Category: CDE

Study Guide: Diabetes and Mental Health (2023 Update)

Post author By Michael Boivin
Post date December 19, 2025

1. Overview

The relationship between diabetes and mental health is bidirectional. Having diabetes increases the risk of psychiatric disorders, and psychiatric disorders increase the risk of developing diabetes (and complicating its management).

Prevalence: Mental health disorders are more common in people with diabetes than the general population.
Impact: Co-occurring mental health issues lead to:
- Decreased self-care participation.
- Reduced quality of life.
- Increased risk of diabetes complications.
- Increased healthcare costs.
- Earlier all-cause mortality (specifically for depression).

2. Screening Recommendations (The "30-Second" Rule)

The guidelines emphasize regular screening using validated tools. You don’t need to be a psychiatrist to screen; it is a core CDE competency.

Condition	Frequency	Screening Tool Examples	Notes
Diabetes Distress	Routine / Regular	DDS (Diabetes Distress Scale) PAID (Problem Areas in Diabetes)	Distress is distinct from depression. It relates specifically to the burden of diabetes management.
Depression	Routine / Regular	PHQ-9 (Patient Health Questionnaire) HADS (Hospital Anxiety and Depression Scale)	Depression affects ~30% of people with diabetes (10% major depression).
Anxiety Disorders	Routine / Regular	GAD-7 (Generalized Anxiety Disorder-7)	Generalized Anxiety Disorder affects ~14% of people with diabetes.
Eating Disorders	As clinically indicated	DEPS-R (Diabetes Eating Problem Survey-Revised)	Especially “Diabulimia” (insulin restriction to lose weight) in T1D.

3. Key Conditions & Associations

A. Diabetes Distress

Definition: An emotional response to the burden of living with and managing diabetes (e.g., “burnout,” feeling overwhelmed). It is not a psychiatric disorder but can lead to one if untreated.
Management: Education, support, and validating feelings often help. It does not necessarily require medication; it requires diabetes-specific support.

B. Depression

Link: Bi-directional.
Treatment:
- Psychotherapy (CBT is gold standard).
- Pharmacotherapy (SSRIs/SNRIs). Note: Treatment improves mood but does not consistently improve A1C unless self-care behaviors also change.

C. Schizophrenia & Bipolar Disorder

Risk: People with these conditions have a higher risk of developing Type 2 diabetes.
Medication Impact: Second-generation (atypical) antipsychotics (e.g., olanzapine, clozapine, quetiapine) are associated with significant metabolic side effects (weight gain, dyslipidemia, hyperglycemia).
Recommendation: Mandatory metabolic monitoring (weight, waist circumference, BP, FPG/A1C, lipids) for anyone on atypical antipsychotics.

D. Eating Disorders

Insulin Omission: In Type 1 diabetes, restricting insulin to cause glycosuria and weight loss is a dangerous purging behavior (often called “Diabulimia”).
Screening: Look for unexplained A1C elevation, recurrent DKA, or weight loss despite reported good intake.

4. Psychosocial Treatment Approaches

The guidelines recommend integrating psychosocial care into routine diabetes practice.

Motivational Interviewing (MI): A person-centered approach to strengthen motivation for change.
Cognitive Behavioral Therapy (CBT): Effective for depression and anxiety in diabetes.
Coping Skills Training: Helps patients manage stress and the mental load of diabetes.
Family Therapy: Particularly useful for children/adolescents to address family conflict regarding management.

5. Diabetes Canada Clinical Practice Guidelines Recommendations

Screening: All individuals with diabetes should be regularly screened for diabetes distress and symptoms of common psychiatric disorders (depression, anxiety) [Grade D, Consensus].
Psychosocial Interventions: Incorporate interventions like CBT, motivational interviewing, and coping skills training into care to improve outcomes [Grade B, Level 2].
Severe Mental Illness: Individuals with severe mental illness (schizophrenia, bipolar) require frequent screening for diabetes and metabolic risk factors, especially if prescribed atypical antipsychotics [Grade D, Consensus].
Youth: Adolescents with Type 1 diabetes should be screened for eating disorders (insulin omission) when there is unexplained hyperglycemia or weight loss [Grade D, Consensus].

Reference:

Robinson DJ, Hanson K, Jain AB, et al. Diabetes and Mental Health – 2023. Canadian Journal of Diabetes. 2023;47(4):308-344. doi:10.1016/j.jcjd.2023.04.009

Tags CDE, Diabetes

Flashcards: Weight Management in Diabetes (Chapter 17)

Post author By Michael Boivin
Post date December 19, 2025

Weight management is a primary therapeutic goal in the 2018 Clinical Practice Guidelines, as obesity is a major driver of type 2 diabetes and its complications. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the evidence-based strategies for assessment, behavioural intervention, pharmacotherapy, and surgery to support patients in achieving healthier weights.

Key Topics Covered:

Therapeutic Targets: Memorizing the impact of sustained weight loss ( $\ge$ 5% of initial body weight) on glycemic control and cardiovascular risk factors.
Intervention Hierarchy: Reviewing the tiered approach that begins with healthy behavior interventions as the foundation for all treatment plans.
Pharmacotherapy: Identifying specific weight management medications approved for use in Canada and their mechanisms of action.
Surgical Options: Understanding the indications for bariatric surgery and its role in potentially inducing diabetes remission.
Medication Selection: Recalling which antihyperglycemic agents promote weight loss or are weight-neutral versus those associated with weight gain.

Tags CDE, Diabetes

CDE Diabetes

Practice Exam: Weight Management in Diabetes (Chapter 17)

Post author By Michael Boivin
Post date December 19, 2025

Tags CDE, Diabetes

CDE Diabetes

Study Guide: Weight Management in Diabetes (Chapter 17)

Post author By Michael Boivin
Post date December 19, 2025

1. Overview & Pathophysiology

Obesity is a major driver of Type 2 diabetes and complicates its management.

Prevalence: 80-90% of people with Type 2 diabetes have overweight or obesity. Rates are also rising in Type 1 diabetes (sevenfold increase in 20 years).
Benefits of Weight Loss: A modest weight loss of 5–10% of initial body weight can improve insulin sensitivity, glycemic control, and blood pressure.
Greater weight loss may be required to improve Obstructive Sleep Apnea (OSA) and dyslipidemia.
Sustained weight loss can be achieved through healthy behavior interventions, medications, or bariatric surgery.

2. Assessment of Overweight and Obesity

Assessment should go beyond just BMI to include distribution of adiposity and contributing factors.

Clinical Measurements:
- Height, weight, BMI, and Waist Circumference (WC).
- WC Risk Thresholds: $\ge 102$ cm (Men), $\ge 88$ cm (Women) indicate increased health risk.
- Note: Ethnic-specific cut-offs exist (e.g., lower thresholds for South Asian/Chinese populations: $\ge 90$ cm for men, $\ge 80$ cm for women).
Contributing Factors:
- Medications (antipsychotics, antidepressants, some antihyperglycemics).
- Psychological factors (emotional eating, depression, ADHD).
- Physical barriers (osteoarthritis, dyspnea).

3. Treatment Strategies

A. Healthy Behaviour Interventions

Cornerstone: Combined dietary modification, physical activity, and behavior therapy is most effective.
Structure: Interprofessional and group programs show better results than solo interventions.
Diet: Moderate carbohydrate reduction has shown benefits in lipids and glycemic stability.
Goals: Reasonable weight loss goals are 1–2 kg/month (requires ~500 kcal/day deficit).

B. Pharmacotherapy for Diabetes (Weight Considerations)

The choice of diabetes medication profoundly impacts weight.

Weight Gain: Insulin, Insulin Secretagogues (Sulfonylureas, Meglitinides), Thiazolidinediones (TZDs).
Weight Neutral: Metformin, DPP-4 Inhibitors, Acarbose.
Weight Loss:
- GLP-1 Receptor Agonists: ~3 kg loss.
- SGLT2 Inhibitors: 2–3 kg loss.

NOTE: This chapter was written in 2018 prior to the launch of semaglutide and tirzepatide. For more up to date information please visit: Obesity Canada’s Pharmacotherapy Guideline chapter

D. Bariatric Surgery

Indications: Considered for Type 2 diabetes with BMI $\ge 40.0$ OR BMI $35.0-39.9$ with comorbidities (like diabetes) when other methods fail.
Benefits: Can lead to remission of Type 2 diabetes.
Procedures:
- Roux-en-Y Gastric Bypass (RYGB): High remission rates.
- Sleeve Gastrectomy: Effective; removes ghrelin-rich fundus.
- Gastric Banding: Largely abandoned due to complications and lower efficacy.
Predictors of Remission: Higher C-peptide (good beta-cell reserve), younger age, shorter diabetes duration, no insulin use pre-op.

4. 2018 Clinical Practice Guidelines Recommendations

Program: Interprofessional weight management programs are recommended for those with/at risk of diabetes to improve CV risk [Grade A, Level 1A].
Medications: Weight management medications (Liraglutide 3.0 mg or Orlistat) may be considered to promote weight loss and improve glycemic control [Grade A, Level 1A].
Choice of Agent: When selecting antihyperglycemic agents for adults with Type 2 diabetes and obesity, the effect on body weight should be considered [Grade D, Consensus].
Surgery: Bariatric surgery may be considered for adults with Type 2 diabetes and BMI $\ge 35.0 \text{ kg/m}^2$

Reference:

Wharton S, Pedersen SD, Lau DCW, Sharma AM. Weight Management in Diabetes. Canadian Journal of Diabetes. 2018;42:S124-S129. doi:10.1016/j.jcjd.2017.10.015

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CDE Diabetes

Flashcards: In-Hospital Management of Diabetes (Chapter 16)

Post author By Michael Boivin
Post date December 18, 2025

Hyperglycemia in the hospital setting is a strong predictor of adverse outcomes, including infection and mortality. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2018 Clinical Practice Guidelines recommendations for insulin regimens, glucose targets, and perioperative care, facilitating a shift away from reactive “sliding scale” management.

Key Topics Covered:

Glycemic Targets: Memorizing the specific glucose ranges for critically ill (6.0–10.0 mmol/L) versus non-critically ill patients (preprandial 5.0–8.0 mmol/L).
Insulin Regimens: Understanding the superiority of scheduled basal-bolus-correction insulin over correction-only (sliding scale) therapy for maintaining stability.
Monitoring Protocols: Reviewing the required frequency of blood glucose checks for patients on oral intake (pre-meal) vs. NPO or IV insulin (every 1–2 hours).
Perioperative Care: Identifying targets (5.5–10.0 mmol/L) and strategies to optimize glycemic control before and during surgery.
Discharge Planning: Recalling the essential components of a safe discharge plan, including medication reconciliation and sick-day education.

Tags CDE, Diabetes

CDE Diabetes

Practice Exam: In-Hospital Management of Diabetes (Chapter 16)

Post author By Michael Boivin
Post date December 18, 2025

Hyperglycemia in hospitalized patients—whether they have a history of diabetes or not—is a common and serious condition associated with increased morbidity, infection rates, and mortality. This exam tests your ability to apply the 2018 Clinical Practice Guidelines to the acute care setting, focusing on the shift away from “sliding scale” monotherapy toward proactive, physiologic insulin regimens.

Key Concepts Covered in This Exam:

Glycemic Targets: Differentiating targets for critically ill versus non-critically ill patients (e.g., maintaining preprandial glucose between 5.0–8.0 mmol/L for most non-critically ill patients).
Insulin Protocols: Understanding why scheduled basal-bolus-correction regimens are preferred over correction-only (sliding scale) insulin to prevent “glycemic rollercoasters”.
Perioperative Care: Managing glycemic control before, during, and after surgery to minimize infection risk and improve wound healing.
Safety & Monitoring: Identifying the correct frequency for blood glucose monitoring (e.g., every 1–2 hours for IV insulin) and strategies to prevent inpatient hypoglycemia.
Transition of Care: Reviewing best practices for discharge planning to ensure safe transitions back to community settings.

Please go to Practice Exam: In-Hospital Management of Diabetes (Chapter 16) to view this quiz

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CDE Diabetes

Study Guide: In-Hospital Management of Diabetes (Chapter 16)

Post author By Michael Boivin
Post date December 18, 2025

1. Overview & Pathophysiology

Hyperglycemia in the hospital setting is a strong predictor of adverse outcomes, including increased mortality, infection rates, and length of stay.

Definition: In-hospital hyperglycemia is defined as any glucose value $> 7.8 \text{ mmol/L}$ .
Prevalence: Occurs in ~38% of hospitalized patients (26% known diabetes, 12% no prior history).
Stress Hyperglycemia: Acute illness increases stress hormones (cortisol, catecholamines) and inflammatory cytokines, which increase insulin resistance and hepatic glucose production.

2. Screening & Diagnosis

Identifying undiagnosed diabetes is a key opportunity during admission.

A1C Screening:
- Perform on admission for all patients with diabetes or hyperglycemia if not done in the past 3 months.
- Helps differentiate stress hyperglycemia from undiagnosed diabetes.
- Interpretation: An A1C $> 6.0\%$ is highly specific for diagnosing dysglycemia post-hospitalization.
Monitoring Frequency:
- Eating: Before meals and at bedtime.
- NPO/Enteral Feeds: Every 4–6 hours.
- IV Insulin/Critical Care: Every 1–2 hours.

3. Glycemic Targets

The guidelines distinguish between critically ill and non-critically ill patients.

Patient Population	Glycemic Target (mmol/L)	Notes
Non-Critically Ill	Preprandial: 5.0 – 8.0 Random: < 10.0	Applies to the majority of medical/surgical patients.
Critically Ill	6.0 – 10.0	Avoid < 6.0 to minimize mortality/hypoglycemia risk.
CABG (Intraoperative)	5.5 – 11.1	Continuous IV insulin preferred to reduce sternal wound infections.
Perioperative (General)	5.0 – 10.0	For minor/moderate surgeries.

4. Pharmacologic Management

Insulin is the preferred agent for in-hospital management due to its safety, efficacy, and adjustability.

A. Non-Critically Ill (Subcutaneous Insulin)

Preferred Regimen: Basal + Bolus + Correction (Basal-Bolus-Supplemental).
- Basal: Long-acting (e.g., glargine, detemir) controls fasting/inter-meal glucose.
- Bolus: Rapid-acting (e.g., aspart, lispro) covers meals.
- Correction: Rapid-acting covers hyperglycemia above target.
Discouraged Regimen: Correction-only (Sliding Scale) insulin alone is strongly discouraged as it results in “reactive” management and poorer control.
Insulin Naïve: Start 0.4–0.5 units/kg/day (50% basal, 50% bolus).

B. Critically Ill (Intravenous Insulin)

Indication: Critically ill, NPO, or hyperglycemic emergencies (DKA/HHS).
Protocol: Continuous IV insulin infusion targeting 6.0–10.0 mmol/L.
Transitioning IV to SC:
- Calculate Total Daily Dose (TDD) based on the last 6–8 hours of stable IV requirements.
- Give 60–80% of this extrapolated dose as SC basal insulin.
- Overlap: Administer SC basal 2–3 hours (or rapid 1–2 hours) before stopping the IV drip to prevent rebound hyperglycemia.

C. Non-Insulin Agents

Oral agents (e.g., metformin, sulfonylureas) are often discontinued due to contraindications like renal variation, contrast dye exposure, or irregular eating.

5. Special Clinical Situations

Enteral & Parenteral Nutrition:

Parenteral (TPN): Insulin can be added to the TPN bag (Regular insulin) or given SC.
Enteral (Tube Feeds):
Continuous: Basal insulin or longer-acting insulin (NPH) helps match the continuous carb load.
Bolus Feeds: 50% Basal / 50% Bolus (divided to match feed times).

Corticosteroid Therapy:

Steroids cause significant insulin resistance and postprandial hyperglycemia.
Management: Basal-Bolus-Correction is superior to sliding scale. NPH may be used to match the steroid profile.
Monitoring: Monitor BG for at least 48 hours after starting high-dose steroids.

Self-Management & Pumps (CSII):

Patients who are mentally competent and physically able may continue self-management (including pumps) if hospital policy permits.
Requirements: Must utilize a flowsheet, provide own supplies, and demonstrate competency (e.g., changing sets, calculating bolus).

6. Diabetes Canada Clinical Practice Guidelines Recommendations

Screening: Measure A1C on admission for all with diabetes (if not done in 3 months) and those with new hyperglycemia [Grade D/C].
Monitoring: Individualize frequency; usually AC+HS for eating, q4-6h for NPO/Enteral, q1-2h for IV insulin [Grade D].
Preferred Therapy: Use proactive Basal-Bolus-Correction insulin rather than correction-only (sliding scale) [Grade A, Level 1A].
Targets:
- Non-Critically Ill: 5.0–8.0 mmol/L (preprandial) [Grade D].
- Critically Ill: < 10.0 mmol/L and > 6.0 mmol/L [Grade B/D].
CABG: Use IV insulin to target 5.5–11.1 mmol/L intraoperatively to reduce infection risk [Grade A, Level 1A].
Safety: Implement nurse-initiated hypoglycemia protocols (including glucagon) [Grade D].

Reference:

Malcolm J, Halperin I, Miller DB, et al. In-Hospital Management of Diabetes. Canadian Journal of Diabetes. 2018;42:S115-S123. doi:10.1016/j.jcjd.2017.10.014

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CDE Diabetes

Flashcards: Hyperglycemic Emergencies in Adults (Chapter 15)

Post author By Michael Boivin
Post date December 18, 2025

Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) are medical emergencies that require immediate recognition and a structured management approach to prevent mortality. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the diagnostic criteria, precipitating factors, and critical treatment steps outlined in the 2018 Clinical Practice Guidelines.

Key Topics Covered:

Diagnostic Criteria: Differentiating DKA from HHS based on arterial pH, anion gap, serum bicarbonate, and plasma osmolality.
Treatment Priorities: Memorizing the strict “order of operations” for management: Fluid resuscitation (ECFV restoration) first, followed by potassium correction, and then insulin.
Precipitating Factors: Identifying common triggers such as infection, insulin omission, myocardial infarction, and medications like SGLT2 inhibitors.
Euglycemic DKA: Recognizing that DKA can occur with normal or mildly elevated blood glucose levels, particularly in pregnancy or with SGLT2 inhibitor use.
Sick Day Management: Reviewing patient counselling points for illness, including the frequency of blood glucose/ketone monitoring and hydration protocols.

Tags CDE, Diabetes

CDE Diabetes

Practice Exam: Hyperglycemic Emergencies in Adults (Chapter 15)

Post author By Michael Boivin
Post date December 18, 2025

Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) are critical, life-threatening complications that demand rapid assessment and precise intervention. This exam tests your ability to navigate the 2018 Clinical Practice Guidelines to effectively diagnose these conditions, manage electrolyte imbalances, and safely resolve hyperglycemia.

Key Concepts Covered in This Exam:

Diagnosis & Differentiation: Distinguishing between DKA and HHS based on arterial pH, serum bicarbonate, anion gap, and plasma osmolality.
Precipitating Factors: Identifying common triggers such as infection, insulin omission, myocardial infarction, and new-onset diabetes.
Treatment Protocol: Mastering the “order of operations” for management: prioritizing fluid resuscitation (restoring ECFV) and potassium correction before insulin administration.
Electrolyte Safety: Understanding the critical importance of monitoring potassium levels to prevent fatal arrhythmias during insulin therapy.
Special Situations: Recognizing “euglycemic DKA” (normal or mildly elevated blood glucose with ketoacidosis), particularly in patients taking SGLT2 inhibitors or during pregnancy.

Please go to Practice Exam: Hyperglycemic Emergencies in Adults (Chapter 15) to view this quiz

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CDE Diabetes

Study Guide: Hyperglycemic Emergencies in Adults (DKA & HHS) (Chapter 15)

Post author By Michael Boivin
Post date December 18, 2025

1. Definitions & Pathophysiology

Hyperglycemic emergencies are medical emergencies requiring immediate treatment. They are distinct but can overlap.

Diabetic Ketoacidosis (DKA):
- Mechanism: Severe insulin deficiency + elevated counter-regulatory hormones (glucagon, catecholamines) $\rightarrow$ hyperglycemia, lipolysis, and ketone production (acidosis).
- Population: Primarily Type 1 Diabetes, but can occur in Type 2 (especially “Ketosis-Prone Diabetes”).
- Main Feature: Ketoacidosis.
Hyperosmolar Hyperglycemic State (HHS):
- Mechanism: Relative insulin deficiency (enough to prevent ketosis but not hyperglycemia) $\rightarrow$ profound hyperglycemia + osmotic diuresis $\rightarrow$ severe dehydration (ECFV depletion).
- Population: Type 2 Diabetes, often elderly.
- Main Feature: Hyperosmolarity and dehydration.

Key Concepts:

Incidence: DKA is more common in Type 1, but Type 2 patients can experience it (approx. 0.32-2.0 per 1,000 patient-years). HHS is less common but has higher mortality (12-17%).
Ketosis-Prone Diabetes (KPD): A term for patients who present with DKA but lack typical Type 1 features (often have very little beta-cell function).
Euglycemic DKA: DKA presenting with normal or mildly elevated blood glucose, commonly associated with SGLT2 inhibitor use or pregnancy.

2. Clinical Presentation & Risk Factors

Feature	Diabetic Ketoacidosis (DKA)	Hyperosmolar Hyperglycemic State (HHS)
Onset	Rapid (hours to days)	Slow/Insidious (days to weeks)
Symptoms	Polyuria, polydipsia, weight loss, nausea, vomiting, abdominal pain, air hunger (Kussmaul breathing).	Polyuria, polydipsia, weakness, altered level of consciousness (confusion, coma, seizures).
Signs	Acetone breath (fruity odor), tachycardia, hypotension, Kussmaul respirations.	Profound dehydration (poor skin turgor, dry mucous membranes), neurological deficits (stroke-like state).
Precipitants	Insulin omission/reduction, new diagnosis, infection, pump failure, SGLT2 inhibitors, cocaine.	Infection (40-60% of cases), MI, stroke, diuretics, glucocorticoids, restricted fluid intake (elderly).

3. Diagnosis & Lab Findings

DKA Criteria:

Arterial pH: $\le 7.3$
Serum Bicarbonate: $\le 15$ mmol/L
Anion Gap: $> 12$ mmol/L
Ketones: Positive in serum and/or urine.
Glucose: Usually $\ge 14.0$ mmol/L (but can be lower in “Euglycemic DKA”).

HHS Criteria:

Plasma Osmolality: $> 320$ mOsm/kg
Glucose: Typically $\ge 34.0$ mmol/L
pH & Bicarbonate: Usually normal (minimal acid-base disturbance).

Beta-Hydroxybutyrate (beta-OHB): Measuring blood ketones (beta-OHB) is preferred over urine ketones. A level $> 1.5$ mmol/L warrants further testing for DKA.

Note: Negative urine ketones cannot rule out DKA (as they measure acetoacetate, not beta-OHB).

4. Management Algorithm

Management focuses on 4 pillars: Fluid resuscitation, Potassium correction, Insulin therapy, and Acidosis resolution.

Step 1: Fluid Resuscitation (ECFV Restoration)

Initial: 0.9% NaCl (Normal Saline).
- Shock: 1–2 L/h.
- No Shock: 500 mL/h for 4 hours, then 250 mL/h.
Maintenance: Once euvolemic, switch to 0.45% NaCl (half-normal saline) to match ongoing losses.
Preventing Hypoglycemia: Once Plasma Glucose reaches 14.0 mmol/L, add dextrose (D5W or D10W) to the IV fluids to maintain glucose between 12.0–14.0 mmol/L.
- CDE Pearl: Do not stop insulin when glucose drops; add dextrose instead to allow continued insulin for clearing ketones.

Step 2: Potassium ( $K^+$ ) Management

Hypokalemia ( $K^+ < 3.3$ mmol/L): HOLD INSULIN. Give $K^+$ (40 mmol/L) until $K^+ \ge 3.3$ mmol/L. Insulin drives K+ into cells and can cause fatal arrhythmias if started too early.
Normokalemia ( $3.3 - 5.5$ mmol/L): Give $K^+$ (10-40 mmol/L) with insulin to prevent drop
Hyperkalemia ( $> 5.5$ mmol/L): Do not give $K^+$ initially. Wait until it falls and diuresis begins

Step 3: Insulin Therapy

Standard Dose: IV short-acting insulin infusion at 0.1 units/kg/h.
Bolus? Not routinely recommended for adults; definitely avoided in children (risk of cerebral edema).
Target: Continue insulin infusion until the anion gap normalizes (resolution of ketoacidosis), not just until glucose is normal.

Step 4: Acidosis Management

Bicarbonate: Only recommended if pH is extremely low ( $\le 7.0$ ) or in severe shock. Routine use does not improve outcomes.

5. Sick Day Management (Prevention)

Educating patients on “Sick Day Rules” is a key CDE responsibility.

Medications:

S.A.D.M.A.N.S.: Hold Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, and SGLT2 inhibitors if dehydrated/vomiting.
Insulin: Never stop insulin completely (even if not eating) for Type 1 diabetes. Doses may need adjustment.

Monitoring: Check BG every 2–4 hours.

Ketones: If T1D and BG $> 14.0$ mmol/L (or symptoms present), check for ketones.

Hydration: Drink plenty of sugar-free fluids. If unable to retain fluids, go to ER.

6. Diabetes Canada Guidelines Recommendations

Protocol Use: All adults with DKA/HHS should be managed using a standard protocol focusing on fluid, potassium, insulin, and precipitating causes.
Screening: Use capillary beta-hydroxybutyrate (beta-OHB) to screen for DKA if BG $> 14.0$ mmol/L. Do not use negative urine ketones to rule out DKA.
Fluid Rate: For DKA, start 0.9% NaCl at 500 mL/h for 4 hours, then 250 mL/h (unless in shock).
Insulin Rate: Use 0.1 units/kg/h IV infusion. Maintain until anion gap normalizes.
Add Dextrose: Start IV dextrose when plasma glucose drops to 14.0 mmol/L to prevent hypoglycemia while continuing to treat acidosis.
SGLT2 Inhibitors: Suspect DKA in symptomatic patients on SGLT2 inhibitors even if BG is not elevated (Euglycemic DKA).

Reference:

Goguen J, Gilbert J. Hyperglycemic Emergencies in Adults. Canadian Journal of Diabetes. 2018;42:S109-S114. doi:10.1016/j.jcjd.2017.10.013

Tags CDE, Diabetes