UK doctor calls for DKA guidelines revision in bid to improve diagnosis

A UK doctor has called for an overhaul of guidance related to the diagnosis and management of diabetic ketoacidosis (DKA) in adults.
DKA is a complication of type 1 diabetes and, in some cases, latent autoimmune diabetes of adults (LADA), characterised by a lack of insulin aggravated by high blood sugar levels and the build-up of ketone bodies in the blood.
In a new editorial written in The Lancet, Dr Ketan Dhatariya, a diabetes and endocrinology consultant based at the Norfolk and Norwich University Hospitals NHS Trust, argues that our national guidance is laconic.
He believes that the international recommendations we resort to are largely outdated, and that a number of modifications should be made, highlighting new evidence that has emerged since the American Diabetes Association’s (ADA) last position statement on DKA in 2009.
Dhatariya’s proposed changes include the use of more criteria to define DKA and different management options for short-term complications of DKA.
The problem with the diagnosis of DKA, as seen by Dhatariya, is twofold: the blood sugar cut-off point of 13.9 mmol/L to identify DKA is set too high, and DKA is too often diagnosed based on a single risk factor like the disruption of insulin treatment or elevated ketone levels.
Drawing from accumulated professional experience, Dhatariya knows that many patients vulnerable to DKA can present with smaller increases in blood sugar levels than this cut-off point after lowering their insulin dose, reducing their food intake, or when ill.
By referring to the standardised cut off score of 13.9 mmol/mol, euglycemic DKA (defined as DKA without marked hyperglycemia) seen in patients with gestational diabetes or those treated with SGLT2 inhibitors, can go amiss too. Euglycemic DKA is thought to occur when blood sugar levels are as low as 11.1 mmol/L.
Dhatariya would also like to see introduced an alternate ketone testing method in the guidelines. Urine methods for the early diagnosis of DKA test for the ketone body acetoacetate, but do not usually detect for a separate ketone body known as beta-hydroxybutyrate (BHA).
Recent studies have found BHA to be the predominant ketone body at the onset of DKA and suggest that the measurement of blood BHA is a more accurate predictor of ketosis than is the detection of acetoacetate through the urine.
In terms of in-hospital care, Dhatariya urged simplified DKA management, similar to the Emergency Valuable Approach and Diabetes Education (EVADE) protocol used in US emergency rooms, to treat patients with mild and moderate DKA.
Dhatariya concluded by calling for either new national guidelines or revised DKA international guidance that is evidence-based, practical, and easy to follow to be used by healthcare staff managing DKA in the UK.