The diagnostic criteria for diabetic ketoacidosis (DKA) have changed from 2009 to 2024. In 2024, DKA can be diagnosed with glucose ≥200 mg/dL or a prior diabetes history, compared to >250 mg/dL in 2009. Metabolic acidosis criteria remain similar, with pH <7.3 and/or bicarbonate <18 mmol/L. The diagnostic criteria for hyperosmolar hyperglycemic syndrome (HHS) include hyperglycemia (plasma glucose ≥600 mg/dL), hyperosmolarity, absence of significant ketonemia, and absence of acidosis. Recent updates lowered the effective serum osmolality threshold to >300 mOsm/L and introduced quantitative cut-offs for ketones and bicarbonate.
DKA is a rare adverse event during SGLT2i therapy. A detailed data was retrieved on 105 SGLT2i-associated DKA case reports, wherein 37% of patients showed glucose levels of less than 200 mg/dL. ~10% of all DKA patients had a presenting glucose <200 mg/dL (11.1 mmol/L). A cluster analysis of two RCTs showed that DKA resolved faster with Lactated Ringer’s compared to isotonic saline (median 13.0 vs 16.9 hours). Patients with uncomplicated mild or moderate DKA may be treated with SC-RAPID acting insulin analogs every 1-2 hrs in the ED. Rapid acting subcutaneous insulins are not recommended for the severe or complicated DKA or HHS. Flash CGM use significantly reduced acute hospital events, with a 56.2% drop in DKA cases among people with T1D and a 52.1% reduction in T2DM (Roussel et al. 2021).
Conclusion:
