34 HOW TO TREAT : ACUTE KETOACIDOSIS
34 HOW TO TREAT : ACUTE KETOACIDOSIS
6 OCTOBER 2023 ausdoc . com . au
PAGE 32 had gastroenteritis , feeling sick and throwing up . Julie has checked and she is not pregnant . She now has diffuse abdominal pain and feels miserable .
On clinical examination she appears dry , and Julie explains she has not been able to eat or drink much with her ‘ gastro ’. The GP checks her blood sugar levels and her plasma glucose concentration is 23mmol / L ( normal is less than 11.1mmol / L ) confirming the presence of diabetes . Her blood ketones are elevated at 4.0mmol / L ( normal is less than 0.6mmol / L ). The GP enacts an action plan to call an ambulance and have her transferred to hospital for the management of her diabetic ketoacidosis .
Case study two
Karen is a 55-year-old woman with type 2 diabetes . Her blood glucose levels have not been well controlled on metformin monotherapy , so the GP recently added in an SGLT2 inhibitor to her treatment , as well as recommending improved adherence to diet and lifestyle measures . Her HbA1c has come down well from above 8 % to 7.3 % and she also has lost a few kilos .
However , a month after initiating the SGLT2 inhibitor Karen returns to her GP . She reports feeling tired and unwell and wonders if she has picked up a virus . Her capillary blood glucose levels are 7mmol / L ( normal is less than 11.1mmol / L ) but her blood ketones are elevated at 3.6mmol / L ( normal is less than 0.6mmol / L ).
1 . Which THREE statements regarding the epidemiology of ketoacidosis are correct ? a Most patients with type 1 diabetes who present with DKA don ’ t go on to experience multiple recurrent episodes . b The risk of DKA is lower in older adults with established type 1 diabetes . c Between 5 % and 10 % of all patients presenting with ketoacidosis have plasma glucose levels in the normal range . d DKA is never seen in those with type 2 diabetes .
2 . Which THREE conditions are associated with an increased risk of euglycaemic ketoacidosis ? a Hyperthyroidism . b Diabetes . c Treatment with SGLT2 inhibitors . d Severe restriction of dietary carbohydrate intake .
3 . Which TWO statements regarding the pathogenesis of ketoacidosis are correct ? a The goal of keto diets is to induce ketoacidosis . b Ketones are naturally generated as an alternative mitochondrial fuel source for metabolically demanding tissues .
On further questioning , Karen tells her GP she has taken their advice to lose some more weight and has undertaken intermittent fasting , which was going very well until this episode .
The GP explains that she has EKA and arranges for her transfer to hospital for emergency care .
CONCLUSION
KETOACIDOSIS is a medical emergency . However , it is one that can be easily missed by doctors because of
How to Treat Quiz .
c The characteristic breath odour of ketoacidosis smells like ‘ rotten eggs ’. d Most DKA events are sudden , associated with an event that liberates stress hormones .
4 . Which THREE statements regarding the risk factors and triggers for DKA are correct ? a Ketoacidosis is almost always the result of a trigger event in susceptible individuals . b DKA is the presenting feature in a third to half of cases of new onset type 1 diabetes . c The most common trigger event for DKA in patients with type 1 diabetes is severe dehydration associated with severe hyperglycaemia . d Most patients with established type 1 diabetes develop DKA during intercurrent infections .
5 . Which ONE is not part of the triad that constitutes DKA ? a Hyperglycaemia . b Acidosis . c Fever . its non-specific presentation , often in the setting of severe intercurrent illness . It is important for all practitioners to be familiar with the presentation , diagnosis and management of DKA in hyperglycaemic individuals with type 1 diabetes and have an action plan to respond appropriately and without delay .
Note that acute ketoacidosis is being increasingly observed in the absence of hyperglycaemia in individuals with type 2 diabetes put under
GO ONLINE TO COMPLETE THE QUIZ ausdoc . com . au / how-to-treat
d Ketosis .
6 . Which THREE laboratory findings are present in DKA ? a Blood ketone concentration of
0.6mmol / L or greater . b Blood pH less than 7.3 . c Blood glucose level less than
11.1mmol / L . d Serum bicarbonate less than
15mmol / L .
7 . Which TWO statements regarding the treatment of ketoacidosis are correct ? a Urgently transfer all patients with suspected ketoacidosis to ED / hospital . b In EKA , fluid replacement and insulin are supported by oral dextrose . c Ketoacidosis can be detected by glucose monitoring alone . d Patients with DKA generally require aggressive crystalloid fluid replacement in combination with an infusion of fast-acting insulin .
8 . In which ONE group is self-monitoring of blood ketone levels
EARN CPD OR PDP POINTS
• Read this article and take the quiz via ausdoc . com . au / how-to-treat
• Each article has been allocated one hour by the RACGP and ACRRM .
• RACGP points are uploaded every six weeks and ACRRM points quarterly .
ACUTE KETOACIDOSIS
extreme metabolic stress , and particularly those also treated with SGLT2 inhibitors . Although a serious complication , the risk of ketoacidosis should not be a reason not to appropriately use SGLT2 inhibitors in adults with type 2 diabetes .
Educate all patients , including provision of appropriate dietary advice ( for example , to avoid ketogenic diets ) and ‘ sick day ’ rules for when to pause their therapy , on these agents to mitigate their risks .
recommended , where indicated ? a Patients with type 2 diabetes . b Individuals with type 1 diabetes . c Those receiving SGLT2 inhibitors . d Pregnant women .
9 . Which THREE strategies may assist in preventing ketoacidosis ? a Patient education . b Have a practical ‘ sick day ’ plan . c Stopping the SGLT2 inhibitor in those with type 2 diabetes who develop EKA while taking the drug . d Not prescribing SGLT2 inhibitors .
10 . Which TWO statements regarding the prognosis of ketoacidosis in adults are correct ? a DKA is a potentially life-threatening disorder in adults with type 1 diabetes . b Pregnant women and their babies are at lower risk of mortality . c DKA remains one of the biggest contributors to loss of life years associated with type 1 diabetes in adults . d Most adults with DKA respond poorly and slowly to emergency treatment .
Figure 8 . Urine ketone testing .
RESOURCES
• Diabetes Australia : What are ketones and why it ’ s important to monitor them . bit . ly / 43NHQ9g
• Lea-Henry T , et al . ‘ Medication management on sick days ’. Aust Prescr 2017 ; 40:168-73 bit . ly / 444uRjq
• Williams D , et al . ‘ Sodiumglucose co-transporter 2 inhibitors beyond diabetes ’. Aust Prescr 2022 ; 45:121-24 bit . ly / 3CA0HsA
• D ’ Elia J , et al . ‘ Sodium – glucose cotransporter-2 inhibition and acidosis in patients with type 2 diabetes : a review of US FDA data and possible conclusions ’. Int J Nephrol Renovasc Dis 2017 ; 10:153 – 58 bit . ly / 3CFeU7H
• Plewa M , et al . ‘ Euglycemic diabetic ketoacidosis ’. StatPearls ; Updated 29 Jan 2023 bit . ly / 3PliQlC
• RACGP : Emergency management of hyperglycaemia in primary care bit . ly / 3rm89oL
• Virdi N , et al . ‘ Prevalence , cost , and burden of diabetic ketoacidosis ’. Diabetes Technology & Therapeutics 2023 ; Vol . 25 , No . S3 bit . ly / 4472GQP
• Diabetes Victoria : Everyday illness and type-1 diabetes www . diabetesvic . org . au / everyday-illness
• OzDAFNE Ketones and Illness Guidelines www . dafne . org . au / servlet / servlet . FileDownload ? file = 00P0o00002HFDRuEAP
• RACGP Sick day plan for type 2 diabetes – template www . racgp . org . au / getattachment / ae279c2d- 7e4e-43f6-af26-823b2fb5101b / Type-2-diabetes-sick-daymanagement-plan-template . docx . aspx
• AIHW : Diabetic ketoacidosis statistic bit . ly / 3OgjBv5
References Available on request from howtotreat @ adg . com . au