Euglycemic DKA

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Adan A., MD -

Great discussion on EDKA...

Now I have a question for the experts and masses on regular DKA.

About 10 yrs ago, I worked at a hospital where all DKA patients were seen by endocrine in the ED. Yes, that's right. Endocrinologist coming to the ED. (Not in the U.S.A.). The endo guy will review the management started by the EP, and will often add a dose of long acting SQ insulin to the orders, along with the insulin drip. I had not seen or heard about such approach, so I asked him why he did it. His response made a lot of sense. He said that by giving a long acting insulin was his way to ensure the pt will stop gluconeogenesis and partially, ketogenesis. Basically ensuring a "smooth landing" once the rapid insulin drip was discontinued.

Anyone with experience or comments on this approach?

Cheers!

Brit L. -

Great question! Use of long-acting insulins such as glargine or detemir in those with hyperglycemic DKA is supported by the literature. It may result in more rapid resolution of DKA, as well as faster and smoother discontinuation of the IV insulin infusion the patient is receiving. It’s also helpful in patients who normally receive basal insulin at home and have mild DKA. In these patients, administration of their basal insulin may assist in avoiding an ICU admission. Long-acting basal insulin is even suggested by the UK guidelines on DKA management!

These studies support its use:
Doshi P, Potter AJ, De Los Santos D, Banuelos R, Darger BF, Chathampally Y. Prospective randomized trial of insulin glargine in acute management of diabetic ketoacidosis in the emergency department: a pilot study. Acad Emerg Med. 2015 Jun;22(6):657-62.

Houshyar J, Bahrami A, Aliasgarzadeh A. Effectiveness of Insulin Glargine on Recovery of Patients with Diabetic Ketoacidosis: A Randomized Controlled Trial. J Clin Diagn Res. 2015 May;9(5):OC01-5.

Rappaport SH, Endicott JA, Gilbert MP, Farkas JD, Clouser RD, McMillian WD. A Retrospective Study of Early vs Delayed Home Dose Basal Insulin in the Acute Management of Diabetic Ketoacidosis. J Endocr Soc. 2019 Apr 11;3(5):1079-1086.

Barski L, Brandstaetter E, Sagy I, Jotkowitz A. Basal insulin for the management of diabetic ketoacidosis. Eur J Intern Med. 2018 Jan;47:14-16.

Also, Josh Farkas has a great post on long-acting insulins at https://emcrit.org/pulmcrit/early-basal-insulin/

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