Developing a Protocol for Management of Euglycemic Diabetic Ketoacidosis

Euglycemic diabetic ketoacidosis (euDKA) has been described since the 1970s, however the incidence appears to be increasing in association with the increased use of sodium-glucose cotransporter 2 inhibitor (SGLT2i) medications. Traditional hospital-based DKA protocols in which an insulin infusion is adjusted based on glucose levels are not effective in euDKA due to the presence of euglycemia which limits the capacity for insulin administration. This review was completed to review the data on euDKA and introduce a protocol for targeted management of this condition.

Data comparing euDKA outcomes to traditional hyperglycemia DKA demonstrate longer hospital length of stay and mean time to anion gap closure in euDKA based on current DKA management standards. Furthermore, the increase in prescribing SGLT2i medications thereby increases the risk of euDKA. At present, there are no reported protocols specific for euDKA and it is not directly addressed in the most recent guidelines issued by Endocrinology specialty societies. We created a protocol within our hospital intensive care unit to standardize treatment of euDKA using fixed insulin infusion and titration of dextrose-containing fluids. The protocol has been approved by our hospital regulatory committees and is currently being utilized in intensive care units. Future studies should review ongoing safety and efficacy of protocol use in various hospital settings.