Diabetic ketoacidosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]


Diabetic ketoacidosis (DKA) is a medical emergency. The mainstay of therapy for DKA is medical therapy including intravenous insulin, fluids, potassium replacement and bicarbonate therapy in case of severe acidosis (pH <6.9). The basic principles guiding therapy include rapid restoration of adequate circulation and perfusion, insulin to reverse ketosis and lower glucose levels, and close monitoring to prevent and treat complications if they develop. There are minor differences in the management of DKA in U.S.A. and U.K. which are opinion based and depend on the healthcare setting.

Medical Therapy

The United States (US) and United Kingdom (UK) follow slightly different guidelines for the management of diabetic ketoacidosis (DKA) but the basic principles are same.

Basic principles

The basic principles of diabetic ketoacidosis treatment (DKA) are:

ADA guidelines

The American Diabetes Association (ADA) recommends the following therapy for diabetic ketoacidosis (DKA):[1][2][3]

Fluid therapy

Insulin therapy

Potassium replacement

  • Potassium replacement is started when the levels fall below the upper limit of normal (5.0-5.2 mEq/L).[8]
  • Goal is to maintain serum potassium levels within the normal range of 4–5 mEq/L.



Criteria for resolution


Differences in management between US and UK

The following are differences in management of DKA between the US and UK:[1][11][15][16][17]

Region Treatment
Insulin Intravenous fluids Bicarbonate
United states
United Kingdom

Step-wise approach to management of diabetic ketoacidosis

DKA treatment protocol according to ADA guidelines
Hydration status
pH greater than equal to 6.9
pH less than 6.9
0.1 u/kg/B.WT. as IV bolus
0.14 u/kg/B.WT/hr as continous IV infusion
K < 3.3 mEq/L
K = 3.3 - 5.2 mEq/L
K > 5.2 mEq/L
Severe hypovolemia
Mild dehydration
Cardiogenic shock
0.1 u/kg/B.WT. as IV continous infusion
Hold insulin and give 20-30mEq/L of potassium until K+ > 3.3mEq/L
Give 20-30mEq/L in each liter of IV fluids to maintain serum K 4-5mEq/L
Do not give potassium but check serum potassium every 2 hours
0.9% Nacl (1L/hr) as IV infusion
Check corrected serum sodium
Hemodynamic monitoring and add pressors accordingly
If serum glucose does not fall by 10 % within one hour of therapy then give 0.14 U/Kg as IV bolus and continue previous regimen
High serum Na (>145 mEq/L)
Normal serum Na (135-145 mEq/L)
Low serum Na (< 135 mEq/L)
When serum glucose drops to 200 mg/dl, reduce regular insulin to 0.02-0.05 U/Kg/hour, or give rapid-acting insulin at 0.1 U/kg SC every 2 hours, maintain serum glucose between 150 mg/dl to,200 mg/dl until resolution
0.45% NaCl (250-500 ml per hour depending on hydration status
0.9% NaCl (200-500 ml per hour) depending on hydration status
When serum glucose decreases to 200 mg/dl, switch to 5% dextrose with 0.45% NaCl at 150-250 ml/hour

Contraindicated medications

Diabetic ketoacidosis is considered an absolute contraindication to the use of the following medications:


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