Patient discussions
Management should be reviewed periodically with all patients. 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.
Patients should be advised to always continue insulin during illness and to seek professional advice early.
Sodium-glucose cotransporter 2 (SGLT-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.[3] Patients treated with SGLT-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 be provided with the tools to measure their ketones.[3] To reduce the risk of DKA, it is important to assess, and regularly reassess, susceptibility to DKA in those with type 1 diabetes being treated with an SGLT-2 inhibitor, in addition to providing regular patient education on DKA.[3] DKA prevention strategies should include withholding SGLT-2 inhibitors when precipitants are present (e.g., discontinue 3-4 days before scheduled surgery), and avoiding insulin omission or large insulin dose reduction.[3][37][38]
The patient (or family member or carer) must be able to accurately measure and record blood glucose, insulin administration, temperature, respiratory rate, and pulse. Blood ketone (BOHB) should be checked when blood glucose is >300 mg/dL and, if it is high, 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 (HbA1c >7.0%), it is recommended to check blood glucose before each meal, plus at bedtime.[1][88]
It is recommended that the patient’s understanding of their diagnosis and management plan (including monitoring, glycemic goals and how and when to take their medications), and how to avoid and detect further DKA (including sick day management), is reviewed prior to discharge following a DKA admission.[3]
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