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DKA — USMLE Step 3 MCQ

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HardEmergency MedicineDKAUSMLE Step 3

A patient with DKA has received fluids, potassium, and intravenous insulin. Glucose is 176 mg/dL, plasma beta-hydroxybutyrate is 0.4 mmol/L, venous pH is 7.31, and bicarbonate is 17 mEq/L. He can eat and a subcutaneous basal-bolus regimen is ready. What is the best transition plan?

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Correct answer: B — Give basal insulin now and overlap intravenous insulin for 1–2 hours

The best answer is “Give basal insulin now and overlap intravenous insulin for 1–2 hours”. DKA is resolved when plasma ketones are below 0.6 mmol/L and venous pH is at least 7.3 or bicarbonate is at least 18 mmol/L; glucose should ideally be below 200 mg/dL. This patient meets ketone, pH, and glucose criteria. Basal insulin should precede infusion discontinuation by 1–2 hours to prevent rebound hyperglycemia or ketoacidosis.

Reference: Hyperglycemic Crises in Adults With Diabetes: 2024 Consensus Report: https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A