Diabetic Ketoacidosis: Considerations and Residual Controversies in Management After the 2024 ADA, EASD, JBDS, AACE,...

Diabetic ketoacidosis (DKA) is the most serious and life-threatening complication of Diabetes Mellitus (DM), characterized by the triad of hyperglycemia, ketonemia, and anion gap metabolic acidosis. DKA is more common in young people with type 1 diabetes (T1D) but can also occur in patients with type 2 diabetes (T2D) and in pregnant women with pregestational T1D or T2D or gestational DM. Moreover, DKA may be a rare complication of immune check-point inhibitor therapy. Euglycemic DKA (eDKA) is a variant of DKA with normal or minimally elevated serum glucose associated with using sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of anti-hyperglycemic medications. Prompt identification of DKA in the emergency setting is mandatory, and the management of its critical aspects and its possible underlying precipitating factors are often life-changing choices for patients. Despite diagnostic and therapeutic improvements, DKA still stands as one of the main causes of morbidity and mortality in DM individuals. Recently, an inter-society consensus report has been published to provide up-to-date knowledge on DKA. Nevertheless, controversies concerning the clinical management of this acute complication of DM remain to be unfolded and high-quality evidence is lacking in concern to solve such critical aspects. This narrative review aims to explore and discuss DKA, its epidemiology, pathogenesis, diagnosis, clinical onset, and treatment, highlighting some of the main remaining open controversies.