{ "schema_version": 1, "kind": "condition", "id": "diabetic-ketoacidosis", "name": "Diabetic Ketoacidosis (Emergency Referral)", "category": "emergency", "sources": "Adult Diabetic Ketoacidosis - StatPearls, updated 30 November 2025 - https://www.ncbi.nlm.nih.gov/books/NBK560723/", "review_status": "reviewed", "verified_against": "Adult Diabetic Ketoacidosis - StatPearls, updated 30 November 2025 - https://www.ncbi.nlm.nih.gov/books/NBK560723/", "verified_date": "2026-08", "treatments": [ { "id": 579, "generic": "Insulin neutral human", "line": 1, "is_adjunct": false, "form": "injection", "strength_mg": null, "adult_dose": "CHECK POTASSIUM FIRST - do not start insulin until serum potassium is above 3.5 mmol/L. Then intravenous infusion at 0.14 units/kg/hour with no bolus, or a 0.1 units/kg bolus followed by 0.1 units/kg/hour. Drop to 0.05 units/kg/hour once glucose reaches 200 to 250 mg/dL, with dextrose added to the fluids.", "adult_duration": "Continued until the ketoacidosis resolves, and for 2 hours after subcutaneous insulin is started", "dose_source": "Adult Diabetic Ketoacidosis - StatPearls, updated 30 November 2025 - https://www.ncbi.nlm.nih.gov/books/NBK560723/", "rationale": "The cited article states that intravenous insulin by continuous infusion is the standard of care, and gives both regimens: an initial bolus of 0.1 units/kg followed by an infusion of 0.1 units/kg/hour, or - on a more recent randomised trial it names - an hourly infusion of 0.14 units/kg/hour with no bolus at all. It states that the rate may need to fall to 0.05 units/kg/hour once plasma glucose reaches 200 to 250 mg/dL and dextrose-containing fluid is started, and that in euglycaemic DKA no bolus is given and the infusion runs at 0.05 units/kg/hour from the start with 5% to 10% dextrose in the fluids throughout.", "cautions": [ "POTASSIUM BEFORE INSULIN, EVERY TIME. The article states that insulin should only be started when serum potassium is 3.5 mmol/L or higher, because insulin drives potassium into the cells and can produce severe hypokalaemia - cardiac arrhythmia, cardiac arrest, and respiratory arrest from respiratory muscle weakness. Below 3.5 mmol/L the patient gets fluid and potassium first, and insulin waits.", "AND POTASSIUM ALONGSIDE IT AFTERWARDS. The article starts potassium replacement once the serum level is below 5.2 mEq/L, aiming to hold it between 4 and 5 mEq/L, at 20 to 30 mEq per litre of fluid for most patients and less in acute or chronic renal failure.", "EUGLYCAEMIC DKA IS REAL AND THE REGIMEN IS DIFFERENT. The article describes DKA with a glucose below 250 mg/dL, gives no bolus in it, runs the infusion at 0.05 units/kg/hour, and puts 5% to 10% dextrose in the fluids from the beginning.", "THIS IS AN AMBULANCE, NOT A CLINIC. Insulin here is an intravenous infusion titrated against hourly glucose, potassium and the anion gap. The regimen is printed so the GP knows what the patient is being sent for and can recognise it - not so it is started in the surgery.", "MILD, UNCOMPLICATED DKA HAS A SUBCUTANEOUS ALTERNATIVE, AND IT IS A DIFFERENT INSULIN. The article gives subcutaneous lispro 0.1 units/kg initially then 0.1 units/kg hourly until glucose is under 250 mg/dL, then 0.1 units/kg hourly or 0.2 units/kg every 2 hours until the DKA resolves, and says aspart has been found equally effective. That is a non-intensive-care regimen for a mild case, not a substitute for the infusion in a sick patient.", "DO NOT STOP THE INFUSION THE MOMENT SUBCUTANEOUS INSULIN GOES IN. The article asks for the infusion to continue for 2 hours after the first subcutaneous dose, to stop the ketoacidosis recurring in the gap." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "The article gives no separate paediatric regimen, so none is printed. What it does say about children is a warning rather than a dose: rates of cerebral oedema rose with aggressive fluid volumes particularly in children, and in a paediatric study the children at higher risk of cerebral oedema were those presenting with a low PaCO2 and a high blood urea nitrogen, and those treated with bicarbonate. A child in DKA is managed on a paediatric protocol by the unit that admits them.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "HUMAN INSULIN R VACSERA-BIOTON 100I.U./ML VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "VACSERA > BIOTON CO. LTD-POLAND", "price_egp": 31.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "INSUMAN RAPID 100 I.U./ML 10ML VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SANOFI > FRANCO", "price_egp": 55.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "INSULIN H BIO R 100I.U.VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SEDICO", "price_egp": 77.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "ACTRAPID HM 100 I.U./ML 10 ML VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "NOVO NORDISK", "price_egp": 130.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "INSUMAN RAPID 100 I.U./ML 5*3ML PENFILLS", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SANOFI > FRANCO", "price_egp": 133.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "HUMAXIN RAPID 100 I.U./ML 5*3ML PENFILLS", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "EVA PHARMA", "price_egp": 322.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "ACTRAPID HM 100 I.U./ML 5*3ML PENFILLS", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "NOVO NORDISK", "price_egp": 338.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "HUMULIN R 100 I.U./ML 5 CARTRIDGE", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "ELI LILLY", "price_egp": 338.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null } ], "condition_id": "diabetic-ketoacidosis" }, { "id": 580, "generic": "Referral & safety-netting (no drug therapy)", "line": 1, "is_adjunct": false, "form": null, "strength_mg": null, "adult_dose": "Emergency admission, now. Thirst, polyuria and weight loss progressing to vomiting, abdominal pain, deep sighing (Kussmaul) breathing and a fruity smell on the breath. Diagnosis is glucose above 250 mg/dL, arterial pH below 7.3, bicarbonate below 15 mEq/L, and ketones in blood or urine. Check a capillary glucose and ketones if you can, but a patient who looks like this goes to hospital whether or not you can measure them.", "adult_duration": "Refer, with advice", "dose_source": "No dose - referral pathway, no medicine given in primary care", "rationale": null, "cautions": [ "HOSPITAL ONLY. StatPearls: intravenous insulin by continuous infusion is the standard of care, with hourly glucose monitoring. There is no outpatient version of this.", "DO NOT give insulin before potassium is known. StatPearls requires a potassium of at least 3.5 mmol/L before insulin is started - giving insulin first can cause fatal hypokalaemia.", "It can be the FIRST presentation of diabetes. A previously well young person with these symptoms has new type 1 diabetes until proved otherwise - see [Type 1 Diabetes].", "Infection, missed insulin doses, corticosteroids, thiazides and SGLT-2 inhibitors are the common precipitants. SGLT-2 inhibitors can produce ketoacidosis with a near-normal glucose.", "Abdominal pain in DKA is often taken for a surgical abdomen. Check ketones before referring the pain instead of the patient." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "Children decompensate faster and are at risk of cerebral oedema during treatment. Emergency transfer; do not attempt rehydration protocols in the clinic.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [], "condition_id": "diabetic-ketoacidosis" } ] }