Preventing Diabetic Ketoacidosis: Clinical Decisions in Action (On-Demand)-DKA_Euglycemic

Pdf Summary

Euglycemic diabetic ketoacidosis (euDKA) is ketoacidosis with normal or only mildly elevated blood glucose, often below 200 mg/dL, and sometimes even under 140 mg/dL. Diagnosis requires the combination of ketone elevation (preferably blood beta-hydroxybutyrate), metabolic acidosis (pH below 7.3 and/or bicarbonate below 18 mmol/L), and an elevated anion gap. The key warning is that normal glucose does not rule out DKA.<br /><br />It is increasingly seen with SGLT2 inhibitor use, but also occurs in pregnancy, after surgery, during fasting or very low-carbohydrate intake, and with insulin pump failure or acute illness. The common mechanism is carbohydrate unavailability plus a stress-driven rise in counter-regulatory hormones, allowing ketogenesis despite near-normal glucose.<br /><br />Because the glucose can look reassuring, euDKA is often missed. Common pitfalls include checking glucose but not ketones, attributing nausea, abdominal pain, or tachypnea to other causes, relying on urine ketones early in illness, and withholding insulin because the patient is not hyperglycemic.<br /><br />Management differs from typical DKA in important ways: stop any SGLT2 inhibitor immediately and do not restart it during acute illness; begin dextrose early so insulin can be safely given; give insulin anyway because it suppresses ketogenesis; and treat until ketones resolve, not just until the anion gap improves. Monitoring should continue because the drug effect can persist for days.<br /><br />For outpatient worsening ketones in an SGLT2 inhibitor user, the STICH approach is recommended: Stop the drug, Inject rapid-acting insulin, Take carbohydrate, and Hydrate, with urgent escalation if ketones remain high or GI symptoms develop.

Asset Subtitle

Quick Reference

Meta Tag

Concept Euglycemic Diabetic Ketoacidosis

Concept Ketones

Concept Metabolic Acidosis

Concept SGLT2 Inhibitors

Concept Insulin

Keywords

euglycemic diabetic ketoacidosis

euDKA

normal blood glucose

ketone elevation

metabolic acidosis

anion gap

SGLT2 inhibitor

beta-hydroxybutyrate

insulin pump failure

STICH approach

Euglycemic Diabetic Ketoacidosis

Ketones

Metabolic Acidosis

SGLT2 Inhibitors

Insulin