32 HOW TO TREAT : ACUTE KETOACIDOSIS
32 HOW TO TREAT : ACUTE KETOACIDOSIS
6 OCTOBER 2023 ausdoc . com . au
treatment . Mortality rates from |
years associated with type 1 diabe- |
and treatment , although prognosis is |
which is why ketoacidosis is consid- |
active bank accountant . She pre- |
DKA ( about 35 deaths per 10,000 |
tes in adults . 5 , 6 |
frequently complicated by the effects |
ered an obstetric emergency . |
sents to her GP with a three-week |
cases ) are low and have been declining over the past 30 years . However , DKA still remains one of the biggest contributors to loss of life |
Ketoacidosis is generally milder and slower in onset in non-diabetic individuals ; most patients with EKA recover well with prompt diagnosis |
of the underlying trigger ( for example , sepsis , severe infection , COVID- 19 , MI ). Pregnant women and their babies are at greater mortality risk , |
CASE STUDIES
Case study one
JULIE , 26 , is a fit and ( normally )
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history of increasing polyuria , thirst , fatigue and 5kg of unintentional weight loss . For the last few days , she thinks she has PAGE 34 |
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Table 2 . SADMANS-DOG rules |
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Headache |
Fatigue |
Dizzy / lightheaded |
SADMANS Drug class Consideration |
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Dry mouth and lips
Confusion
Thirst
Dry or flushed skin
Heavy breathing
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Drowsiness
Blurred vision
Nausea and vomiting
Weight loss
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S |
SGLT2 inhibitors |
If taken during an acute illness that can lead |
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to dehydration , there is an increased risk of |
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developing EKA |
A |
ACE inhibitors |
If taken during an acute illness that can lead to dehydration , there is an increased risk of developing acute kidney injury ( AKI ) because of reduced renal efferent vasoconstriction |
D |
Diuretics |
If taken during an acute illness that can lead |
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to dehydration , there is an increased risk of |
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developing AKI |
M |
Metformin |
If taken during an acute illness that can lead |
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to dehydration , there is an increased risk of |
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developing lactic acidosis |
A
Angiotensin receptor blockers and ACE inhibitors
If taken during an acute illness that can lead to dehydration , there is an increased risk of developing AKI
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N |
NSAIDs |
If taken during an acute illness that can lead to dehydration , there is an increased risk of developing AKI because of reduced renal afferent vasodilation |
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Loss of appetite |
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S |
Sulphonylureas |
If taken during an acute illness , these |
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agents can lead to low blood sugars or |
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hypoglycaemia |
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D
Direct oral anticoagulants ( DOAC ), also known as NOACs
If taken during an acute illness , these agents may accumulate , increasing the risks of bleeding
O |
Opioids |
If taken during an acute illness , these agents |
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may accumulate , increasing CNS and |
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respiratory depression |
Abdominal pain
G Gabapentin / pregabalin
Source : Hawke ’ s Bay District Health Board 24
If taken during an acute illness , these agents may accumulate , increasing CNS side effects ( eg , confusion and sedation )
Figure 5 . Symptoms of DKA .
Muscle cramps and weakness
Box 3 . When treatment with SGLT2 inhibitors should be temporally paused
• For surgery and contrast-based procedures requiring one or more days in hospital , and / or requiring ‘ bowel preparation ’ including colonoscopy . — Ideally , pause SGLT2 inhibition at least three days pre-procedure ( two days before surgery and the day of surgery / procedure ) and stopping immediately for emergency surgery .
— For day-stay procedures ( including gastroscopy ), SGLT2 inhibitors can be stopped just for the day of procedure . — Fasting before and after the procedure should be minimised .
• During any extreme stress event or other trigger for ketoacidosis ( eg , SGLT2 inhibitor when unwell [ vomiting , diarrhoea , fever ] or not eating or drinking normally ). — Pausing before intense physical activity ( eg , a half-marathon ) has also been recommended .
Figure 6 . The first step in diagnosing ketoacidosis is suspicion . The next is measuring blood ketone concentrations on a finger prick test .
Figure 7 . Self-measurement of ketones .