Patient education about management of their diabetes during periods of mild illness (sick-day management) is vital for preventing DKA. This should include information on when to contact a healthcare professional, blood glucose monitoring, use of insulin, and initiation of appropriate nutrition during illness. This information should be reinforced with patients periodically. Patients should be advised to continue insulin and to seek professional advice early in the course of the illness. Close follow-up is very important, as it has been shown that 3-month visits to the endocrine clinic will reduce the number of emergency department admissions for DKA.[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43.
https://care.diabetesjournals.org/content/32/7/1335.full
http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
[34]Runyan JW Jr, Zwaag RV, Joyner MB, et al. The Memphis diabetes continuing care program. Diabetes Care. 1980 Mar-Apr;3(2):382-6.
http://www.ncbi.nlm.nih.gov/pubmed/7389550?tool=bestpractice.com
[35]Vanelli M, Chiari G, Ghizzoni L, et al. Effectiveness of a prevention program for diabetes ketoacidosis in children. An 8-year study in schools and private practices. Diabetes Care. 1999 Jan;22(1):7-9.
http://www.ncbi.nlm.nih.gov/pubmed/10333896?tool=bestpractice.com
Self-monitoring of ketones is also emerging as a potential strategy.[36]Weber C, Kocher S, Neeser K, et al. Prevention of diabetic ketoacidosis and self-monitoring of ketone bodies: an overview. Curr Med Res Opin. 2009 May;25(5):1197-207.
http://www.ncbi.nlm.nih.gov/pubmed/19327102?tool=bestpractice.com
During illness (or when experiencing other stressful events such as trauma or surgery) it may be advisable for ketosis-prone individuals to monitor their ketones, in addition to increasing frequency of blood glucose monitoring.[3]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1
Pregnant individuals with type 1 diabetes should be counseled about the increased risk of DKA during pregnancy, how to avoid and recognize this, and be provided with ketone-monitoring tools (as DKA in pregnancy is associated with a high risk of stillbirth).[3]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1
Autoantibody testing may be used to screen family members of those with type 1 diabetes, to detect other individuals at risk of developing the disease: providing these individuals with diabetes and DKA education and follow-up has been demonstrated to result in more prompt diagnosis of diabetes and to prevent DKA.[3]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1
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]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1
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]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1
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]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1
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]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1
[37]Henry RR, Dandona P, Pettus J, et al. Dapagliflozin in patients with type 1 diabetes: A post hoc analysis of the effect of insulin dose adjustments on 24-hour continuously monitored mean glucose and fasting β-hydroxybutyrate levels in a phase IIa pilot study. Diabetes Obes Metab. 2017 Jun;19(6):814-21.
http://www.ncbi.nlm.nih.gov/pubmed/28098426?tool=bestpractice.com
[38]Goldenberg RM, Berard LD, Cheng AY, et al. SGLT2 inhibitor-associated diabetic ketoacidosis: clinical review and recommendations for prevention and diagnosis. Clin Ther. 2016 Dec;38(12):2654-64.e1.
http://www.ncbi.nlm.nih.gov/pubmed/28003053?tool=bestpractice.com
Many cases can be prevented by better access to medical care, proper education, and effective communication with a healthcare provider during an intercurrent illness. Adequate supervision by family and healthcare provider may decrease the rates of hospitalization and mortality.[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43.
https://care.diabetesjournals.org/content/32/7/1335.full
http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
[39]Kitabchi AE. Editorial. Hyperglycemic crises: improving prevention and management. Am Fam Physician. 2005 May 1;71(9):1659-60.
https://www.aafp.org/afp/2005/0501/p1659.html
http://www.ncbi.nlm.nih.gov/pubmed/15887446?tool=bestpractice.com
Hospitals should ensure that basal insulin doses are not omitted or delayed for admitted patients, particularly during care transitions, through use of electronic alerts and ongoing staff education.[3]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1
Hospital admission with DKA, and recurrent admissions in particular, may be considered a "red flag" for triggering psychiatric assessment so that mental health problems can be addressed and further admissions with DKA prevented.[20]Price HC, Ismail K, Joint British Diabetes Societies (JBDS) for Inpatient Care. Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS): guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings. Diabet Med. 2018 Aug;35(8):997-1004.
https://www.diabetes.org.uk/professionals/resources/shared-practice/inpatient-and-hospital-care/joint-british-diabetes-society-for-inpatient-care/Management-of-diabetes-in-adults-and-children-with-psychiatric-disorders-in-inpatient-settings
http://www.ncbi.nlm.nih.gov/pubmed/30152583?tool=bestpractice.com
Referral to a behavioral health professional is advisable for youth experiencing recurrent hospitalization for DKA.[3]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1
Diabetes technology can also be used to reduce DKA risk, such as insulin pump therapy in youth with type 1 diabetes and the use of intermittently-scanned continuous glucose monitoring.[3]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S1-321.
https://diabetesjournals.org/care/issue/47/Supplement_1