Introduction
Euglycemic DKA is a rare complication of SGLT-2 inhibitors in people with type 2 diabetes. It is more likely to occur if your patient is:
- Fasting
- Acutely unwell
- Septic
- Following a carbohydrate-restricted diet
- Following missed insulin doses if patient is also taking insulin
It presents with a metabolic acidosis and ketonaemia, but the glucose is either normal or mildly elevated. It is treated with the same protocol as a patient with DKA.
Diagnostic criteria
Biochemical diagnosis is based on venous blood result:
- pH <7.30
- Bicarbonate < 18 mmol/L
- Ketones >3.0mmol/L
- Osmolality 250 – 320 mOsm/kg
- Dehydration is moderate
Management
Follow the same management recommendations as for Diabetic Ketoacidosis (DKA) and the SGLT-2 I should not be restarted on discharge.
- Intravenous fluids
- 1st bag: 0.9% Normal Saline resuscitation @ 500ml per hour
- 2nd bag: 0.9% Normal Saline @ 250ml per hour
- 3rd bag: 0.9% Normal Saline @ 125 ml per hour
- Potassium replacement
Give intravenous potassium infusion if serum K+ is below 5 mmol/L:
Serum potassium |
IV potassium |
<3.5mmol/L |
2 x 10 mmol/L over 1 hour |
3.5 – 5 mmol/L |
10 mmol/L over 1 hour |
>5 mmol/L |
Nil potassium needed |
- Dextrose infusion
- Switches off the ketosis
- Give Dextrose 10% at 125ml per hour in a side-line
- Give oral hydration with glucose-containing fluid eg. Hydralyte, weak cordial
- If patient is able to eat without vomiting, give low-GI carbohydrate eg. slice of bread
- Insulin infusion
- Starting infusion rate of 0.5 units per hour with Dextrose infusion
- 1-hourly glucose monitoring
- Aims to reverse ketosis
- Investigate underlying cause
- Bloods for CRP, Troponin, blood cultures, lipase
- Urine for MCS
- Chest x-ray
- Lumbar puncture if indicated
- 12-lead ECG
- Monitoring
- 1-hourly capillary blood glucose
- 2-hourly capillary blood ketones
- 1-hourly fluid balance
- Venous blood at 2 hours, 4 hours, 8 hours, 12 hours for:
- pH
- Bicarbonate
- Osmolality
- Non-diabetic care
- Thromboprophylaxis
- Pantoprazole 20 mg daily to prevent gastritis
- Aperients
- Pressure care