Patient discussions

Following a diabetic ketoacidosis (DKA) admission, review the patient’s understanding of their diagnosis and management plan (including monitoring, glycemic goals and how and when to take their drug treatment) and how to avoid and detect further DKA (including sick day management) prior to discharge.[4]

Review diabetes management and DKA risk periodically with all patients with diabetes. This should include:

  • When to contact the healthcare provider

  • Blood glucose goals and the use of supplemental short- or rapid-acting insulin during illness

  • Means to suppress fever and treat infection

  • Initiation of an easily digestible fluid diet containing electrolytes and glucose during illness

  • Advice to always continue insulin during illness and to seek professional advice early

The patient (or family member or caregiver) must be able to accurately measure and record blood glucose, insulin administration, temperature, respiratory rate, and pulse. Blood ketones (beta-hydroxybutyrate; BOHB) should be checked when blood glucose is >300 mg/dL (>16.7 mmol/L); if levels are elevated, the patient should present to the hospital for further evaluation. The frequency of blood glucose monitoring depends on the patient's clinical condition: in uncontrolled diabetes (hemoglobin A1c >7.0% [>53 mmol/mol]), it is recommended to check blood glucose before each meal, plus at bedtime.​[112]

DKA risk is increased with sodium-glucose cotransporter-2 (SGLT2) inhibitors (e.g., dapagliflozin, canagliflozin, empagliflozin, ertugliflozin) and the dual SGLT1/SGLT2 inhibitor sotagliflozin in patients with type 1 diabetes and, to a lesser degree, those with type 2 diabetes. SGLT2 inhibitor- and dual SGLT1/2 inhibitor-associated DKA is rare in patients with type 2 diabetes, may present with euglycemia, and is typically precipitated by insulin omission or significant dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets (e.g., ketogenic diet) or prolonged fasting, or excessive alcohol intake.[4]​ Patients treated with SGLT2 and dual SGLT1/2 inhibitors, especially those with type 1 diabetes or ketosis-prone type 2 diabetes, and/or on a ketogenic diet, should be educated about the risk of DKA and how to prevent and recognize this, and should be provided with the tools to measure their ketones.[4]​ DKA prevention strategies should include withholding SGLT2 and dual SGLT1/2 inhibitors when precipitants are present (e.g., discontinue 3-4 days before scheduled surgery) and avoiding insulin omission or large insulin dose reduction.[4][53][54]

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