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 (EASD) 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
Goal
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.

See: Type 1 diabetes mellitus

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
Goal
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
Goal
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.

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
Goal
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
Goal
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
Goal
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
Goal
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

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.

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.[112] 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][113]

A consensus report on type 1 diabetes by the ADA and EASD recommends CGM as the monitoring method of choice for most people with type 1 diabetes.[114] 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.[115] These results were observed both in patients treated with multidose insulin and in those treated with continuous insulin infusion (pump) therapy.[116] 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][117] 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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