Asian Journal of Medical Principles and Clinical Practice

Recent Advancement in the Management of Diabetic Ketoacidosis

Hossamaldin Fawzy Ramadan Alshorfa *

Burjeel Royal Hospital - Al Ain, United Arab Emirates.

*Author to whom correspondence should be addressed.

---

Abstract

Diabetic ketoacidosis (DKA) is a condition of diabetes mellitus that is life-threatening and occurs whenever blood sugar levels rise, ketones are produced and the body begins to get acidosis. The issue of timely and appropriate management is critical to avoid the development of fatal conditions. Over the years, two main approaches to DKA management have emerged: slow and fast. The conventional way of treating DKA attacks is through a gradual improvement of the hyperglycemia and metabolic abnormalities, which may span up to 24 to 48 hours. This procedure mainly involves intravenous fluid replenishment, insulin infusion, and the correction of electrolyte imbalance. However, this method has certain shortcomings. The disadvantage includes the long time that the patient has to stay in hospital, which results in extra costs for treatment and inconvenience for the person. Moreover, overcorrection may heighten the chance of cerebral edema, a rare but fatal issue that may occur during or after DKA treatment. In the last few years, there has been a lot of attention around fast management methods which are aimed at getting rid of excessive blood sugar levels as well as other abnormalities within a shorter time range typically of 6 to 12 hours. Aggressive approaches to quick control include higher insulin infusion rates, intensive fluid resuscitation, and close checks on electrolytes, acid-base status, and other parameters. Supporters of fast treatment say that it shortens the length of hospitalization, makes it less costly, and minimizes brain edema, which is one of the complications. Nevertheless, the negative impacts may involve the incidence of hypoglycemia, hypokalemia, and rebound hyperglycemia by rapid correction. Many studies have demonstrated that the therapeutic and medicinal efficacy and safety levels of both slow and rapid management approaches to DKA are almost similar. In some instances, trials may reveal similar outcomes of the two strategies, on the other hand, conflicting results have also been reported. This review shall reflect on both the slow and fast management of diabetic ketoacidosis and enlist the ways that have been decided as per the guidelines to help manage the patients on urgent basis in the emergency room.

Keywords: Diabetic ketoacidosis, fast management, slow management, aggressive management, reversal of DKA, improved patient outcomes

---

---

---

References

1.Lizzo JM, Goyal A, Gupta V. Adult Diabetic Ketoacidosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Apr 29]. Available:http://www.ncbi.nlm.nih.gov/books/NBK560723/

Eledrisi MS, Elzouki AN. Management of Diabetic Ketoacidosis in Adults: A Narrative Review. Saudi J Med Med Sci. 2020;8(3):165–73.

Basetty S, Yeshvanth Kumar GS, Shalini M, Angeline RP, David KV, Abraham S. Management of diabetic ketosis and ketoacidosis with intramuscular regular insulin in a low-resource family medicine setting. J Fam Med Prim Care. 2017; 6(1):25–8.

Ghimire P, Dhamoon AS. Ketoacidosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Apr 30]. Available:http://www.ncbi.nlm.nih.gov/books/NBK534848/

Gosmanov AR, Kitabchi AE. Diabetic Ketoacidosis. In: Feingold KR, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000 [cited 2024 Apr 30]. Available:http://www.ncbi.nlm.nih.gov/books/NBK279146/

Shahid W, Khan F, Makda A, Kumar V, Memon S, Rizwan A. diabetic ketoacidosis: clinical characteristics and precipitating factors. Cureus. 2020;12(10):e10792.

Passanisi S, Salzano G, Basile P, Bombaci B, Caime F, Rulli I, et al. Prevalence and clinical features of severe diabetic ketoacidosis treated in pediatric intensive care unit: a 5-year monocentric experience. Ital J Pediatr. 2023;49: 58.

Virdi N, Poon Y, Abaniel R, Bergenstal RM. Prevalence, Cost, and Burden of Diabetic Ketoacidosis. Diabetes Technol Ther. 2023;25(S3):S75–84.

Jayashree M, Williams V, Iyer R. Fluid Therapy For Pediatric Patients With Diabetic Ketoacidosis: Current Perspectives. Diabetes Metab Syndr Obes Targets Ther. 2019;12:2355–61.

McGregor S, Metzger DL, Amed S, Goldman RD. Fluid management in children with diabetic ketoacidosis. Can Fam Physician. 2020;66(11):817–9.

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Med Clin North Am. 2017;101(3):587–606.

Islam T, Sherani K, Surani S, Vakil A. Guidelines and controversies in the management of diabetic ketoacidosis – A mini-review. World J Diabetes. 2018 ;9(12):226–9.

Taye GM, Bacha AJ, Taye FA, Bule MH, Tefera GM. Diabetic Ketoacidosis Management and Treatment Outcome at Medical Ward of Shashemene Referral Hospital, Ethiopia: A Retrospective Study. Clin Med Insights Endocrinol Diabetes. 2021;14:11795514211004957.

Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335–43.

Nyenwe EA, Kitabchi AE. Evidence- based management of hyperglycemic emergencies in diabetes mellitus . Diabetes Res Clin Pract. 2011;94(3):340–51.

Diabetes Canada Clinical Practice Guidelines Expert Committee, Goguen J, Gilbert J. Hyperglycemic Emergencies in Adults. Can J Diabetes. 2018;42 Suppl 1:S109–14.

Gamba G, Oseguera J, Castrejón M, Gómez-Pérez FJ. Bicarbonate therapy in severe diabetic ketoacidosis. A double blind, randomized, placebo controlled trial. Rev Investig Clin Organo Hosp Enfermedades Nutr. 1991;43(3):234–8.

Luzi L, Barrett EJ, Groop LC, Ferrannini E, DeFronzo RA. Metabolic effects of low-dose insulin therapy on glucose metabolism in diabetic ketoacidosis. Diabetes. 1988;37(11):1470–7.

Page MMcB, Alberti KGMM, Greenwood R, Gumaa KA, Hockaday TDR, Lowy C, et al. Treatment of Diabetic Coma with Continuous Low-dose Infusion of Insulin. Br Med J. 1974;2(5921):687–90.

Kitabchi AE, Murphy MB, Spencer J, Matteri R, Karas J. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Diabetes Care. 2008;31(11):2081–5.

Goyal N, Miller JB, Sankey SS, Mossallam U. Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med. 2010;38(4):422–7.

Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees J a. E, Courtney CH, et al. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med J Br Diabet Assoc. 2011;28(5):508–15.

Kitabchi AE, Umpierrez GE, Fisher JN, Murphy MB, Stentz FB. Thirty Years of Personal Experience in Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. J Clin Endocrinol Metab. 2008;93(5):1541–52.

Umpierrez GE, Cuervo R, Karabell A, Latif K, Freire AX, Kitabchi AE. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care. 2004; 27(8):1873–8.

Ersöz HO, Ukinc K, Köse M, Erem C, Gunduz A, Hacihasanoglu AB, et al. Subcutaneous lispro and intravenous regular insulin treatments are equally effective and safe for the treatment of mild and moderate diabetic ketoacidosis in adult patients. Int J Clin Pract. 2006; 60(4):429–33.

Grout S, Maue D, Berrens Z, Swinger N, Malin S. Diabetic Ketoacidosis with Refractory Hypokalemia Leading to Cardiac Arrest. Cureus. 14(3):e23439.

Laffel L. Sick-day management in type 1 diabetes. Endocrinol Metab Clin North Am. 2000;29(4):707–23.

Ditzel J, Lervang HH. Disturbance of inorganic phosphate metabolism in diabetes mellitus: clinical manifestations of phosphorus-depletion syndrome during recovery from diabetic ketoacidosis. Diabetes Metab Syndr Obes Targets Ther. 2010;3:319–24.