EMA Topics · Endocrine & metabolic

Diabetic ketoacidosis

Updated Oct 15, 2026Adults · ED management5 sources · 4 in PubMed1 figure2024 international consensus

Bottom line

Diagnose on ketones and acidosis, not glucose. About 10% of DKA presents with glucose under 200 mg/dL (euglycemic DKA), often with SGLT2 inhibitors.¹
Potassium gates insulin. If K is under 3.5, replace at 10 mmol/h and hold insulin until K is above 3.5.¹
Insulin infusion at 0.1 units/kg/h. When glucose falls under 250 mg/dL, halve it to 0.05 and add dextrose. Keep going until the ketoacidosis has resolved, not until the glucose is normal.¹
Resolution means ketones < 0.6 mmol/L and pH ≥ 7.3 or bicarbonate ≥ 18. Don't use the anion gap or urine ketones.¹
Overlap subcutaneous and IV insulin by 1–2 hours. Early basal insulin during the infusion prevents rebound hyperglycemia.^1,3

Diagnosis and severity

	Mild	Moderate	Severe
Glucose	≥ 200 mg/dL or known diabetes	≥ 200 or known diabetes	≥ 200 or known diabetes
β-hydroxybutyrate	3.0–6.0 mmol/L	3.0–6.0 mmol/L	> 6.0 mmol/L
pH or bicarbonate	pH > 7.25 to < 7.30, or HCO₃ 15–18	pH 7.0–7.25, or HCO₃ 10 to < 15	pH < 7.0, or HCO₃ < 10
Mental status	Alert	Alert or drowsy	Stupor or coma
Level of care	Ward or observation	Step-down or intermediate	ICU

Adapted from the 2024 ADA/EASD/JBDS/AACE/DTS consensus.¹ A β-hydroxybutyrate ≥ 3.0 mmol/L tracks the acid-base change with over 90% sensitivity and specificity. The anion gap is not recommended as a first-line diagnostic criterion.¹

First hour

Check potassium before insulin. It decides whether insulin can start (table below).¹
Start fluid: isotonic saline or balanced crystalloid at 500–1,000 mL/h for the first 2–4 hours. Give smaller boluses (e.g. 250 mL) to older adults and patients with heart failure or on dialysis.¹
Start insulin at 0.1 units/kg/h IV. If IV access is delayed, a 0.1 units/kg IV or IM bolus can bridge.¹
Stop SGLT2 inhibitors and look for the trigger: infection and missed insulin are the most common.¹
Set the monitoring clock: capillary glucose every 1–2 hours; electrolytes, phosphate, creatinine, β-hydroxybutyrate and venous pH every 4 hours.¹

Potassium on arrival	Insulin	Potassium replacement
< 3.5 mmol/L	Hold until K > 3.5	10 mmol/h
3.5 to < 5.0 mmol/L	Start	20–30 mmol per liter of IV fluid, aiming for 4–5
≥ 5.0 mmol/L	Start	None yet; recheck

Recheck K 2 hours after starting insulin, then every 4 hours until DKA resolves.¹ About 55% of patients become hypokalemic during treatment and 16% severely so (≤ 2.5), which is linked to higher inpatient mortality.¹

The next 12 hours

FIG 1A typical course. Drawn for this page from the consensus timings. Glucose usually falls under 250 mg/dL within 4–8 hours. That is when dextrose starts and insulin halves, not when insulin stops. Dashed lines mark potassium checks.¹

At glucose < 250 mg/dL: reduce insulin to 0.05 units/kg/h and add 5–10% dextrose. Titrate to about 200 mg/dL until ketoacidosis resolves.¹
Euglycemic DKA: start dextrose from the beginning alongside the saline.¹
Balanced crystalloid: in a 172-patient subgroup of two cluster trials, DKA resolved faster than with saline (median 13.0 vs 16.9 hours).²
Subcutaneous rapid-acting insulin every 1–2 hours is an alternative for mild or moderate DKA only, not severe or complicated cases.¹

Bicarbonate and phosphate

Bicarbonate: not routine. Consider only if pH < 7.0: 100 mmol sodium bicarbonate (8.4%) in 400 mL sterile water every 2 hours until pH > 7.0.¹
Phosphate: not routine. Consider 20–30 mmol potassium phosphate in fluids if the patient has muscle weakness and phosphate < 1.0 mmol/L.¹

Resolution and transition

DKA has resolved when

β-hydroxybutyrate < 0.6 mmol/L and venous pH ≥ 7.3 or bicarbonate ≥ 18 mmol/L. Glucose should ideally be under 200 mg/dL.¹

Overlap subcutaneous insulin with the infusion for 1–2 hours before stopping IV insulin.¹
Basal-bolus is the preferred regimen. For insulin-naive patients estimate 0.5–0.6 units/kg/day, or about 0.3 units/kg/day with kidney failure, frailty or other hypoglycemia risks.¹
Basal insulin during the infusion (0.15–0.3 units/kg) shortens resolution, though some avoid it for hypoglycemia and hypokalemia risk.¹ In a randomized study of 61 patients on insulin infusions (DKA and other causes), glargine 0.25 units/kg started during the infusion cut rebound hyperglycemia (> 180 mg/dL) from 93.5% to 33.3%, with no added hypoglycemia.³

Complications

Hypoglycemia (< 70 mg/dL) affects 16–28% of patients; about 2% fall below 40.¹
Hypokalemia affects about 55%; severe in 16%.¹
Cerebral edema is rare in adults (< 0.1%) but carries about 30% mortality. Mannitol and mechanical ventilation are suggested.¹

Triggers

Infection is the most common trigger worldwide (14–58%).¹
Missed insulin accounts for 41–60% of US cases.¹
New type 1 diabetes: 6–21% of adults present with DKA as their first diagnosis.¹
SGLT2 inhibitors: stop on admission. Others: stroke, alcohol or substance use, pancreatitis, PE, MI and trauma.¹

Pitfalls

Starting insulin before seeing the potassium.¹
Missing euglycemic DKA because the glucose is under 200 mg/dL.¹
Stopping the infusion when glucose normalizes instead of adding dextrose.¹
Declaring resolution on a closed anion gap or negative urine ketones.¹
Stopping IV insulin without a 1–2 hour subcutaneous overlap.¹

How strong is the evidence?

Most recommendations come from expert consensus by five societies, published in 2024, which updated the 2009 ADA statement. The same report is published open access in Diabetologia.^1,5 The fluid choice rests on a trial subgroup analysis² and early basal insulin on a small randomized study.³ For a bedside summary see LITFL.⁴

On-shift teaching

Questions to ask a learner at the bedside. Tap a question to see the answer. Every answer uses facts cited above.

Q1Potassium is 3.2 on arrival. What do you do with the insulin?

Hold it. Replace potassium at 10 mmol/h and start insulin once K is above 3.5.¹

Q2Glucose is 230 mg/dL but pH is still 7.18. Do you stop the insulin drip?

No. Halve the infusion to 0.05 units/kg/h and add 5–10% dextrose, aiming for a glucose of about 200 mg/dL, and continue until the ketoacidosis resolves.¹

Q3How do you define resolution of DKA?

β-hydroxybutyrate < 0.6 mmol/L and venous pH ≥ 7.3 or bicarbonate ≥ 18 mmol/L, ideally with glucose under 200 mg/dL. Don't use the anion gap or urine ketones.¹

Q4How can a patient be in DKA with a glucose of 150 mg/dL?

Euglycemic DKA: about 10% of cases present with glucose under 200 mg/dL, often with SGLT2 inhibitors. Start dextrose from the beginning, and stop the SGLT2 inhibitor.¹

Q5When is bicarbonate considered, and how much?

Only if pH < 7.0: 100 mmol sodium bicarbonate (8.4%) in 400 mL sterile water every 2 hours until pH is above 7.0.¹

Q6Saline or balanced crystalloid?

The consensus allows either.¹ In a 172-patient trial subgroup, DKA resolved faster with balanced crystalloid (median 13.0 vs 16.9 hours).²

References

1
Umpierrez GE, et al. Hyperglycemic crises in adults with diabetes: a consensus report. Diabetes Care. 2024;47(8):1257–1275.ConsensusPMID 39052901 PMCFull text read (key sections)
2
Self WH, Evans CS, Jenkins CA, et al. Clinical effects of balanced crystalloids vs saline in adults with diabetic ketoacidosis: a subgroup analysis of cluster randomized clinical trials. JAMA Netw Open. 2020;3(11):e2024596.RCTPMID 33196806 PMCPubMed
3
Hsia E, Seggelke S, Gibbs J, et al. Subcutaneous administration of glargine to diabetic patients receiving insulin infusion prevents rebound hyperglycemia. J Clin Endocrinol Metab. 2012;97(9):3132–3137.RCTPMID 22685233PubMed
4
Life in the Fast Lane. Diabetic ketoacidosis.FOAMlitfl.comLink checked
5
Umpierrez GE, et al. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia. 2024;67(8):1455–1479. Same report, open access.ConsensusPMID 38907161 PMCPubMed record

Not for clinical use

AI-generated draft. Not reviewed by a physician. This page is for education only and may contain errors, including in doses. Do not use it to diagnose, treat or make decisions about any patient. Rely on your own clinical judgment, your institution's protocols and current drug labeling. Reading this page does not create a physician-patient relationship. Full terms