Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Diabetic Ketoacidosis Medication

  • Author: Osama Hamdy, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
 
Updated: Jul 20, 2016
 

Medication Summary

Regular and analog human insulins[2] are used for correction of hyperglycemia, unless bovine or pork insulin is the only available insulin. Clinical considerations in treating diabetic ketoacidosis (DKA) include the following:

  • Only short-acting insulin is used for correction of hyperglycemia in DKA.
  • The optimal rate of glucose decline is 100 mg/dL/h.
  • The blood glucose level should not be allowed to fall lower than 200 mg/dL during the first 4-5 hours of treatment.
  • Avoid induction of hypoglycemia because it may develop rapidly during correction of ketoacidosis and may not provide sufficient warning time.

Treatment of ketoacidosis should aim to correct dehydration, reverse the acidosis and ketosis, reduce plasma glucose concentration to normal, replenish electrolyte and volume losses, and identify the underlying cause.

According to the 2011 JBDS DKA guideline, patients who are already taking long-acting insulin analogues such as glargine or detemir should be maintained at their usual doses.[16, 17]

Next

Rapid-acting insulins

Class Summary

Rapid-acting insulins have a rapid onset and short duration of action and are associated with less hypoglycemia than regular insulin.

Insulin aspart (NovoLog)

 

Insulin aspart has an onset of action of 5-15 minutes. The peak effect occurs within 30-90 minutes, and its usual duration of action is 4 hours.

Insulin glulisine (Apidra)

 

Insulin glulisine has an onset of action of 5-15 minutes. The peak effect occurs within 30-90 minutes, and its usual duration of action is 4 hours.

Insulin lispro (Humalog)

 

Insulin lispro has an onset of action of 5-15 minutes, and its usual duration of action is 4 hours.

Previous
Next

Short-acting insulins

Class Summary

Insulin suppresses hepatic glucose output and enhances glucose uptake by peripheral tissues. Insulin also suppresses ketogenesis and lipolysis, stimulates proper use of glucose by the cells, and reduces blood sugar levels. Only short-acting insulin is used for correction of hyperglycemia.

Regular insulin (Humulin R, Novolin R)

 

Regular insulin has an onset of action of 0.5-1 hours. Its peak effect occurs within 2-4 hours, and its usual duration of action is 4-6 hours.

Previous
Next

Electrolyte Supplement

Class Summary

Serum potassium levels initially are high or within the reference range in patients with DKA. This needs to be checked frequently, as values drop very rapidly with treatment. Supplements such as potassium chloride work to correct such electrolyte imbalances.

Potassium chloride (Klor-Con, K-Dur, Kaon Cl)

 

Potassium deficits are high in patients with diabetic ketoacidosis, even with paradoxically high K+ due to acidotic state, which shifts H+ into cells and K+ out of cells into blood. Repletion with potassium phosphate often thought unnecessary, although some recommend giving potassium phosphate to replete both of these electrolytes. Potassium replacement should be started with initial fluid replacement if potassium levels are normal or low. Monitor the potassium level every 1-2 hours initially.

Previous
Next

Alkalinizing Agents

Class Summary

These agents may be used as a temporizing measure in very severe acidosis and in patients who become hemodynamically unstable because of the acidosis.

Sodium bicarbonate (Neut)

 

Sodium bicarbonate is only infused if decompensated acidosis starts to threaten the patient's life, especially when associated with either sepsis or lactic acidosis. If sodium bicarbonate is indicated, 100-150 mL of 1.4% concentration is infused initially. This may be repeated every half hour if necessary. Rapid and early correction of acidosis with sodium bicarbonate may worsen hypokalemia and cause paradoxical cellular acidosis.

Previous
 
Contributor Information and Disclosures
Author

Osama Hamdy, MD, PhD Medical Director, Obesity Clinical Program, Director of Inpatient Diabetes Program, Joslin Diabetes Center; Assistant Professor of Medicine, Harvard Medical School

Osama Hamdy, MD, PhD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Diabetes Association

Disclosure: Received consulting fee from Merck Inc for speaking and teaching; Received consulting fee from Abbott Nutrition for consulting; Received grant/research funds from Metagenics for research support; Received grant/research funds from Neurometrix for research support.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences,and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Vasudevan A Raghavan, MBBS, MD, MRCP(UK) Director, Cardiometabolic and Lipid (CAMEL) Clinic Services, Division of Endocrinology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine

Vasudevan A Raghavan, MBBS, MD, MRCP(UK) is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Heart Association, National Lipid Association, Royal College of Physicians, and The Endocrine Society

Disclosure: Nothing to disclose.

Donald W Rucker, MD, MBA, MS Clinical Assistant Professor of Emergency Medicine, University of Pennsylvania School of Medicine

Donald W Rucker, MD, MBA, MS is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, American Medical Association, American Medical Informatics Association, and Society for Academic Emergency Medicine

Disclosure: Siemens Healthcare Salary Employment

David S Schade, MD Chief, Division of Endocrinology and Metabolism, Professor, Department of Internal Medicine, University of New Mexico School of Medicine and Health Sciences Center

David S Schade, MD is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, New Mexico Medical Society, New York Academy of Sciences, Society for Experimental Biology and Medicine, and The Endocrine Society

Disclosure: Nothing to disclose.

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and The Endocrine Society

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. 2008 Jun 25. [Medline].

  2. Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. 2009 Jul. 32(7):1164-9. [Medline]. [Full Text].

  3. Herrington WG, Nye HJ, Hammersley MS, Watkinson PJ. Are arterial and venous samples clinically equivalent for the estimation of pH, serum bicarbonate and potassium concentration in critically ill patients?. Diabet Med. 2012 Jan. 29(1):32-5. [Medline].

  4. Mrozik LT, Yung M. Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit. Aust Crit Care. 2009 Jun 26. [Medline].

  5. Bowden SA, Duck MM, Hoffman RP. Young children (12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes. 2008 Jun. 9(3 Pt 1):197-201. [Medline].

  6. Potenza M, Via MA, Yanagisawa RT. Excess thyroid hormone and carbohydrate metabolism. Endocr Pract. 2009 May-Jun. 15(3):254-62. [Medline].

  7. Zargar AH, Wani AI, Masoodi SR, et al. Causes of mortality in diabetes mellitus: data from a tertiary teaching hospital in India. Postgrad Med J. 2009 May. 85(1003):227-32. [Medline].

  8. Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ. 2011 Jul 7. 343:d4092. [Medline].

  9. Lin SF, Lin JD, Huang YY. Diabetic ketoacidosis: comparisons of patient characteristics, clinical presentations and outcomes today and 20 years ago. Chang Gung Med J. 2005 Jan. 28(1):24-30. [Medline].

  10. Pugliese G, Zanuso S, Alessi E, et al. Self glucose monitoring and physical exercise in diabetes. Diabetes Metab Res Rev. 2009 Sep. 25 Suppl 1:S11-7. [Medline].

  11. Weber C, Kocher S, Neeser K, et al. Prevention of diabetic ketoacidosis and self-monitoring of ketone bodies: an overview. Curr Med Res Opin. 2009 May. 25(5):1197-207. [Medline].

  12. Crossen SS, Wilson DM, Saynina O, Sanders LM. Outpatient Care Preceding Hospitalization for Diabetic Ketoacidosis. Pediatrics. 2016 Jun. 137 (6):[Medline].

  13. Jessup AB, Grimley MB, Meyer E, et al. Effects of Diabetic Ketoacidosis on Visual and Verbal Neurocognitive Function in Young Patients Presenting with New-Onset Type 1 Diabetes. J Clin Res Pediatr Endocrinol. 2015 Sep. 7 (3):203-10. [Medline]. [Full Text].

  14. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in diabetes. Diabetes Care. 2004 Jan. 27 Suppl 1:S94-102. [Medline].

  15. Arora S, Henderson SO, Long T, Menchine M. Diagnostic Accuracy of Point-of-Care Testing for Diabetic Ketoacidosis at Emergency-Department Triage: {beta}-Hydroxybutyrate versus the urine dipstick. Diabetes Care. 2011 Apr. 34(4):852-4. [Medline]. [Full Text].

  16. Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees JA, Courtney CH, et al. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med. 2011 May. 28(5):508-15. [Medline].

  17. Joint British Diabetes Societies Inpatient Care Group. The Management of Diabetic Ketoacidosis in Adults. March 2010. Available at http://www.diabetes.nhs.uk/document.php?o=1336. Accessed: June 27, 2011.

  18. Wallace TM, Matthews DR. Recent advances in the monitoring and management of diabetic ketoacidosis. QJM. 2004 Dec. 97(12):773-80. [Medline].

  19. Ma OJ, Rush MD, Godfrey MM, Gaddis G. Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. 2003 Aug. 10(8):836-41. [Medline].

  20. Brandenburg MA, Dire DJ. Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis. Ann Emerg Med. 1998 Apr. 31(4):459-65. [Medline].

  21. Goyal N, Miller JB, Sankey SS, Mossallam U. Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med. 2010 May. 38(4):422-7. [Medline].

  22. [Guideline] Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee WR, et al. Diabetic ketoacidosis. Pediatr Diabetes. 2007 Feb. 8(1):28-43. [Medline].

  23. Glaser NS, Wootton-Gorges SL, Buonocore MH, Marcin JP, Rewers A, Strain J, et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. 2006 Apr. 7(2):75-80. [Medline].

  24. Muir AB, Quisling RG, Yang MC, Rosenbloom AL. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care. 2004 Jul. 27(7):1541-6. [Medline].

  25. Hom J, Sinert R. Evidence-based emergency medicine/critically appraised topic. Is fluid therapy associated with cerebral edema in children with diabetic ketoacidosis?. Ann Emerg Med. 2008 Jul. 52(1):69-75.e1. [Medline].

  26. Bradley P, Tobias JD. An evaluation of the outside therapy of diabetic ketoacidosis in pediatric patients. Am J Ther. 2008 Nov-Dec. 15(6):516-9. [Medline].

  27. Chandu A, Macisaac RJ, Smith AC, Bach LA. Diabetic ketoacidosis secondary to dento-alveolar infection. Int J Oral Maxillofac Surg. 2002 Feb. 31(1):57-9. [Medline].

  28. Ai D, Roper TA, Riley JA. Diabetic ketoacidosis and clozapine. Postgrad Med J. 1998 Aug. 74(874):493-4. [Medline].

  29. Amemiya S. Constant infused glucose regimen during the recovery phase of diabetic ketoacidosis in children and adolescents with IDDM. Diabetes Care. 1998 Apr. 21(4):676-7. [Medline].

  30. Bohan JS. Chemical measurements in ketoacidosis. Arch Intern Med. 1999 Sep 27. 159(17):2089. [Medline].

  31. Brink SJ. Diabetic ketoacidosis: prevention, treatment and complications in children and adolescents. Diabetes Nutr Metab. 1999 Apr. 12(2):122-35. [Medline].

  32. Carroll MA, Yeomans ER. Diabetic ketoacidosis in pregnancy. Crit Care Med. 2005 Oct. 33(10 Suppl):S347-53. [Medline].

  33. Catalano C, Fabbian F, Di Landro D. Acute pulmonary oedema occurring in association with diabetic ketoacidosis in a diabetic patient with chronic renal failure. Nephrol Dial Transplant. 1998 Feb. 13(2):491-2. [Medline].

  34. Charfen MA, Fernández-Frackelton M. Diabetic ketoacidosis. Emerg Med Clin North Am. 2005 Aug. 23(3):609-28, vii. [Medline].

  35. Della Manna T, Steinmetz L, Campos PR, Farhat SC, Schvartsman C, Kuperman H. Subcutaneous use of a fast-acting insulin analog: an alternative treatment for pediatric patients with diabetic ketoacidosis. Diabetes Care. 2005 Aug. 28(8):1856-61. [Medline].

  36. Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990-96. Arch Dis Child. 1999 Oct. 81(4):318-23. [Medline].

  37. Fearon DM, Steele DW. End-tidal carbon dioxide predicts the presence and severity of acidosis in children with diabetes. Acad Emerg Med. 2002 Dec. 9(12):1373-8. [Medline].

  38. Fisken RA. Severe diabetic ketoacidosis: the need for large doses of insulin. Diabet Med. 1999 Apr. 16(4):347-50. [Medline].

  39. Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001 Jan 25. 344(4):264-9. [Medline].

  40. Green SM, Rothrock SG, Ho JD, Gallant RD, Borger R, Thomas TL, et al. Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med. 1998 Jan. 31(1):41-8. [Medline].

  41. Grimberg A, Cerri RW, Satin-Smith M, Cohen P. The "two bag system" for variable intravenous dextrose and fluid administration: benefits in diabetic ketoacidosis management. J Pediatr. 1999 Mar. 134(3):376-8. [Medline].

  42. Guenette MD, Hahn M, Cohn TA, Teo C, Remington GJ. Atypical antipsychotics and diabetic ketoacidosis: a review. Psychopharmacology (Berl). 2013 Mar. 226(1):1-12. [Medline].

  43. Hjort U, Christensen JH. Diabetic ketoacidosis and compliance. Lancet. 1998 Feb 28. 351(9103):674-5. [Medline].

  44. Hoffman WH, Locksmith JP, Burton EM, et al. Interstitial pulmonary edema in children and adolescents with diabetic ketoacidosis. J Diabetes Complications. 12(6):314-20. [Medline].

  45. Kannan CR. Bicarbonate therapy in the management of severe diabetic ketoacidosis. Crit Care Med. 1999 Dec. 27(12):2833-4. [Medline].

  46. Kaufman FR, Halvorson M. The treatment and prevention of diabetic ketoacidosis in children and adolescents with type I diabetes mellitus. Pediatr Ann. 1999 Sep. 28(9):576-82. [Medline].

  47. Kaufman FR, Halvorson M, Fisher L, Pitukcheewanont P. Insulin pump therapy in type 1 pediatric patients. J Pediatr Endocrinol Metab. 1999. 12 Suppl 3:759-64. [Medline].

  48. Kitabchi AE, Nyenwe EA. Hyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Endocrinol Metab Clin North Am. 2006 Dec. 35(4):725-51, viii. [Medline].

  49. Kreshak A, Chen EH. Arterial blood gas analysis: are its values needed for the management of diabetic ketoacidosis?. Ann Emerg Med. 2005 May. 45(5):550-1. [Medline].

  50. Laffel L. Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. Diabetes Metab Res Rev. 1999 Nov-Dec. 15(6):412-26. [Medline].

  51. Liss DS, Waller DA, Kennard BD, McIntire D, Capra P, Stephens J. Psychiatric illness and family support in children and adolescents with diabetic ketoacidosis: a controlled study. J Am Acad Child Adolesc Psychiatry. 1998 May. 37(5):536-44. [Medline].

  52. Mahoney CP, Vlcek BW, DelAguila M. Risk factors for developing brain herniation during diabetic ketoacidosis. Pediatr Neurol. 1999 Oct. 21(4):721-7. [Medline].

  53. Martin SL, Hoffman WH, Marcus DM, Passmore GG, Dalton RR. Retinal vascular integrity following correction of diabetic ketoacidosis in children and adolescents. J Diabetes Complications. 2005 Jul-Aug. 19(4):233-7. [Medline].

  54. McDonnell CM, Pedreira CC, Vadamalayan B, Cameron FJ, Werther GA. Diabetic ketoacidosis, hyperosmolarity and hypernatremia: are high-carbohydrate drinks worsening initial presentation?. Pediatr Diabetes. 2005 Jun. 6(2):90-4. [Medline].

  55. Moller N, Foss AC, Gravholt CH, Mortensen UM, Poulsen SH, Mogensen CE. Myocardial injury with biomarker elevation in diabetic ketoacidosis. J Diabetes Complications. 2005 Nov-Dec. 19(6):361-3. [Medline].

  56. Newton CA, Raskin P. Diabetic ketoacidosis in type 1 and type 2 diabetes mellitus: clinical and biochemical differences. Arch Intern Med. 2004 Sep 27. 164(17):1925-31. [Medline].

  57. Paton RC, Sathiavageeswaran M. Severe diabetic ketoacidosis. Diabet Med. 1999 Oct. 16(10):884. [Medline].

  58. Reichel A, Rietzsch H, Kohler HJ, Pfutzner A, Gudat U, Schulze J. Cessation of insulin infusion at night-time during CSII-therapy: comparison of regular human insulin and insulin lispro. Exp Clin Endocrinol Diabetes. 1998. 106(3):168-72. [Medline].

  59. Smith CP, Firth D, Bennett S, Howard C, Chisholm P. Ketoacidosis occurring in newly diagnosed and established diabetic children. Acta Paediatr. 1998 May. 87(5):537-41. [Medline].

  60. Timmons JA, Myer P, Maturen A, et al. Use of beta-hydroxybutyric acid levels in the emergency department. Am J Ther. 1998 May. 5(3):159-63. [Medline].

  61. Umpierrez GE, Cuervo R, Karabell A, Latif K, Freire AX, Kitabchi AE. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care. 2004 Aug. 27(8):1873-8. [Medline].

  62. Umpierrez GE, Smiley D, Kitabchi AE. Narrative review: ketosis-prone type 2 diabetes mellitus. Ann Intern Med. 2006 Mar 7. 144(5):350-7. [Medline].

  63. Viallon A, Zeni F, Lafond P, et al. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis?. Crit Care Med. 1999 Dec. 27(12):2690-3. [Medline].

  64. Wagner A, Risse A, Brill HL, et al. Therapy of severe diabetic ketoacidosis. Zero-mortality under very-low-dose insulin application. Diabetes Care. 1999 May. 22(5):674-7. [Medline].

  65. Warner EA, Greene GS, Buchsbaum MS, Cooper DS, Robinson BE. Diabetic ketoacidosis associated with cocaine use. Arch Intern Med. 1998 Sep 14. 158(16):1799-802. [Medline].

  66. Whiteman VE, Homko CJ, Reece EA. Management of hypoglycemia and diabetic ketoacidosis in pregnancy. Obstet Gynecol Clin North Am. 1996 Mar. 23(1):87-107. [Medline].

  67. Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care. 2006 May. 29(5):1150-9. [Medline].

  68. Yan SH, Sheu WH, Song YM, Tseng LN. The occurrence of diabetic ketoacidosis in adults. Intern Med. 2000 Jan. 39(1):10-4. [Medline].

  69. Younis N, Austin MJ, Casson IF. A respiratory complication of diabetic ketoacidosis. Postgrad Med J. 1999 Dec. 75(890):753-4. [Medline].

  70. Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors May Predispose to Ketoacidosis. J Clin Endocrinol Metab. 2015 Aug. 100 (8):2849-52. [Medline].

Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.