Diabetic Ketoacidosis Author: Heather Lochnan, MD
Approved for review - 2009-03-25
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Drug Therapy
  • Begin rehydration for DKA immediately.
  • Begin insulin therapy when serum electrolytes are available.
  • Monitor potassium levels closely and replace potassium deficit in all patients with DKA.
  • Determine the need for bicarbonate therapy.
Drug Treatment for Diabetic Ketoacidosis (table)

Begin rehydration for DKA immediately. BC

  • Begin treatment with normal saline (0.9% sodium chloride).
  • Reassess fluid replacement hourly.
  • Switch to 0.45% sodium chloride after the initial bolus if the serum sodium is high or normal.
  • Begin fluid infusion at an initial rate of 15 to 20 mL/kg·h depending on the fluid deficit; continue fluid therapy at 4 to 14 mL/kg·h after initial bolus; switch to dextrose containing fluids once the blood sugar level is approximately 250 mg/dL.
  • Use extra caution in children, who have higher incidence of cerebral edema associated with DKA therapy, and in children at risk of pulmonary edema.
  • See table Drug Treatment for Diabetic Ketoacidosis.
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Begin insulin therapy when serum electrolytes are available. B

  • Begin treatment with iv regular insulin if serum potassium is ≥3.3 mEq/L.
  • If K is <3.3 mEq/L, hold insulin, replace K at 20 to 30 mEq/h (may add 40 to 60 mEq of KCl in 500 mL of 1/2 NS) and monitor frequently.
  • Use an initial bolus of 0.1 U/kg·h iv, followed by an infusion of 0.1 U/kg·h (alternatively, give regular insulin infusion at the rate of 0.14 U/kg·h without initial bolus).
  • If the blood glucose is <200 mg/dL, begin treatment with 5% dextrose in 1/2 NS; insulin dose may then be reduced to 0.05 to 0.1 U/kg·h; monitor therapy using the anion gap and presence of serum ketones.
  • Change to multiple dose insulin regimen when DKA resolves.
  • As an alternative to regular insulin infusion, treat uncomplicated mild-to-moderate DKA in adults with subcutaneously administered rapid acting insulin analogs (lispro, aspart) at 0.2 U/kg every 2 hours after initial bolus of 0.3 U/kg.
  • Treat children with mild-to-moderate DKA with subcutaneous lispro at 0.15 U/kg given every 2 hours.
  • See table Drug Treatment for Diabetic Ketoacidosis.
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Monitor potassium levels closely and replace potassium deficit in all patients with DKA. BC

  • Measure serum potassium at baseline, at 1 hour, then every 2 hours during initial therapy.
  • Consider ECG and cardiac monitoring to monitor potassium status.
  • Initiate potassium therapy once the serum potassium level is <5.5 mEq/L unless the patient is anuric or in significant renal failure.
  • If potassium level is <3.3 mEq/L, replace at 20 to 30 mEq/h; if potassium is >3.3 and <5.5 mEq/L, replace at approximately 20 mEq/h; use 2/3 as KCl and 1/3 as KPO4.
  • See table Drug Treatment for Diabetic Ketoacidosis.
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Determine the need for bicarbonate therapy. BC

  • Consider bicarbonate therapy only if pH is ≤7.0.
  • If pH is <6.9, give 100 mmol NaHCO3 in 400 mL of water at 200 mL/h.
  • If pH is 6.9 to 7.0, give 50 mmol of NaHCO3 in 200 mL of sterile water.
  • Deliver each infusion at a rate of 200 mL/h and repeat every 2 hours until the pH is >7.0.
  • See table Drug Treatment for Diabetic Ketoacidosis.
Background | Back to top

FAQs
Ebenezer A. Nyenwe, MD, editorial consultant, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Heather Lochnan, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Deborah Korenstein, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Richard B. Lynn, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.

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