---

DKA: Latest 2025-2026 Updates

What's New - Key Changes

---

1. Updated Diagnostic Criteria

DKA Severity Classification (2024 Update)

---

2. Fluid Resuscitation - Updated Approach

• Initial bolus: 0.9% NaCl at 500-1000 mL/hr for 1-2 hours in adults (titrated to hemodynamic status)
• Key change - Balanced crystalloids preferred: Evidence now supports Lactated Ringer's (LR) or Plasma-Lyte over 0.9% NaCl to reduce hyperchloremic acidosis, especially in the maintenance phase. Multiple trials showed LR reduces non-AG acidosis and may shorten resolution time.
• Avoid over-aggressive hydration in patients with cardiac or renal failure
• Switch to 0.45% NaCl + dextrose when glucose falls to 200-250 mg/dL

---

3. Insulin Therapy - The Biggest Changes

3a. Subcutaneous Insulin for Mild-Moderate DKA (New Recommendation)

• No significant difference in time to DKA resolution (MD +0.17 h, 95% CI -3.45 to 3.79)
• No difference in hypoglycemia risk (RR 1.02)
• Trend toward shorter length of stay with SC insulin
• Conclusion: SC insulin (rapid-acting analogues like lispro or aspart) is safe and effective for mild-moderate DKA

• Rapid-acting insulin 0.3 units/kg SC bolus, then 0.1 units/kg SC every hour OR
• 0.2 units/kg SC every 2 hours
• Once glucose <250 mg/dL, reduce to 0.05 units/kg/hr and add dextrose

3b. Early Basal Insulin Alongside IV Insulin Infusion (New 2026 Recommendation)

• Early SC basal insulin (0.15-0.3 units/kg) alongside IV infusion reduced time to DKA resolution by 4.02 hours (95% CI -5.52 to -2.52, p<0.001)
• Reduced total IV insulin required by ~19 units
• No increase in hypoglycemia, hypokalemia, or mortality

• Time to resolution shorter by 4.06 hours (95% CI -5.53 to -2.58, p<0.0001)
• Total fluid requirements reduced by ~400 mL
• No difference in hospital length of stay, rebound hyperglycemia, or recurrent DKA

Note on erratum: The Thammakosol 2026 meta-analysis has a published erratum (PMID 41582724) - verify final figures when applying to clinical practice.

---

4. The Two-Bag Method - Now Strongly Supported

---

5. Potassium Management

• Do NOT start insulin if K+ <3.3 mEq/L - correct first, then start insulin
• K+ 3.3-5.0: Add 20-40 mEq/L to IV fluids, monitor every 2 hours
• K+ >5.0: No supplementation, recheck every 2 hours
• Target K+ 4.0-5.0 mEq/L throughout treatment
• IV potassium preferred over oral during acute management (unreliable GI absorption in acute illness)
• In severe DKA (K+ ≤3.3 mmol/L), low threshold for central venous access

---

6. Bicarbonate - Still Restricted

• pH <7.0 (or some guidelines say <6.9)
• Severe hyperkalemia with cardiac instability
• Dose: 50-100 mEq NaHCO3 over 1-2 hours if used at all

---

7. Resolution Criteria (2024 Update)

---

8. Transition to Subcutaneous Insulin

• Overlap IV insulin with first SC dose for at least 1-2 hours before stopping infusion (prevents rebound hyperglycemia)
• Resume home insulin if on it; if insulin-naive, start at 0.5-0.8 units/kg/day in basal-bolus regimen
• ADA 2026: Early basal insulin during admission may bridge this transition

---

9. New 2026 ADA Additions Related to DKA

• Rec. 9.33 (new): Patients on cancer immunotherapy who develop hyperglycemia should be assessed for immunotherapy-associated diabetes and potential DKA risk - prompt insulin therapy evaluation needed
• Rec. 9.35b (new): For hyperglycemia due to PI3K inhibitors, insulin should be reserved for severe hyperglycemia/hyperglycemic crises due to risk of impacting PI3K inhibitor efficacy
• Section 6 expansion: More content added on outpatient prevention and management of DKA, including sick-day rules and ketone monitoring for at-risk patients
• SGLT2 inhibitor-associated DKA: Continues to be highlighted as euglycemic DKA (glucose may be <250 mg/dL) - requires high clinical suspicion; hold SGLT2i at hospital admission

---

10. Special Populations

---

Quick Reference Summary

FLUIDS:  0.9% NaCl bolus → switch to LR or Plasma-Lyte → add dextrose when glucose <250
INSULIN: Mild-mod DKA: SC rapid-acting acceptable | All: consider early basal (0.15-0.3 U/kg)
         Severe: IV infusion 0.1 U/kg/hr (no bolus unless delay in infusion start)
K+:      Hold insulin if K+ <3.3 | Replace aggressively | Target 4-5 mEq/L
BICARB:  Only if pH <7.0 with cardiac instability
END:     BOHB <0.6 + pH >7.3 + HCO3 >18 → transition to SC with 1-2h overlap
TWO-BAG: Preferred method - 50% less hypoglycemia, faster resolution

---

• ADA Standards of Care 2026, Section 16 (Diabetes Care, Jan 2026)
• 2024 ADA Consensus Report on Hyperglycemic Crises - Cleveland Clinic review (PMID 40032308)
• SC vs IV insulin meta-analysis - Alnuaimi et al. 2024 (PMID 39090718)
• Early basal insulin meta-analysis - Thammakosol et al. Feb 2026 (PMID 41208563)
• Early basal insulin meta-analysis 2 - AbuJlambo et al. Jul 2026 (PMID 42405473)
• Two-bag method meta-analysis - Srikrishnaraj et al. Mar 2026 (PMID 40913602)
• Goldman-Cecil Medicine, p. 1241-1316 | Rosen's Emergency Medicine, p. 2542

---

DKA Update: ADA 2024 Consensus Report

---

1. DIAGNOSIS - What Changed

Updated Glucose Criterion

• This change formally recognizes euglycemic DKA, which affects ~10% of DKA cases - especially in patients on SGLT2 inhibitors, pregnancy, fasting, or alcohol use

New Ketone Measurement Standard

• Urine acetoacetate underestimates ketone burden early in DKA (BOHB not yet converted)
• Urine acetoacetate overestimates severity later in DKA (BOHB clears faster and gets converted back to acetoacetate)
• BOHB directly reflects the dominant ketone body in DKA (~75-85% of total ketones)
• Direct measurement by bedside glucometer-style devices is now widely available

Full 2024 Diagnostic Criteria (ALL 3 must be present)

Severity Classification (2024 Update - now includes BOHB tiers)

---

2. FLUID RESUSCITATION - What Changed

Phase 1 - Initial Resuscitation

• 0.9% NaCl remains the first-line for initial volume resuscitation (500-1000 mL/hr for 1-2 hours depending on hemodynamic status and severity)
• Goal: restore tissue perfusion and urine output

Phase 2 - Maintenance Fluids (Key Update)

• High-chloride load from prolonged 0.9% NaCl can cause hyperchloremic metabolic acidosis, masking true DKA resolution and complicating anion gap interpretation
• Balanced crystalloids may reduce non-anion-gap acidosis and facilitate faster apparent resolution
• Current guidance: After initial resuscitation, switching to LR or Plasma-Lyte is reasonable - particularly in moderate/severe DKA where prolonged IV fluids are needed
• Rate of osmolality correction should not exceed 3-8 mOsm/kg/hour

Phase 3 - Dextrose Addition

• When blood glucose falls to 200-250 mg/dL: switch to dextrose-containing fluids (D5-0.45% NaCl or D5-LR)
• This allows continuation of insulin infusion to clear ketones without causing hypoglycemia
• Maintain glucose 150-250 mg/dL until DKA fully resolves

---

3. INSULIN THERAPY - Major Changes

3a. Intravenous Insulin (Standard for Moderate-Severe DKA)

• Fixed-rate infusion has shown improved outcomes over variable-rate protocols
• Do NOT reduce insulin infusion to clear ketones just because glucose is falling - add dextrose instead

3b. Subcutaneous Insulin for Mild DKA (New Endorsement)

• Lispro or aspart: 0.3 units/kg SC bolus, then 0.1 units/kg/hr SC every hour OR 0.2 units/kg every 2 hours
• When glucose <250 mg/dL: reduce to 0.05 units/kg and add dextrose

• Moderate or severe DKA
• Hemodynamic instability or shock
• Altered mental status
• Inability to eat/drink
• Concurrent HHS

---

4. POTASSIUM - Updated Protocol

ADA 2024 Potassium Algorithm

• Measure K+ at baseline, 2 hours after starting insulin, then every 4 hours until crisis resolves
• Severe hypokalemia (≤2.5 mEq/L) is associated with a 3-fold increase in mortality
• Consider central venous access for rapid K+ replacement in severe cases (K+ ≤3.3 with severe DKA)

---

5. PHOSPHATE & OTHER ELECTROLYTES

• Routine phosphate replacement is not recommended (no evidence of clinical benefit in randomized trials)
• Consider phosphate only if: severe hypophosphatemia (<1.0 mg/dL), respiratory muscle weakness, or hemolytic anemia
• Magnesium: correct if serum Mg <1.2 mg/dL or significant hypokalemia unresponsive to K+ replacement
• Bicarbonate: see below

---

6. BICARBONATE - Still Restrictive

• Routine bicarbonate is not recommended in DKA
• Associated with paradoxical CNS acidosis, hypokalemia worsening, and cerebral edema risk
• Only consider if pH <7.0 in the setting of hemodynamic compromise or severe hyperkalemia with cardiac effects
• If used: 100 mEq NaHCO3 in 400 mL sterile water + 20 mEq KCl over 2 hours; recheck pH after

---

7. MONITORING DURING TREATMENT

---

8. RESOLUTION CRITERIA - Key Change (BOHB-Based)

Why this matters: Anion gap can remain elevated due to hyperchloremia from NS infusion even after true ketoacidosis has cleared - BOHB gives a more accurate end-point.

---

9. TRANSITION TO SUBCUTANEOUS INSULIN

1. Give first SC dose 1-2 hours before stopping the IV insulin infusion
2. Resume pre-admission insulin if patient was on it
3. For insulin-naive patients: start basal-bolus at 0.5 units/kg/day (50% basal, 50% bolus)
4. For type 1 DM specifically: early basal insulin during admission (0.15-0.3 units/kg) may bridge the transition and prevent rebound hyperglycemia (now supported by multiple 2026 meta-analyses)
5. Patient must be able to eat before transitioning to SC insulin

---

10. EUGLYCEMIC DKA - Heightened Emphasis

• Glucose may be <200 mg/dL at presentation (especially with SGLT2 inhibitors, pregnancy, fasting, alcohol, or gastroparesis)
• Mechanism: SGLT2i increase urinary glucose excretion + ketogenesis while lowering plasma glucose
• SGLT2i should be held on admission and not restarted until the patient is eating, DKA is resolved, and after review of appropriateness
• High clinical suspicion required in SGLT2i users with nausea/vomiting, abdominal pain, or Kussmaul breathing even if glucose is normal
• Treatment is the same: fluids, insulin, dextrose (add dextrose early since glucose is already low)

---

11. PREVENTION & OUTPATIENT MANAGEMENT (New Section)

• Sick-day rules: Never stop insulin during illness; increase monitoring frequency; check BOHB if glucose >250 mg/dL
• Ketone monitoring: Use BOHB meters at home; start preventive measures if BOHB >0.6 mmol/L
• Threshold for seeking care: BOHB >3.0 mmol/L, inability to keep fluids down, or pH <7.3 symptoms
• Education: Structured sick-day management plans should be given to all insulin users
• Technology: Continuous glucose monitoring (CGM) and closed-loop systems may reduce DKA incidence in type 1 DM

---

Summary: Key Changes vs. 2009 Guidelines

---