain potassium between 4.0 and 5.5 mmol/L
References
- This is the development of DKA in people known to have diabetes but where the glucose is normal, or not particularly raised.
- Initiate glucose 10% straight away at 125 ml/hr because the glucose is <14 mmol/L
- This condition is treated in exactly the same way as hyperglycaemic DKA.
- If DKA occurs with SGLT inhibitor use, they should be stopped.
- Begin with 0.1 units/kg/hr insulin rate
- If glucose falling despite 10% glucose reduce to 0.05 units/kg/hr to avoid hypoglycaemia
- Reduction of the blood ketone concentration by 0.5 mmol/L/hour
- Increase the venous bicarbonate by 3.0 mmol/L/hour
- Reduce capillary blood glucose by 3.0 mmol/L/hour
- Maintain potassium between 4.0 and 5.5 mmol/L