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The management of DKA in adults: An update to the JBDS guidance

Quick summary of the changes to JBDS guidance on diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) is a common and potentially life-threatening complication of type 1 diabetes. Although mortality rates today are relatively low, it is generally accepted that mismanagement after hospital admission is an important contributory factor to in-hospital mortality, morbidity, increased length of stay and high readmission rates. Guidance on the management of DKA from the Joint British Diabetes Societies for Inpatient Care (JBDS) has been widely adopted across the UK; however, it is now over a decade old. Therefore, the launch of new guidance from the JBDS, published in June 2021, is a welcome update.

Some of the recommendations in the original document were based on expert opinion. While many of these now have support in the literature and have become standard practice, others have been amended. The key changes to the document are outlined below.

Treatment of young adults aged 16–18 years

The guideline now states that it is appropriate for use when treating young adults aged 16–18 years if they are being cared for by adult diabetes teams, the rationale being that it is more appropriate for them to be managed by local adult guidelines that the teams are familiar with, rather than using potentially unfamiliar paediatric guidelines.

In contrast, where young adults in this age group are being treated by paediatric teams, the BSPED paediatric guidelines should be adhered to.

Reducing the insulin infusion rate once blood glucose has fallen below 14.0 mmol/L

The updated guideline recommends that, when blood glucose drops below 14 mmol/L, clinicians can consider (always using appropriate clinical judgement) reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour. This is in order to reduce the risk of hypoglycaemia and hypokalaemia. While these complications may occur as a result of dextrose solution not being added to treatment in a timely manner or potassium-containing fluids not being given correctly, the main driver for both of these complications is the use of insulin, and several paediatric studies have suggested that reducing infusion rates to this level does not increase the time to resolution of DKA compared with a rate of 0.1 units/kg/hour.

End-stage renal disease and dialysis

A short section on managing DKA in those with end stage renal disease or on dialysis has been added. Although fortunately a relatively rare occurrence, certain issues require consideration, including the possibility that fluid replacement may not be required; the increased risk of hypoglycaemia due to reduced renal clearance of insulin; and the possible risk of hyperkalaemia.

Euglycaemic DKA and ketosis-prone diabetes

The guideline has new sections on euglycaemic DKA (that occurring despite normal or near-normal blood glucose) and ketosis-prone type 2 diabetes.

Euglycaemic DKA is a known complication of sodium–glucose cotransporter 2 (SGLT2) inhibitor therapy in people with type 2 diabetes and, increasingly, type 1 diabetes. The condition should be treated identically to hyperglycaemic DKA, and the SGLT2 inhibitor should be stopped at least until recovery; the decision of whether to restart the drug should be discussed with the individual and their diabetes team.

Ketosis-prone type 2 diabetes most often occurs in people of African–Caribbean or Hispanic descent. The treatment for this condition is the same as for others with DKA, but the individual will often be able to stop insulin quickly after the resolution of the DKA and its underlying precipitating condition.

Concluding remarks

This new edition aims to update the guidance using recent evidence that has become available. The document has also been reorganised so that the algorithm for the management of DKA is now near the front, making it easier to access.

To enable the guideline to stay relevant, it is envisaged that all of the JBDS guidelines will be updated or reviewed each year. As such, these are “living” documents, designed to be updated based on recently published evidence or experience, and feedback on any of the guidelines is welcomed. The updated guideline is available at: https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults

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