Approach Considerations
The treatment of patients who present with diabetic ketoacidosis (DKA) is fairly standardized and does not differ according to their Aβ phenotype. Detailed discussion of DKA treatment can be found in the following Medscape Drugs & Diseases articles: Diabetic Ketoacidosis and Pediatric Diabetic Ketoacidosis.
At the time of initial presentation with new-onset diabetes and DKA, determining which "type" of diabetes is present is not possible or needed. Predicting the need for long-term insulin treatment is also not possible. Therefore, after an initial episode of DKA, all affected patients should be continued on insulin treatment for some time period (typically weeks to months). Patients who are found to be β- should be continued on insulin indefinitely.
No generally accepted guidelines are available for disposition of DKA after initial treatment. Clinical experience and practice suggests that patients with mild DKA may be safely discharged with close follow-up after successful initial treatment. A large, multicenter study of US emergency departments found that 13% of patients were discharged; approximately one fourth were admitted to an intensive care unit (ICU). [20] Appropriate initial treatment may decrease the length of stay and the need for ICU admission. [21]
Medical Care
For newly diagnosed diabetic patients discharged after a first episode of diabetic ketoacidosis (DKA), a typical insulin regimen is a total of 0.6-0.7 units of insulin/kg/day. Typically, two thirds of the total daily dose is given before breakfast, and one third is given before dinner. Two thirds of the dose is given as intermediate-acting insulin (NPH), and one third is given as short-acting insulin (regular insulin).
About 4 to 8 weeks after resolution of DKA, perform an assessment to measure β-cell functional reserve and autoimmunity by fasting blood glucose.
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Patients are classified as β- (absent β-cell function) if the fasting serum C-peptide concentration is less than 0.33 nmol/L (< 1 ng/mL) and the peak serum C-peptide response to glucagon (measured at 5 and 10 min after intravenous injection of 1 mg of glucagon) is less than 0.5 nmol/L (1.5 ng/mL).
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Patients are classified as β+ (adequate β-cell function), if the fasting serum C-peptide concentration is at least 0.33 nmol/L (≥1 ng/mL), or the peak serum C-peptide response to glucagon is at least 0.5 nmol/L (≥1.5 ng/mL).
These cut-offs accurately predict β-cell function after 6 months and 1 year. [14] The long-term dependence of patients on insulin is predicted by their autoimmune status; hence, also assess their autoimmunity against β cells. Positive autoimmunity indicates long-term dependence on insulin.
Patients with the ketosis-prone A-β+ phenotype can attempt oral hypoglycemic agents under careful supervision. After discontinuation of insulin therapy, initiate oral therapy with metformin or low-dose sulphonylurea. The duration of insulin withdrawal and initiation of oral hypoglycemics is variable and may range from 10 weeks to 14 weeks or longer. Patients with positive autoimmunity or with inadequate insulin secretion are more likely to relapse; these individuals should continue on insulin therapy with careful monitoring for recurrence of hyperglycemia or ketosis. [6]
Long-term management of diabetes is discussed in the following Medscape Drug & Diseases articles Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus, Pediatric Type 1 Diabetes Mellitus, and Pediatric Type 2 Diabetes Mellitus.
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Medication
- Medication Summary
- Antidiabetics, Insulins
- Antidiabetics, Biguanides
- Antidiabetics, Amylinomimetics
- Antidiabetics, Sulfonylureas
- Hypoglycemia Antidotes
- Antidiabetics, Meglitinide Derivatives
- Antidiabetics, Alpha-Glucosidase Inhibitors
- Antidiabetics, Thiazolidinediones
- Antidiabetics, Glucagonlike Peptide-1 Agonists
- Antidiabetics, Dipeptidyl Peptidase IV Inhibitors
- Bile Acid Sequestrants
- Antidiabetics, Intermediate-Acting Insulins
- Antiparkinson Agents, Dopamine Agonists
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- References
