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
[33]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
[34]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.[35]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
SGLT-2 inhibitor-associated DKA in patients with type 2 diabetes is typically precipitated by insulin omission or significant dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive alcohol intake. DKA prevention strategies should include withholding SGLT-2 inhibitors when precipitants are present, and avoiding insulin omission or large insulin dose reduction.[36]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
[37]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
[38]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
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.[19]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