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

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This document is an evidence-based sick-day and DKA prevention guide for insulin-treated people with type 1 or type 2 diabetes. It emphasizes that <strong>blood beta-hydroxybutyrate (BHB) ketone testing is preferred over urine ketones</strong>, because urine testing can miss early ketosis and can look worse during recovery.

Key points:
- <strong>Never stop basal insulin</strong>, even if not eating.
- <strong>Check ketones whenever ill</strong>, regardless of glucose level.
- <strong>Monitor glucose and ketones frequently</strong>: every 2–4 hours until BHB is below 0.6 mmol/L.
- <strong>Hydrate continuously</strong> with sugar-free fluids if glucose is high, or carbohydrate-containing fluids if glucose is falling or intake is poor.
- Have a <strong>written escalation plan</strong> specifying when to call for help.

Ketone thresholds:
- <strong>< 0.6 mmol/L:</strong> normal
- <strong>0.6–1.5:</strong> early insulin insufficiency; outpatient rescue may work
- <strong>1.5–3.0:</strong> significant ketosis
- <strong>≥ 3.0:</strong> meets ketone criterion for DKA

Supplemental rapid-acting insulin is recommended based on ketone level:
- <strong>0.6–1.5:</strong> 10% of total daily dose (or 0.1 units/kg)
- <strong>≥ 1.5:</strong> 20% of total daily dose (or 0.2 units/kg)
Insulin should not be withheld just because glucose is low; instead, give carbohydrate if needed to allow insulin to continue.

Special warnings include <strong>SGLT2 inhibitor–associated euglycemic DKA</strong>, where glucose may be below 200 mg/dL. These drugs should be held during illness, fasting, vomiting, surgery, or after DKA.

For pump users, unexplained hyperglycemia with ketones should be treated as <strong>insulin delivery failure</strong>.

Immediate emergency care is required for vomiting with elevated ketones, confusion, breathing difficulty, persistent high ketones, or ketones ≥ 3.0 mmol/L.

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Meta Tag

Concept Blood Ketone

Concept Sick-Day Management

Concept Diabetic Ketoacidosis

Concept Euglycemic Diabetic Ketoacidosis

Concept Emergency Evaluation

Keywords

diabetes

DKA

ketone testing

beta-hydroxybutyrate

sick-day rules

basal insulin

hyperglycemia

euglycemic DKA

SGLT2 inhibitors

insulin pump failure

Blood Ketone

Sick-Day Management

Diabetic Ketoacidosis

Euglycemic Diabetic Ketoacidosis

Emergency Evaluation