Patient discussions

Before discharge, all individuals admitted with diabetic ketoacidosis (DKA) should be offered appropriate education focused on both the current event and overall diabetes management.[1]​ This should include education on insulin administration and 'sick day rules', including:

  • Injection technique (including sites)

  • Glucose monitoring and urine or blood ketone testing

  • When to contact the healthcare provider

  • Blood glucose goals and the use of supplemental short- or rapid-acting insulin during illness

  • Means to suppress fever and treat infection

  • Initiation of an easily digestible fluid diet containing electrolytes and glucose during illness

Assess precipitating and contributing causes of DKA admission, provide appropriate information and education about these, and emphasise the importance of follow-up within 2-4 weeks after discharge to help reduce the risk of recurrent DKA.[1]

Patients should be advised to always continue insulin during illness and to seek professional advice early. Sodium-glucose cotransporter-2 (SGLT2) inhibitor and dual SGLT1/SGLT2 inhibitor-associated DKA in patients with type 2 diabetes is typically precipitated by insulin omission or significant dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive alcohol intake. DKA prevention strategies should include withholding SGLT2 or dual SGLT1/SGLT2 inhibitors when precipitants are present, and avoiding insulin omission or large insulin dose reductions.[59][60]

Home measurement of capillary blood glucose and ketones can help detect early signs of impending DKA; however, appropriate use of ketone testing among adults with diabetes remains low.[1][174]​​​​​ Patients, or their carers, must be able to accurately measure and record blood glucose, insulin doses, temperature, respiratory rate, and pulse. Blood ketone levels should be checked when blood glucose exceeds 16.7 mmol/L. If ketone levels are increased, the patient should present to hospital for further evaluation. The frequency of blood glucose monitoring should be tailored to the individual’s clinical status: in those with uncontrolled diabetes (HbA1c >53 mmol/mol), it is recommended to check blood glucose before each meal and at bedtime.​[175]​​

In the UK, the National Institute for Health and Care Excellence (NICE) recommends that all patients with type 1 diabetes mellitus should be offered continuous glucose monitoring (CGM).[56]​ Furthermore, although CGM has not been approved for use in hospitalised patients with diabetes or with DKA, consensus guidelines from the American Diabetes Association, European Association for the Study of Diabetes, American Association of Clinical Endocrinology, Joint British Diabetes Societies for Inpatient Care, and Diabetes Technology Society recommend that CGM be offered to all individuals admitted with DKA, either just prior to or shortly after hospital discharge.[1]

Bear in mind that people with diabetes might be struggling to manage their diabetes effectively owing to psychological and social challenges; these patients will require an integrated multidisciplinary approach, including psychologists, psychiatrists, and support workers.[1][176]

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