Rationale:

• Insulin is required to treat the hyperglycemia and ketosis.
• Insulin results in a shift of potassium from the extracellular space to the intracellular space; therefore, treatment with insulin in the hypokalemic patient could result in profound hypokalemia and serious arrhythmias.
• Insulin therapy is required to suppress ketosis.
• Inadequate therapy results in prolongation of the ketosis and elevation in anion gap.

Evidence:

• Early reduction in insulin therapy because of normalization of blood glucose will prolong the duration of DKA (23).
• Low-dose insulin therapy is as effective as older high-dose regimens (24).
• DKA can be treated without initial bous of regular insulin (25).
• Rapid-acting insulin analogs are as efficacious as regular insulin in mild-to-moderate DKA (26; 27; 28).

Comments:

• Cardiac monitoring may give an indication of potassium concentration and allow early administration of insulin if there is evidence of hypokalemia.