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Drug Treatment for Diabetic Ketoacidosis
AgentMechanism of ActionDosageBenefitsSide EffectsNotes
Insulin (regular insulin; insulin aspart; insulin lispro; insulin glulisine; isophane insulin [NPH]; lente insulin; ultralente insulin; insulin glargine; insulin detemir; insulin lispro, insulin lispro protamine; insulin aspart, insulin aspart protamine; regular insulin, isophane insulin [NPH]; semilente insulin; protamine zinc insulin [PZI])Corrects insulin deficiency and overcomes insulin resistance. Allows shift of glucose into cells and suppresses hepatic glucose productionInitial bolus of 0.15 U/kg, then 0.1 U/kg·h iv. Hold insulin until K is >3.3 mEq/LCorrect hyperglycemia and stop ketogenesisHypoglycemia, hypokalemia.
Low-dose insulin less likely to cause hypoglycemia or hypokalemia
Once blood glucose level is ~200 mg/dL, switch fluids to include dextrose 5%-10%. Target blood glucose to 150-200 mg/dL.
Once DKA is resolved (blood glucose <=200 mg/dL, bicarbonate >=18 mEq/L, pH >7.30) subcutaneous insulin therapy with multiple dose insulin can begin at 0.5-0.8 U/kg·d. Overlap therapy for 1-2 h before stopping iv regular insulin. If patient is unable to eat, continue iv insulin therapy
PotassiumReplace potassium deficitReplace at rate of 20-30 mEq/h if K is <3.3 mEq/L. Use 20 mEq/h if >3.3 and <5.0-5.5 mEq/LReverse hypokalemia and associated complicationsRisk of over treatment leading to hyperkalemia.
Use cautiously in anuric patients and only if K+ is <3.3 mEq/L
Monitor potassium at least every 2 hours until normal.
KCl is most common form of potassium replacement. Can use 2/3 KCl and 1/3 KPO4 to prevent excessive Cl levels
Sodium bicarbonateCorrects metabolic acidosisIf pH is <6.9 give 100 mmol NaHCO3 in 400 mL water at 200 mL/h. If pH is 6.9 to 7.0, give 50 mmol of NaHCO3 in 200 mL sterile water at 200 mL/h, repeat every 2 hours until pH is >7By correcting severe metabolic acidosis, decreases risk of cardiac arrhythmias, decreases cardiac output, cerebral vasodilitationHypokalemia, metabolic alkalosis, ketoacid overproduction. Other theoretical risks include: paradoxical CSF alkalosis, altered tissue oxygenation, increased CO2 productionConsider use if arterial pH <=7.0
Infuse slowly, to prevent shift of potassium to intracellular space
Fluid therapyVolume expansionInitial bolus of 0.9% NaCl, ~1 L in first hour (15-20 mL/kg·h), continue 0.9% NaCl if fluid deficit is large or corrected serum Na and osmolality are high. Once major deficit is corrected, and corrected serum Na is normal or high, use 0.45% NaCl, continue at 4-14 mL/kg·hCorrects dehydration, improves insulin sensitivity, improves hyperkalemia, improves metabolic acidosisFluid overload, cerebral edema (may be associated with rapid change in serum osmolality)Careful monitoring of fluid status is needed; estimate volume depletion using physical exam. Orthostatic tachycardia ~10% fluid deficit, orthostatic drop ~15%-20% deficit, supine hypotension ~20% decrease in extracellular fluid volume. Shock would require hemodynamic monitoring and pressors
Glucose therapyProvide adequate blood glucose level while maintaining insulin therapyOnce glucose is <=200 mg/dL, begin 5% dextrose with 0.45% NaCl at 150-200 mL/h. Maintain insulin infusion at 0.05-0.1 U/kg·h, use 10% dextrose if neededAllows continuation of adequate insulin therapy that is required to treat the metabolic acidosis and stop ketogenesisMay require ongoing adjustment of insulin dosage to maintain glucose ~150-200 mg/dLEarly reduction or cessation of insulin therapy because of normalization or low blood glucose may result in worsening of DKA and delay of cure
Phosphate therapyReplacement20-30 mEq of KPO4 over several hours. Add to replacement fluid if serum PO4 is <1 mg/dLCorrect severe hypophosphatemiaRisk of hypocalcemiaAlthough phosphate level may be low, replacement is not necessary except in unusual circumstances of extremely low phosphate level.
Phosphate administration may lead to severe hypocalcemia and deposition of calcium phosphate. If phosphate is used, monitor calcium levels. Use 20-30 mEq of KPO4 over several hours if needed

CSF = cerebrospinal fluid; DKA = diabetic ketoacidosis; iv = intravenous; sc = subcutaneous.