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Diabetic ketoacidosis — USMLE Step 3 MCQ

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HardEmergency MedicineDiabetic ketoacidosisUSMLE Step 3

A 58-year-old taking empagliflozin has vomiting, glucose 184 mg/dL, beta-hydroxybutyrate 6.2 mmol/L, pH 7.19, bicarbonate 11 mEq/L, and potassium 4.6 mEq/L. After initial isotonic crystalloid, which regimen best suppresses ketogenesis while limiting hypoglycemia?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Stop empagliflozin; give 5–10% dextrose and intravenous insulin at 0.05 units/kg/hour with potassium monitoring

The best answer is “Stop empagliflozin; give 5–10% dextrose and intravenous insulin at 0.05 units/kg/hour with potassium monitoring”. This is SGLT2-associated euglycemic DKA. Because glucose is already below 250 mg/dL, the consensus protocol adds 5–10% dextrose immediately and uses the reduced intravenous insulin rate of 0.05 units/kg/hour so insulin can continue until ketonemia and acidosis resolve. Potassium and glucose require frequent monitoring; stopping the precipitating SGLT2 inhibitor is essential.

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