Patient education about managing diabetes during periods of mild illness ('sick day rules') is vital for preventing diabetic ketoacidosis (DKA). Counsel patients about potential precipitating factors and early warning symptoms of DKA. Consider the following measures:[2][20]
Review of usual glycaemic control
Review of injection technique, blood glucose monitoring, equipment, and injection sites
Checking the patient’s insulin before use (it may be expired or denatured)
Assessing the need for provision of handheld ketone meters for use at home
Provision of information on how to contact the diabetes specialist team out of hours
Provision of a written care plan (including ‘sick day rules’) that enables the patient to take an active role in diabetes management, with a copy sent to their GP.
Diabetes technology, such as insulin pump therapy and continuous glucose monitoring (CGM), can be used to reduce the risk of DKA.[6][55] In the UK, the National Institute for Health and Care Excellence (NICE) recommends that all patients with type 1 diabetes mellitus be offered CGM.[56] Use of CGM in patients with type 1 diabetes (regardless of insulin delivery method) has been shown to significantly reduce hospitalisations for DKA, lower HbA1c, decrease severe hypoglycaemic events, and increase time in range.[57] NICE also recommends offering CGM to adults with type 2 diabetes if they are:[58]
on multiple daily insulin injections and have:
recurrent hypoglycaemia or severe hypoglycaemia, or
impaired hypoglycaemia awareness, or
a condition or disability that means they cannot monitor their blood glucose by self-monitoring of blood glucose (SMBG) but could use a CGM device, or
they would otherwise be advised to self-measure at least 8 times a day.
insulin-treated and would need help from a care worker or healthcare professional to monitor their blood glucose.
Pregnant women with type 1 diabetes should be counselled about the increased risk of DKA during pregnancy, how to avoid and recognise this, and be provided with ketone-monitoring tools, as DKA in pregnancy is associated with a high risk of stillbirth.[6]
Sodium-glucose cotransporter-2 (SGLT2) inhibitor- and dual SGLT1/SGLT2 inhibitor-associated DKA is rare in patients with type 2 diabetes, may present with euglycaemia, and is typically precipitated by insulin omission or significant dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets (e.g., ketogenic diet), prolonged fasting, or excessive alcohol intake.[6] The American Diabetes Association (ADA) recommends that these drugs be avoided in cases of severe illness, in people with ketonaemia or ketonuria, and during prolonged fasting and surgical procedures.[6] Patients treated with SGLT2 inhibitors or the dual SGLT1/SGLT2 inhibitor sotagliflozin (especially patients with type 1 diabetes or ketosis-prone type 2 diabetes, and/or those on a ketogenic diet) should be educated about the risk of DKA and how to prevent and recognise it, and be provided with tools to measure their ketones.[6] DKA prevention strategies should include withholding these drugs when precipitants are present (e.g., discontinue 3-4 days before scheduled surgery) and avoiding insulin omission or large insulin dose reductions.[59][60] An example of a risk mitigation strategy is the 'STOP DKA' protocol, which was designed for patients with type 1 diabetes on SGLT2 inhibitors or sotagliflozin: patients are advised to be alert for symptoms of DKA, such as lethargy, loss of appetite, nausea, and abdominal pain, and if present, to stop their SGLT2 inhibitor or sotagliflozin, check blood ketone levels, maintain fluid and carbohydrate intake, and use maintenance and supplemental insulin.[61]
Many cases of DKA can be prevented through better access to medical care, appropriate patient education, and effective communication with healthcare providers during intercurrent illnesses. Omission or insufficient use of insulin therapy remains a major cause of DKA admissions.[1] Hospitals should ensure that basal insulin doses are not omitted or delayed for admitted patients, particularly during care transitions, through use of electronic alerts and ongoing staff education.[6]
Decades of research and monitoring of individuals with islet autoantibody positivity have led to a paradigm shift that recognises type 1 diabetes as a continuum of stages, from genetic risk through to autoimmunity and ultimately metabolic disease.[62] This evolving understanding raises the possibility of early intervention in individuals at high risk, which could facilitate earlier diagnosis and help to prevent complications such as DKA. See Screening.