New Study Prompts Revisions to Current Approaches and Definitions in Diabetes Ketoacidosis (DKA) Care
Diabetes Ketoacidosis (DKA) is a serious complication for people diagnosed with type 1 diabetes caused by sustained high blood sugars coupled with the lack of appropriate dosages of insulin. Often, the care and treatment for DKA is in urgent care facilities where the providers do not specialize in diabetes management. As such, these clinicians must rely on treatment guidelines and best practices from diabetes specialists.
Until recently, there have not been significant changes to the definition and treatment of DKA for over a decade. However, in October 2023, eight international diabetes institutions redefined blood sugar parameters and best practices on how to care for patients diagnosed with DKA. These changes took place at the 2023 European Association for the Study of Diabetes (EASD) Conference in Hamburg, Germany and will no doubt change how patients are advised and managed during DKA events. While the full EASD report is not yet published, we do know that the changes to current DKA care plans and definitions should be known by patients, care givers and clinicians alike.
Reported in the CDC’s National Diabetes Statistics, DKA emergency room visits have increased by over 20% in previous years. Coupled with the increased use of insulin pump technology and adjunctive medications like SGLT-2 Inhibitors, there has been a push to rethink the definition of how DKA should be managed at urgent care facilities.
What’s changing in the treatment of DKA?
First and most notably, the glucose range for newly diagnosed diabetes patients with DKA has changed from 250 mg/dl (13.9 mmol) to 200 mg/dl (11.1 mmol). However, the glucose value has been completely removed from the definition of DKA for those with a history of diabetes. This definition change is based upon recent trends showing that almost 10% of all DKA episodes in adults occur with normal or near-normal blood sugars. As such, people living with diabetes who seek care in an urgent care facility ought to have testing done to rule out DKA regardless of their blood sugar values at the time of admission.
The use of beta-hydroxybutyrate has become the preferred diagnostic testing procedure as it is now more available than it once was from previous consensus reports. However, if a clinic lacks a beta-hydroxybutyrate point-of-care test, urine ketone testing kits can still be used to make a DKA diagnosis.
In the report, DKA will still be classified as mild, moderate or severe. And while all levels can still be treated with IV fluids, IV insulin and electrolyte replacement, mild DKA can be treated with subcutaneous insulin replacement. This is important as it may decrease the length of hospital stays and out-of-pocket cost to patients.
In addition to clinical guidelines and treatment for DKA, the October report urges providers to investigate why the person developed DKA if they had a pre-existing diagnosis of diabetes. Infection and illness have a strong correlation to DKA admissions; however, there is a strong association between missing insulin dosages and financial, mental and psychosocial stressors as well. Close assessment and follow-up should now be part of a DKA discharge plan to prevent readmission for DKA. Studies have shown that up to 22% of patients in the United States develop DKA again within 30 days. Diabetes education and appropriate referrals to social support are advised to be part of the discharge plan. Additionally, patients should be supplied with adequate medication and testing supplies to prevent readmission.
The October 2023 report was endorsed by the American Diabetes Association, the European Association for the Study of Diabetes, the American Association of Clinical Endocrinology, the Diabetes Technology Society and the Joint British Diabetes Society for Inpatient Care. More information on the report can be found at: https://www.easd.org/guidelines/statements-and-guidelines.html
