TITLE: Management of euglycemic diabetic ketoacidosis compared to hyperglycemic diabetic ketoacidosis in intensive care patients
AUTHORS: Lily Gardner, PharmD; Jennifer Bingham, PharmD, MPH, BCPS; Mona Shah, PharmD, MHA, BCPS
LEARNING OBJECTIVE: Identify challenges in drug therapy management for patients with euglycemic diabetic ketoacidosis.
SELF ASSESSMENT QUESTION: When would it be appropriate to discontinue an insulin drip for a patient being treated for euglycemic diabetic ketoacidosis?
- When blood glucose is less that 180 mg/dL
- When the anion gap has closed
- An insulin drip is not necessary to manage DKA if blood glucose is < 250 mg/dL
- If a hypoglycemic event has occurred
BACKGROUND: While diabetic ketoacidosis (DKA) is a widely known, life-threatening complication of diabetes mellitus, euglycemic DKA is a more rare, but just as serious condition characterized by ketoacidosis in the absence of significant hyperglycemia. Euglycemic DKA is challenging to diagnose and treat because of the relatively low blood glucose levels compared to classic DKA presentations. This study aims to evaluate the appropriateness of drug therapy management of euglycemic diabetic ketoacidosis compared to that of hyperglycemic diabetic ketoacidosis.
METHODOLOGY: This study is a retrospective chart review that includes adult patients admitted to the intensive-care unit at a community teaching hospital with an admission diagnosis of either diabetic ketoacidosis or hyperosmolar hyperglycemic state between January 1, 2023 and December 31, 2023. Patients whose treatment began in the emergency department who were later transferred to the intensive-care unit were also included. Minors and pregnant patients were excluded as well as patients who died or had comfort measures initiated within 48 hours of admission. Euglycemic DKA was defined as DKA in patients presenting with blood glucose level < 250 mg/dL. Patient drug regimens were evaluated for use of SGLT2 inhibitors, duration of therapy with intravenous insulin, and initiation of subcutaneous insulin. Insulin therapy management was considered to be appropriate if anion gap was closed at the time of intravenous insulin discontinuation, bolus insulin was initiated at least two hours prior to discontinuation of intravenous insulin, and no episodes of hypoglycemia occurred.
RESULTS: During the study time period, 34 patients were identified as having been treated in the intensive care unit with an admission diagnosis of either diabetic ketoacidosis or hyperosmolar hyperglycemic state. Two patients were excluded due to death or initiation of comfort measures within 48 hours of admission. The baseline characteristics of the 32 patients evaluated included an average age of 54 and A1c of 11.6%. Twenty-two (63%) patients were males, ten (31%) were white, and nine (28%) were black or African American. Average hospital length of stay was 6 days and average duration of ICU admission was 1.6 days. Seven patients (22%) had euglycemic DKA (blood glucose < 250 mg/dL) while the remaining 25 were treated for hyperglycemic DKA.
Drug therapy management was considered to be appropriate in all aspects in only 28.6% of euglycemic DKA patients compared to 60% of hyperglycemic DKA patients. The most common reason that drug therapy was considered inappropriate in both euglycemic and hyperglycemic patients was that subcutaneous bolus insulin was not initiated at least two hours prior to the discontinuation of the intravenous insulin drip (57.1%, 40%). A higher percentage of euglycemic DKA patients (14.3%) experienced a hypoglycemic event compared to hyperglycemic patients (12%).
CONCLUSIONS: Treating patients with euglycemic DKA can be challenging due to the need to continue insulin therapy in order to resolve metabolic acidosis despite normal to low blood glucose levels. Evaluating appropriateness of therapy in this patient population compared to that of patients presenting with hyperglycemic DKA is helpful to improve education and guidance regarding drug therapy management for future patients.
