Primary prevention
Patient education about management of their diabetes during periods of mild illness (sick-day management) is vital for preventing diabetic ketoacidosis (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; it has been shown that 3-month visits to the endocrine clinic will reduce the number of emergency department admissions for DKA.[50][51] 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.[4]
The American Diabetes Association (ADA) advises that people with type 1 diabetes and other forms of diabetes at risk for DKA should not use recreational cannabis in any form due to the risk of cannabis hyperemesis syndrome, which is a risk factor for DKA.[4]
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.[4]
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 earlier diagnosis of diabetes and prevention of DKA.[4] Screening programs are available in some countries, including the US, Australia, and some parts of Europe.[4] The ADA has produced a staging system for type 1 diabetes based on clinical features, glycemic levels, and the presence of islet cell autoantibodies and autoantibodies to insulin, glutamic acid decarboxylase (GAD), islet antigen 2 (IA-2), or zinc transporter 8 (ZnT8):[4]
Stage 1: is the presence of autoimmunity in the absence of dysglycemia (presymptomatic)
Stage 2: is autoimmunity and dysglycemia in the prediabetic range (presymptomatic)
Stage 3: is clinical type 1 diabetes with autoimmunity and overt hyperglycemia (symptomatic)
The ADA and European Association for the Study of Diabetes have published guidelines recommending periodic medical monitoring, including regular assessment of glucose levels and regular education about symptoms of diabetes and DKA, for people who test positive for islet autoantibodies.[52] When multiple autoantibodies are identified, referral to a specialized center for further evaluation and/or consideration of a clinical trial or approved therapy to potentially delay development of clinical diabetes should be considered.[4] See Type 1 Diabetes.
Sodium-glucose cotransporter-2 (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] The ADA recommends that these drugs should be avoided in cases of severe illness, in people with ketonemia or ketonuria, and during prolonged fasting and surgical procedures.[4] Patients treated with SGLT2 inhibitors or the dual SGLT1/2 inhibitor sotagliflozin (especially patients 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 it, and be provided with 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] An example of a risk mitigation strategy is the “STOP DKA” protocol, which was designed for patients with type 1 diabetes on SGLT2 or dual SGLT1/2 inhibitors: patients are advised to be alert for symptoms of DKA, such as lethargy, loss of appetite, nausea, and abdominal pain, and if present, to stop their SGLT2 or dual SGLT1/2 inhibitor, test for ketones, maintain fluid and carbohydrate intake, and use maintenance and supplemental insulin.[55]
Many cases can be prevented by better access to medical care, proper education, and effective communication with a healthcare provider during an intercurrent illness. Omission or insufficient use of insulin therapy is a major cause of DKA admissions.[1] 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.[4]
Diabetes technology can also be used to reduce DKA risk, such as insulin pump therapy in people with type 1 diabetes and the use of intermittently-scanned and real-time continuous glucose monitoring (CGM).[4][56] Use of CGM in patients with type 1 diabetes (regardless of insulin delivery method) has been shown to result in significant reductions in hospitalizations for DKA, as well as reductions in hemoglobin A1c, fewer severe hypoglycemic events, and increased time in range.[57]
The table that follows summarizes recommendations for primary prevention of diabetic ketoacidosis (DKA) taken from the American Diabetes Association (ADA) standards of care in diabetes.[4]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Adult with type 1 diabetes
All
Intervention
Insulin-containing regimen; diabetes self-management education and support; consider continuous glucose monitoring (CGM)
Insulin-containing regimen:
Give insulin in a defined treatment plan tailored to the individual. For most adults with type 1 diabetes, continuous subcutaneous insulin infusion or multiple daily doses of prandial (injected or inhaled) and basal insulin is the preferred regimen.
Advise people treated with intensive insulin therapy not to stop or hold their basal insulin even if not eating. Provide detailed instructions on insulin dose adjustments in the setting of illness or fasting.
It is recommended that automated insulin delivery systems are considered for all adults with type 1 diabetes who are capable of using the device safely.
Diabetes self-management education and support:
Advise all people with diabetes to participate in diabetes self-management education and support.
Programs may be offered in group or individual settings. Consider offering programs via telehealth and/or digital interventions as needed.
Provide structured education on the recognition, prevention and management of hyperglycemic crises to all people with type 1 diabetes. In particular:
Offer those at risk of DKA education on the early signs and symptoms of DKA.
Provide people at risk for DKA with appropriate tools for accurate ketone measurement (urine and/or blood ketone tests).
Provide education on timely self-management of hyperglycemia and ketonemia (‘sick day advice’) to prevent clinical deterioration and need for acute care.
Advise people who are concerned about, or who are experiencing, DKA to contact their diabetes team immediately.
Advise people at risk for DKA to measure urine or blood ketones in the presence of symptoms and potential precipitating factors (e.g., illness, missed insulin doses), particularly if glucose levels exceed 200 mg/dL (11.1 mmol/L).
Advise people to seek immediate medical attention if unable to tolerate oral hydration, if blood glucose levels do not improve with insulin administration, if altered mental status is present, or if any signs of worsening illness occur.
CGM:
Recommend the use of CGM devices from the time of diagnosis for all people with diabetes on any type of insulin therapy. It is recommended that the choice of CGM device is made based on the individual’s circumstances, preferences and needs.
The individual must be capable of using the device safely (either by themselves or with a caregiver).
Goal
Optimal diabetes self-management, including prevention of hyperglycemia and DKA
Insulin-containing regimen:
The goal is to prevent DKA and minimize clinically relevant hypoglycemia while achieving the individual’s glycemic goals.
It is recommended that the treatment plan and insulin-taking behavior is reevaluated at regular intervals (e.g., every 3–6 months) and adjusted to incorporate specific factors that impact choice of treatment and ensure achievement of individualized glycemic goals.
Diabetes self-management and support is recommended at least on an annual basis, and is also recommended:
at diagnosis,
when the person with diabetes is not meeting treatment goals,
when complicating factors develop (medical, physical, and psychosocial), and
when transitions in life and care occur.
CGM:
The goal is better glycemic control (including time in range) and reduced rates of diabetic complications including DKA.
Consideration of CGM needs is recommended at all clinical encounters (initial visit, all follow-up visits and the annual visit).
With intercurrent illness
Intervention
Reevaluation of diabetes treatment plan
Assess any individual with diabetes experiencing acute illness for the need for more frequent monitoring of glucose; ketosis-prone people also require urine or blood ketone monitoring.
Reevaluate diabetes treatment during intercurrent illness and make adjustments as appropriate.
Goal
Prevention of life-threatening conditions relating to hyperglycemia
With hospital admission
Intervention
Individualized approach to glycemic management
An individualized approach to glycemic management is recommended during hospital admission, taking into account factors such as:
prior home use and dose of insulin or non-insulin therapy,
prior HbA1c,
current glucose levels,
oral intake, and
duration of diabetes.
An insulin schedule with basal and correction components is indicated for all hospitalized individuals with type 1 diabetes, even when taking nothing by mouth, with the addition of prandial insulin when eating.
It is important that hospitals ensure that basal insulin is not omitted or delayed for people with type 1 diabetes, especially during care transitions, and that ongoing prescriber and nursing education is provided.
Corticosteroid therapy is common in hospitalized individuals and carries a particularly high risk of hyperglycemia. It is recommended that clinicians working within a hospital setting consider corticosteroid type and duration of action when determining appropriate insulin treatments. Careful blood glucose monitoring is crucial. Daily adjustment of insulin may be required based on levels of glycemia and anticipated changes in type, dose, and duration of corticosteroids.
In particular, the perioperative period is associated with an increased risk of hyperglycemia; management of glycemic treatment and glucose monitoring during this period is complex and typically guided by local protocols.
SGLT2 inhibitors should be avoided during surgical procedures and should be stopped 3-4 days prior to elective surgery.
Goal
Maintenance of euglycemia; prevention of DKA
With alcohol use
Intervention
Patient education on safe alcohol use
Educate people with diabetes about the risk of hyperglycemia with excessive alcohol consumption and encourage them to monitor glucose frequently after drinking any alcohol.
Goal
Avoidance of alcohol-related harm, including hyperglycemia
Advise people with diabetes to follow the same guidelines as those without diabetes.
To reduce risk of alcohol-related harms, adults can choose not to drink or to drink in moderation by limiting intake to:
≤2 drinks a day for men
≤1 drink a day for women
(One drink is equal to a 12-oz beer, a 5-oz glass of wine, or 1.5 oz of distilled spirits).
With cannabis use
Intervention
Advise complete abstinence from cannabis
Advise people with type 1 diabetes not to use recreational cannabis in any form.
Goal
Avoidance of cannabis-hyperemesis syndrome and associated risk of DKA
Symptoms of cannabis hyperemesis syndrome include severe nausea, abdominal pain and vomiting which increases the risk of DKA.
Undergoing exercise
Intervention
Patient education and self glucose monitoring
Advise people with type 1 diabetes to check blood glucose levels or consult sensor glucose values before and after periods of exercise. It is also advisable to educate people about the potential prolonged effects (depending on intensity and duration).
Each individual with type 1 diabetes has a variable glycemic response to exercise. Intense activities may raise blood glucose levels in some people.
Consider this variability when recommending the type and duration of exercise for a given individual.
Goal
Prevention of exercise-induced hyperglycemia
For people with type 1 diabetes, although exercise in general is associated with improvement in disease status, care needs to be taken in titrating exercise with respect to glycemic management.
With fasting for religious or cultural reasons
Intervention
Patient education and support; individualized treatment plan for times of fasting
Inquire about any religious or cultural reasons for fasting for people with diabetes and provide education and support to accommodate their choice.
Use an established tool such as the International Diabetes Federation and Diabetes and Ramadan International Alliance (IDF-DAR) comprehensive prefasting risk assessment to generate a risk score for the safety of religious fasting.
Assess and optimize the treatment plan, dose and timing of medication and fasting for people with diabetes well in advance of religious fasting to mitigate against its associated risks.
Provide fasting-focused education to minimize risks; emphasize that people should increase the frequency of glucose monitoring during fasting.
Offer individualized fluid adjustment and meal advice with emphasis on higher intake of fiber and replacing added sugars with complex carbohydrates. Emphasize the importance of sustaining adequate daily fluid intake.
Consider the use of technology as a useful adjunct to risk calculation and/or nutrition planning and education.
Goal
Prevention of dehydration, hyperglycemia, and ketosis
Pregnant
Intervention
Patient education; advice to monitor ketones
Advise pregnant women with type 1 diabetes to obtain ketone test strips, and offer general education on DKA prevention and detection.
Counsel pregnant women at risk for DKA on the signs and symptoms suggestive of DKA, and advise them to seek immediate medical attention if they are concerned about the possibility of DKA.
Pregnancy is a ketogenic state, and people with type 1 diabetes are at risk for DKA at lower blood glucose levels than when they are not pregnant. DKA in pregnancy is associated with a high risk of stillbirth.
Goal
Prevention or early detection of DKA; reduced risk of stillbirth
Older adult living in a long-term care facility
Intervention
Consider development of a glycemia alert strategy
Care facility staff are advised to call a healthcare professional immediately when:
two or more blood glucose values >250 mg/dL are observed within a 24-hour period and are accompanied by a significant change in status.
Care facility staff are advised to call a healthcare profession as soon as possible when:
glucose values are consistently >250 mg/dL (>13.9 mmol/L) within a 24-hour period,
glucose values are consistently >300 mg/dL (>16.7 mmol/L) over 2 consecutive days,
any reading is too high for the glucose monitoring device, or
the person is sick, with vomiting, symptomatic hyperglycemia, or poor oral intake.
Goal
Timely adjustment of glycemic treatment; prevention of hyperglycemia and DKA
In practice, an alert strategy would include notifications for both hypoglycemia and hyperglycemia (although the former is beyond scope for this table). Hypoglycemia and symptomatic hyperglycemia must be managed immediately.
Healthcare professionals may adjust treatment plans by telephone, fax, or in person directly at the long-term care facility, depending on service arrangements and clinical urgency.
With psychosocial distress or behavioral health diagnosis
Intervention
Individualized psychosocial care; specialist referral
Reinforce diabetes self-management education and support when factors, including psychosocial challenges, arise that may complicate diabetes self-management.
When indicated, refer to behavioral health professionals or other trained healthcare professionals, ideally those with experience in diabetes, to increase engagement in diabetes self-management and support, and for further assessment and treatment for symptoms of:
Diabetes distress
Depression
Suicidality
Anxiety
Treatment-related fear of hypoglycemia
Disordered eating
Goal
Improved glycemic outcomes; reduced risk of DKA
The goals are to:
improve an individual’s or family’s ability to carry out diabetes care tasks,
achieve better glycemic stability, and
in the long-term, reduce mortality risk.
Taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor
Intervention
Patient education; individualized prevention strategy for DKA
The use of SGLT2 inhibitors is associated with an infrequent but serious risk of DKA, particularly when other risk factors or situations occur, e.g.:
insulin pump malfunctions,
significant reduction in insulin doses, or
nutritional intake plans with prolonged periods of fasting or carbohydrate restriction.
Offer individualized education regarding the risks, symptoms, and prevention strategies for DKA, and prescribe tools for home monitoring of ketones (e.g. serum β-hydroxybutyrate).
In particular, advise all people treated with an SGLT2 inhibitor to:
avoid a ketogenic eating pattern,
be aware of the signs of ketoacidosis (following appropriate patient education),
avoid fasting, and
maintain appropriate insulin therapy.
It is recommended that SGLT2 inhibitors are avoided in cases of severe illness, in people with ketonemia or ketonuria, and during prolonged fasting.
Goal
Prevention of DKA
Reassessment of susceptibility to DKA, education, and provision of monitoring supplies is recommended on an ongoing basis throughout the duration of treatment with an SGLT2 inhibitor.
Adult with type 2 diabetes
All
Intervention
Diabetes self-management education and support
Advise all people with diabetes to participate in diabetes self-management education and support.
Programs may be offered in group or individual settings. Consider offering programs via telehealth and/or digital interventions as needed.
For those at high risk of DKA, provide structured education on the recognition, prevention and management of hyperglycemic crises. In particular:
Offer education on the early signs and symptoms of DKA.
Provide appropriate tools for accurate ketone measurement (urine and/or blood ketone tests).
Advise people who are concerned about, or who are experiencing, DKA to contact their diabetes team immediately.
Advise people at risk for DKA to measure urine or blood ketones in the presence of symptoms and potential precipitating factors (e.g., illness, missed insulin doses), particularly if glucose levels exceed 200 mg/dL (11.1 mmol/L).
Advise people to seek immediate medical attention if unable to tolerate oral hydration, if blood glucose levels do not improve with insulin administration, if altered mental status is present, or if any signs of worsening illness occur.
Goal
Optimal diabetes self-management, including prevention of hyperglycemia and DKA
This is recommended at least on an annual basis, and is also recommended:
at diagnosis,
when the person with diabetes is not meeting treatment goals,
when complicating factors develop (medical, physical, and psychosocial), and
when transitions in life and care occur.
Using insulin and capable of safely using a CGM device
Intervention
Recommend CGM
Recommend CGM for diabetes management to all people with diabetes on any type of insulin therapy. It is recommended that the choice of CGM device is made based on the individual’s circumstances, preferences and needs.
The individual must be capable of using the device safely (either by themselves or with a caregiver).
Goal
Better glycemic control; reduced rates of diabetic complications including DKA
Consideration of CGM needs is recommended at all clinical encounters (initial visit, all follow-up visits and the annual visit).
Using glucose-lowering medications other than insulin and capable of safely using a CGM device
Intervention
Consider CGM
Consider using CGM in all adults with type 2 diabetes treated with glucose-lowering medications other than insulin. It is recommended that the choice of CGM device is made based on the individual’s circumstances, preferences and needs.
The individual must be capable of using the device safely (either by themselves or with a caregiver).
Goal
Achieve and maintain individualized glycemic control; reduced rates of diabetic complications including DKA
Consideration of CGM needs is recommended at all clinical encounters (initial visit, all follow-up visits and the annual visit).
Taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor
Intervention
Patient education; individualized prevention strategy for DKA
Assess the individual’s underlying susceptibility to DKA; in particular if they are ketosis prone and/or consuming a ketogenic diet. SGLT2 inhibitors increase the risk of DKA in these individuals, particularly if in combination with other risk factors such as prolonged fasting or carbohydrate restriction.
Offer people who are taking an SGLT2 inhibitor and considered at risk of DKA an individualized education regarding the risks, symptoms, and prevention strategies, and prescribe tools for home monitoring of ketones (e.g. serum β-hydroxybutyrate).
It is recommended that SGLT2 inhibitors are avoided in cases of severe illness, in people with ketonemia or ketonuria, and during prolonged fasting.
Goal
Prevention of DKA
Reassessment of susceptibility, education, and provision of monitoring supplies is recommended on an ongoing basis throughout the duration of treatment with an SGLT2 inhibitor.
With intercurrent illness
Intervention
Reevaluation of diabetes treatment plan
Assess any individual with diabetes experiencing acute illness for the need for more frequent monitoring of glucose; ketosis-prone people also require urine or blood ketone monitoring.
Reevaluate diabetes treatment during intercurrent illness and make adjustments as appropriate.
Goal
Prevention of life-threatening conditions relating to hyperglycemia
With hospital admission
Intervention
Individualized approach for glycemic management
An individualized approach to glycemic management is recommended during hospital admission, taking into account factors such as:
prior home use and dose of insulin or non-insulin therapy,
prior HbA1c,
current glucose levels,
oral intake, and
duration of diabetes.
Corticosteroid therapy is common in hospitalized individuals and carries a particularly high risk of hyperglycemia.
Careful blood glucose monitoring is crucial. If insulin is given, daily adjustment of insulin may be required based on levels of glycemia and anticipated changes in type, dose, and duration of corticosteroids.
In particular, the perioperative period is associated with an increased risk of hyperglycemia; management of glycemic treatment and glucose monitoring during this period is complex and may be guided by local protocols.
SGLT2 inhibitors should be avoided during surgical procedures and should be stopped 3-4 days prior to elective surgery.
Goal
Maintenance of euglycemia; prevention of DKA
With alcohol use
Intervention
Patient education on safe alcohol use
Educate people with diabetes about the risk of hyperglycemia with excessive alcohol consumption, and encourage them to monitor glucose frequently after drinking alcohol.
Goal
Avoidance of alcohol-related harm, including hyperglycemia
Advise people with diabetes to follow the same guidelines as those without diabetes.
To reduce risk of alcohol-related harms, adults can choose not to drink or to drink in moderation by limiting intake to:
≤2 drinks a day for men
≤1 drink a day for women
(One drink is equal to a 12-oz beer, a 5-oz glass of wine, or 1.5 oz of distilled spirits).
With cannabis use and at risk for diabetic ketoacidosis
Intervention
Advise complete abstinence from cannabis
Advise people with type 2 diabetes who are at risk for ketoacidosis not to use recreational cannabis in any form.
Goal
Avoidance of cannabis-hyperemesis syndrome and associated risk of DKA
Symptoms of cannabis hyperemesis syndrome include severe nausea, abdominal pain and vomiting, which increases the risk of DKA.
With fasting for religious or cultural reasons
Intervention
Patient education and support; individualized treatment plan for times of fasting
Inquire about any religious fasting for people with diabetes and provide education and support to accommodate their choice.
Use an established tool such as the IDF-DAR comprehensive prefasting risk assessment to generate a risk score for the safety of religious fasting.
Assess and optimize the treatment plan, dose and timing of medication and fasting for people with diabetes well in advance of religious fasting to mitigate against its associated risks.
Provide fasting-focused education to minimize risks; emphasize that people should increase the frequency of glucose monitoring during fasting.
Offer individualized fluid adjustment and meal advice with emphasis on higher intake of fiber and replacing added sugars with complex carbohydrates. Emphasize the importance of sustaining adequate daily fluid intake.
Consider the use of technology as a useful adjunct to risk calculation and/or nutrition planning and education.
Goal
Prevention of dehydration, hyperglycemia, and ketosis
Older adult living in a long-term care facility
Intervention
Consider development of a glycemia alert strategy
Care facility staff are advised to call a healthcare professional immediately when:
two or more blood glucose values >250 mg/dL are observed within a 24-hour period and are accompanied by a significant change in status.
Care facility staff are advised to call a healthcare profession as soon as possible when:
glucose values are consistently >250 mg/dL (>13.9 mmol/L) within a 24-hour period,
glucose values are consistently >300 mg/dL (>16.7 mmol/L) over 2 consecutive days,
any reading is too high for the glucose monitoring device, or
the person is sick, with vomiting, symptomatic hyperglycemia, or poor oral intake.
Goal
Timely adjustment of glycemic treatment; prevention of hyperglycemia and DKA
In practice, an alert strategy would include notifications for both hypoglycemia and hyperglycemia (although the former is beyond scope for this table). Hypoglycemia and symptomatic hyperglycemia must be managed immediately.
Healthcare professionals may adjust treatment plans by telephone, fax, or in person directly at the long-term care facility, depending on service arrangements and clinical urgency.
With psychosocial distress or behavioral health diagnosis
Intervention
Ind ividualized psychosocial care; specialist referral
Reinforce diabetes self-management education and support when factors, including psychosocial challenges, arise that may complicate diabetes self-management.
When indicated, refer to behavioral health professionals or other trained healthcare professionals, ideally those with experience in diabetes, to increase engagement in diabetes self-management and support, and for further assessment and treatment for symptoms of:
diabetes distress,
depression,
suicidality,
anxiety,
treatment-related fear of hypoglycemia, or
disordered eating.
Goal
Improved glycemic outcomes; reduced risk of DKA
The goals are to:
improve an individual’s or family’s ability to carry out diabetes care tasks,
achieve better glycemic stability, and
in the long-term, reduce mortality risk.
Child or adolescent with type 1 diabetes
All
Intervention
Insulin-containing regimen; developmentally appropriate diabetes self-management education and support
Insulin-containing regimen:
Give some form of insulin in a defined treatment plan tailored to the individual.
Diabetes self-management education and support:
It is recommended that this is provided by an interprofessional team trained in pediatric diabetes management and sensitive to the challenges of children and adolescents with type 1 diabetes and their families.
Self-management in pediatric diabetes involves both the youth and their parents/adult caregivers. Family involvement is a vital component of optimal diabetes management throughout childhood and adolescence.
Provide structured education on the recognition, prevention and management of hyperglycemic crises to all people with type 1 diabetes. In particular:
Offer those at risk of DKA education on the early signs and symptoms of DKA.
Provide people at risk for DKA with appropriate tools for accurate ketone measurement (urine and/or blood ketone tests).
Provide education on timely self-management of hyperglycemia and ketonemia (‘sick day advice’) to prevent clinical deterioration and need for acute care.
Advise people who are concerned about, or who are experiencing, DKA to contact their diabetes team immediately.
Advise people at risk for DKA to measure urine or blood ketones in the presence of symptoms and potential precipitating factors (e.g., illness, missed insulin doses), particularly if glucose levels exceed 200 mg/dL (11.1 mmol/L).
Advise people to seek immediate medical attention if unable to tolerate oral hydration, if blood glucose levels do not improve with insulin administration, if altered mental status is present, or if any signs of worsening illness occur.
Goal
Optimal diabetes self-management including prevention of hyperglycemia and DKA
Insulin-containing regimen:
The goal is to prevent DKA and minimize clinically relevant hypoglycemia while achieving the individual’s glycemic goals.
It is recommended that HbA1c goals are individualized and reassessed over time.
Diabetes self-management education and support:
This is recommended at diagnosis and regularly thereafter in a developmentally appropriate format building on prior knowledge.
Capable of using CGM device and/or advanced insulin delivery technology
Intervention
Recommend CGM and/or advanced insulin delivery technology
Recommend CGM for diabetes management to youth with diabetes on any type of insulin therapy.
The individual must be capable of using the device safely (either by themselves or with a caregiver).
Offer automated insulin delivery (AID) systems for diabetes management to youth with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers).
Offer insulin pump therapy alone for diabetes management to youth on multiple daily injections with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers) if unable to use AID systems.
The choice of device is dependent on the individual’s and family’s circumstances, desires, and needs.
Goal
Improved glycemic management, including prevention of DKA
Attending school or childcare setting
Intervention
Provide training in accordance with the individual’s diabetes treatment plan
It is recommended that the diabetes team assesses the educational needs and skills of, and provide training to, daycare workers, school nurses, and school personnel who are responsible for the care and supervision of the child with diabetes.
It is important that students are supported at school in the use of diabetes technology, including continuous glucose monitors, insulin pumps, connected insulin pens, and AID systems as prescribed by their diabetes care team.
Goal
Safe access to the school or daycare environment, including prevention of DKA
Undergoing exercise
Intervention
Patient and caregiver education and self glucose monitoring
Advise the importance of frequent glucose monitoring before, during, and after exercise, via blood glucose meter or CGM, to prevent, detect, and treat hyperglycemia (and hypoglycemia) associated with exercise.
Educate youth and their parents/caregivers on goals and management of glycemia before, during, and after physical activity, individualized according to the type and intensity of the planned physical activity.
Goal
Prevention of exercise-induced hyperglycemia
A blood glucose goal of 126–180 mg/dL (7.0–10.0 mmol/L) prior to physical activity and exercise is recommended; individualization is necessary based on the type, intensity, and duration of activity.
Advise patients to postpone intense activity in the presence of any of the following factors:
marked hyperglycemia (glucose ≥350 mg/dL [≥19.4 mmol/L]),
moderate to large urine ketones, or
β-hydroxybutyrate >1.5 mmol/L.
Advise patients that caution may be needed when β-hydroxybutyrate levels are ≥0.6 mmol/L.
With intercurrent illness
Intervention
Reevaluation of diabetes treatment plan
Assess any individual with diabetes experiencing acute illness for the need for more frequent monitoring of glucose; ketosis-prone people also require urine or blood ketone monitoring.
Reevaluate diabetes treatment during intercurrent illness and make adjustments as appropriate.
Goal
Prevention of life-threatening conditions relating to hyperglycemia
With hospital admission
Intervention
Individualized approach for glycemic management
An individualized approach to glycemic management is recommended during hospital admission, taking into account factors such as:
prior home use and dose of insulin or non insulin therapy,
prior HbA1c,
current glucose levels,
oral intake, and
duration of diabetes.
Corticosteroid therapy is common in hospitalized individuals and carries a particularly high risk of hyperglycemia. It is recommended that clinicians working within a hospital setting consider corticosteroid type and duration of action when determining appropriate insulin treatments. Careful blood glucose monitoring is crucial. Daily adjustment of insulin may be required based on levels of glycemia and anticipated changes in type, dose, and duration of corticosteroids.
In particular, the perioperative period is associated with an increased risk of hyperglycemia; management of glycemic treatment and glucose monitoring during this period is complex and may be guided by local protocols.
Goal
Maintenance of euglycemia
With alcohol use
Intervention
Patient education
Alcohol use has implications for glycemic management and safety in adolescents with diabetes.
Educate patients and their families about the risks of alcohol use and strategies to minimize risks.
Goal
Avoidance of alcohol-related harm, including hyperglycemia and DKA
With cannabis use
Intervention
Advise complete abstinence from cannabis
Advise all youth with diabetes not to use recreational cannabis in any form.
Goal
Avoidance of cannabis-hyperemesis syndrome and associated risk of DKA
Symptoms of cannabis hyperemesis syndrome include severe nausea, abdominal pain and vomiting which increases the risk of DKA.
With fasting for religious or cultural reasons
Intervention
Patient education and support; individualized treatment plan for times of fasting
Inquire about any religious fasting for people with diabetes and provide education and support to accommodate their choice.
Use an established tool such as the IDF-DAR comprehensive prefasting risk assessment to generate a risk score for the safety of religious fasting.
Assess and optimize the treatment plan, dose and timing of medication and fasting for people with diabetes well in advance of religious fasting to mitigate against its associated risks.
Provide fasting-focused education to minimize risks; emphasize that people should increase the frequency of glucose monitoring during fasting.
Offer individualized fluid adjustment and meal advice with emphasis on higher intake of fiber and replacing added sugars with complex carbohydrates. Emphasize the importance of sustaining adequate daily fluid intake.
Consider the use of technology as a useful adjunct to risk calculation and/or nutrition planning and education.
Goal
Prevention of dehydration, hyperglycemia, and ketosis
With psychosocial distress (e.g., diabetes distress, depressive symptoms, disordered eating) or behavioral health diagnosis
Intervention
Individualized and developmentally appropriate psychosocial care; specialist referral
Reinforce diabetes self-management education and support when factors, including psychosocial challenges, arise that may complicate diabetes self-management.
Refer to a qualified behavioral health professional, preferably experienced in childhood diabetes, as indicated.
Such professionals can provide individualized, evidence-based behavioral healthcare services, e.g.:
Cognitive-behavioral therapy (CBT)
Mindfulness-based therapy
Behavioral health professionals are considered integral members of the pediatric diabetes interprofessional team.
Goal
Early detection and treatment of behavioral health conditions; minimization of adverse effects on diabetes management
The goals are to:
improve an individual’s or family’s ability to carry out diabetes care tasks,
achieve better glycemic stability, and
improve health status/outcomes.
Ongoing assessment of psychosocial status, social determinants of health, and diabetes distress in youth and parents/caregivers during routine diabetes visits is recommended.
Child or adolescent with type 2 diabetes
All
Intervention
Developmentally appropriate diabetes self-management education and support
It is recommended that all youth with type 2 diabetes and their families receive comprehensive diabetes self-management education and support that is specific to youth with type 2 diabetes and is culturally appropriate.
An interprofessional diabetes team, including a physician, diabetes care and education specialist, registered dietitian nutritionist, and psychologist or social worker, is essential.
For those at high risk of DKA, provide structured education on the recognition, prevention and management of hyperglycemic crises. In particular:
Offer education on the early signs and symptoms of DKA.
Provide appropriate tools for accurate ketone measurement (urine and/or blood ketone tests).
Provide education on timely self-management of hyperglycemia and ketonemia (‘sick day advice’) to prevent clinical deterioration and need for acute care.
Advise people who are concerned about, or who are experiencing, DKA to contact their diabetes team immediately.
Advise people at risk for DKA to measure urine or blood ketones in the presence of symptoms and potential precipitating factors (e.g., illness, missed insulin doses), particularly if glucose levels exceed 200 mg/dL (11.1 mmol/L).
Advise people to seek immediate medical attention if unable to tolerate oral hydration, if blood glucose levels do not improve with insulin administration, if altered mental status is present, or if any signs of worsening illness occur.
Goal
Optimal diabetes self-management
On insulin therapy; capable of using CGM device
Intervention
Recommend CGM
Recommend CGM for diabetes management to youth with diabetes on any type of insulin therapy. It is recommended that the choice of CGM device is made based on the individual’s circumstances, preferences and needs.
The individual must be capable of using the device safely (either by themselves or with a caregiver).
Goal
Improved glycemic management, including prevention of DKA
Attending school or childcare setting
Intervention
Provider training in accordance with the individual’s diabetes treatment plan
As with type 1 diabetes, youth with type 2 diabetes spend much of the day in school. Therefore, close communication with and the cooperation of school personnel are essential.
Goal
Optimal diabetes management and safety
With intercurrent illness
Intervention
Reevaluation of diabetes treatment plan
Assess any individual with diabetes experiencing acute illness for the need for more frequent monitoring of glucose; ketosis-prone people also require urine or blood ketone monitoring.
Reevaluate diabetes treatment during intercurrent illness and make adjustments as appropriate.
Goal
Prevention of life-threatening conditions relating to hyperglycemia
With hospital admission
Intervention
Individualized approach for glycemic management
An individualized approach to glycemic management is recommended during hospital admission, taking into account factors such as:
prior home use and dose of insulin or non-insulin therapy,
prior HbA1c,
current glucose levels,
oral intake, and
duration of diabetes.
Corticosteroid therapy is common in hospitalized individuals, and carries a particularly high risk of hyperglycemia. Careful blood glucose monitoring is crucial. If insulin is given, daily adjustment of insulin may be required based on levels of glycemia and anticipated changes in type, dose, and duration of corticosteroids.
In particular, the perioperative period is associated with an increased risk of hyperglycemia; management of glycemic treatment and glucose monitoring during this period is complex and may be guided by local protocols.
Goal
Maintenance of euglycemia
With alcohol use
Intervention
Patient education
Alcohol use has implications for glycemic management and safety in adolescents with diabetes.
Educate patients and their families about the risks of alcohol use and strategies to minimize risks.
Goal
Avoidance of alcohol-related harm, including hyperglycemia and DKA
With cannabis use
Intervention
Advise complete abstinence from cannabis
Advise all youth with diabetes not to use recreational cannabis in any form.
Goal
Avoidance of cannabis-hyperemesis syndrome and associated risk of DKA
Symptoms of cannabis hyperemesis syndrome include severe nausea, abdominal pain and vomiting, which increases the risk of DKA.
With fasting for religious or cultural reasons
Intervention
Patient education and support
Inquire about any religious fasting for people with diabetes and provide education and support to accommodate their choice.
Use an established tool such as the IDF-DAR comprehensive prefasting risk assessment to generate a risk score for the safety of religious fasting.
Assess and optimize the treatment plan, dose and timing of medication and fasting for people with diabetes well in advance of religious fasting to mitigate against its associated risks.
Provide fasting-focused education to minimize risks; emphasize that people should increase the frequency of glucose monitoring during fasting.
Offer individualized fluid adjustment and meal advice with emphasis on higher intake of fiber and replacing added sugars with complex carbohydrates. Emphasize the importance of sustaining adequate daily fluid intake.
Consider the use of technology as a useful adjunct to risk calculation and/or nutrition planning and education.
Goal
Prevention of dehydration, hyperglycemia, and ketosis
With psychosocial distress (e.g., diabetes distress, depressive symptoms, disordered eating) or behavioral health diagnosis
Intervention
Individualized and developmentally appropriate psychosocial care
Most youth with type 2 diabetes come from racial/ethnic minority groups, have low socioeconomic status, and often experience multiple psychosocial stressors. Consideration of the sociocultural context and efforts to personalize diabetes management are important to minimize barriers to care, enhance participation, and maximize response to treatment.
Many of the medications prescribed for diabetes and psychiatric disorders are associated with weight gain and can increase concerns about eating, body shape, and weight.
When psychological symptoms are identified, referral to a behavioral health professional, ideally with experience in pediatric diabetes, may be warranted.
It is important to reinforce diabetes self-management education and support when factors, including psychosocial challenges, arise that may complicate diabetes self-management.
Goal
Early detection and treatment of psychological and behavioral concerns; improved psychosocial wellbeing; support for diabetes outcomes
Secondary prevention
In US nationwide studies, up to 22% of people admitted with DKA had at least one readmission within 30 days or the same calendar year.[32] Among those readmitted within 30 days, 40.8% represented recurrent DKA episodes, with approximately 50% being readmitted within 2 weeks.[32][33] Among those readmitted within the same calendar year, 86% and 14% had 1-3 and ≥4 readmissions for DKA, respectively.[33] Assessment of precipitating and contributing causes of DKA admission and close follow-up within 2-4 weeks after discharge may reduce recurrent DKA.[1] Initiation or continuation of SGLT2 or dual SGLT1/2 inhibitors after DKA resolution is not routinely recommended.[1]
Before discharge, all individuals admitted with DKA should be offered appropriate education focused on both the current event and overall diabetes management.[1] Patient education, especially structured education that includes problem-solving, has been shown to be effective at reducing DKA admissions.[113] Omission or insufficient use of insulin therapy is a major cause of DKA admissions and readmissions. Thus, education on insulin administration and "sick day" advice should be provided or reinforced.[1] Upon discharge, patients should receive an adequate supply of insulin and necessary medical equipment (e.g., glucose monitoring and insulin administration devices), as well as contact information for healthcare professionals who can assist in managing future episodes of high blood glucose and ketone concentrations.[1] Education should include reviewing injection techniques (including sites), glucose monitoring, and urine or blood ketone testing. Each patient and their family need to review the appropriate glucose and ketone monitoring and when to call for assistance.[1] Home measurement of capillary blood and serum ketones helps to identify impending DKA, but the rate of appropriate ketone monitoring among people with diabetes, especially adults, is low.[1][114]
A consensus report on type 1 diabetes by the ADA and European Association for the Study of Diabetes (EASD) recommends continuous glucose monitoring (CGM) as the monitoring method of choice for most people with type 1 diabetes.[115] CGM is superior to capillary blood glucose monitoring for improving glycemic patterns among insulin-treated patients with type 1 diabetes and type 2 diabetes, especially those with out-of-range glucose levels.[1] Results from a nationwide study in France reported that access to a CGM system was associated with a subsequent decrease in the rate of DKA hospitalizations by 53% and by 47% in type 1 diabetes and type 2 diabetes, respectively.[116] These results were observed both in patients treated with multidose insulin and in those treated with continuous insulin infusion (pump) therapy.[117] Although CGM has not been approved for use in hospitalized patients with diabetes or with DKA, consensus guidelines recommend that real-time or intermittently scanned CGM should be offered to people admitted with DKA just prior to, or after, hospital discharge.[1]
Presence of mental health disorders and indicators of socioeconomic disadvantage (such as low income, homelessness, lack of health insurance or underinsurance, food insecurity, and low educational attainment) should be assessed on admission and before discharge.[1][118] Extensive evidence indicates that mental health conditions, particularly eating disorders, depression or schizophrenia, are independent risk factors for poor glycemic control and DKA. Thus, regular screening of people with diabetes for psychologic and behavioral disorders should be implemented in clinical practice.[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.[29]
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