Managing diabetic ketoacidosis in special conditions: Difficulties and dilemmas

Table 3 Key management principles of management of atypical forms of diabetic ketoacidosis

Disease	Key management principles
euDKA	Physicians should have heightened awareness of this nuanced presentation of euDKA
	To minimize the risk of euDKA associated with SGLT-2 inhibitors, the recommendations from international societies should be followed
	To have a low threshold for obtaining ketone levels in diabetic patients with unexplained acidosis, even in absence of significant hyperglycemia
	Insulin dose reduction should be achieved by slow, gentle decrements simultaneously to avoid hypoglycemia and sliding toward euDKA
	Dextrose containing fluids should be used early in these patients to avoid hypoglycemia due to insulin infusion
	In case of euDKA in non-diabetic individuals, insulin infusion is not necessary, whereas fluid replacement and intravenous glucose solution are sufficient for the resolution of acidosis
Diabetic ketoacidosis and hyperosmolar hyperglycemic state overlap	Aggressive hydration is needed in first 12 hours to maintain a positive fluid balance (like management of HHS)
	Higher dose of fixed rate intravenous insulin infusion (0.1 units/kg/hour) is preferred (like management of DKA)
	Early initiation of insulin infusion along with i.v. fluid therapy (like management of DKA)
	Frequent monitoring of serum potassium should be done along with routine supplementation of potassium
	Identification and management of precipitating causes

DKA: Diabetic ketoacidosis; HHS: Hyperosmolar hyperglycemic state; i.v.: Intravenous; euDKA: Euglycemic diabetic ketoacidosis; SGLT-2: Sodium-glucose cotransporter-2 inhibitors.