Definition of diabetic ketoacidosis
- Glucose > 14 mmol/L
- Ketone bodies in urine or blood
- Serum bicarb < 15 mmol/L
Euglycemic ketoacidosis requires the glucose to be normal (<11 mmol/L), or midly elevated.
- Examples of ketoacidosis without insulin deficiency are alcoholic and starvation ketoacidosis.
- Other possibilities include liver disorder or glycogen storage disorder.
Ketone bodies formation are governed by a few factors
- Insulin deficiency which leads to relative increase in glucagon and other stress hormones –> lipolysis to produce FFA as substrate for gluconeogenesis and ketone bodies synthesis
- Starvation which leads to hypoglycemia –> increase in stress hormones –> lipolysis -> ketone bodies synthesis as body fuel
- Excessive ethanol ingestion which leads to starvation (above) and metabolism into acetaldehyde which provides NADH for acetoacetate to be reduced to B-hydroxybutyrate
- In glycogen storage disease or liver disease, glycogen storage is reduced –> in starvation state hypoglycemia can happen
– Note that diabetic patients could develop euglycemic ketoacidosis if they are starved but continue taking the insulin.
– Recently, use of SGLT2 inhibitors (glifozins) have also been proposed to be a mechanism of euglycemic ketoacidosis in diabetic patients.
- Consider in diabetic patients taking SGLT2 inhibitors who present with abdo pain.
- Mechanism: due to excessive glucosuria (which is not insulin dependant process) + insulin deficiency
NOT ALL KETOACIDOSIS IN DIABETES IS DKA !
Is it important to differentiate diabetic vs euglycemic ketoacidosis?
- Yes, because treatment would differ somewhat.
- In DKA, insulin+fluid would be the mainstay of the therapy. D5 is only required to maintain euglycemia.
- In starvation or alcoholic ketoacidosis, patients are normally hypoglycemic, so hypoglycemia correction takes priority.
– Once normal glucose level is restored, the body will shift from using ketone bodies to glucose as fuel.
– Insulin is still needed as it promotes the conversion of acetoacetate to B-hydroxybutyrate which is then excreted in urine. D10 will be needed to faciliate the use of insulin in SKA/AKA.
- Note that there can be a mixed of ketoacidosis due to insulin deficiency and starvation in diabetic patients.
- Psychological management:
– Find out why did they starve themselves? depression, anorexia etc
– Also counselling for alcohol abuse problems if there is any.
Take home messages
- Euglycemic ketoacidosis: consider starvation, alcoholic or liver disease.
- Diabetic patients dont always have DIABETIC ketoacidosis. Consider starvation in state of insulin deficiency or use of SGLT2 inhibitors.
- Correction of hypoglycemia takes priority in treatment of euglycemic ketoacidosis. D10 maybe needed to facilitate the use of insulin.
- Psychological management: always ask why they starve/abuse alcohols ! As in DKA in which infection is the usual cause, depression/anorexia is common in patients with starvation ketoacidosis.
Franklin Joseph1, Lydia Anderson1, Niru Goenka1, and Jiten Vora. Starvation-induced True Diabetic Euglycemic Ketoacidosis in Severe Depression. J Gen Intern Med 2008;24(1):129–31