Immediate stabilization with IV crystalloid fluid therapy is the cornerstone of DKA management in dogs and cats, initiated before insulin is started to correct hypovolemia, hypotension, and electrolyte derangements. Veterinary Clin…+1

Fluid resuscitation should use isotonic crystalloids, with 0.9% sodium chloride (NaCl) reported as safe and effective for resuscitation in feline DKA. Journal of Vete… Electrolyte abnormalities — hyponatremia, hypokalemia, hypophosphatemia, and hypomagnesemia — are over three times more common than above-normal values in DKA patients despite aggressive supplementation, so frequent monitoring and proactive correction are required throughout hospitalization. Journal of Vete…

Insulin therapy is the definitive treatment to halt ketogenesis, and three IV continuous rate infusion (CRI) protocols have been described in dogs and cats. Regular insulin CRI and fixed-rate insulin infusion (FRI) at 0.01 IU/kg/h are both established options. Journal of Vete… Lispro insulin CRI at a starting dose of 0.09 U/kg/h is safe and effective in cats, achieving blood glucose below 250 mg/dL in a median of 7 hours, compared to a median of 12.5 hours with regular insulin CRI. Journal of Vete… Two cats treated with lispro developed non-clinical hypoglycemia (blood glucose 40 mg/dL), so close glucose monitoring is required regardless of protocol. Journal of Vete…

For IV regular insulin CRI, maintaining the insulin infusion rate constant until target beta-hydroxybutyrate (BHB) is reached — rather than reducing the rate when glucose falls — is associated with faster resolution of ketonemia. In cats managed with this approach, median time to resolution of ketonemia was 42 hours. Journal of Vete… When blood glucose falls below 180 mg/dL (10 mmol/L), 5% dextrose solutions should be co-administered to allow continued insulin delivery without inducing hypoglycemia. Journal of Vete… If hypoglycemia develops and a dextrose bolus is needed, 0.5–1 mL/kg (0.25–0.5 g/kg) of 50% dextrose diluted 1:2–1:4 and administered over 2–5 minutes is appropriate, followed by a CRI of 1.25–5% dextrose. AAHA Clinical G… Dextrose concentrations exceeding 5% should be administered through a central line to avoid phlebitis. AAHA Clinical G…

In dogs, FRI and variable-rate insulin infusion (VRI) produce equivalent time to ketosis resolution and equivalent survival to discharge, though dogs receiving FRI had shorter hospitalization. Journal of Vete… Ketosis resolution in dogs is high at 95% regardless of protocol; in cats, overall resolution of ketonemia is lower at 56.3%, and all cats that died (5 of 16) did so within 78 hours without achieving ketosis resolution. Journal of Vete…

Feline DKA mortality ranges from 17% to 50%, and prognosis is guarded until ketonemia resolves. Journal of Vete… Cats that survive to discharge can be transitioned to subcutaneous glargine insulin once they are eating spontaneously and ketonemia has resolved. Journal of Vete…+1

A special consideration in cats receiving sodium-glucose cotransporter-2 (SGLT2) inhibitors — including bexagliflozin and dapagliflozin — is euglycemic DKA, in which ketoacidosis occurs with normal or near-normal blood glucose. Veterinary Reco…+1 These patients require the same insulin CRI and aggressive dextrose supplementation as classic DKA, but the normal glucose concentration can mask the diagnosis if ketones are not measured. Veterinary Reco…+1 SGLT2 inhibitor effects may persist days beyond drug cessation. Journal of Vete…

Frequent blood glucose monitoring every 1–2 hours is standard during insulin CRI, with the primary limitation being iatrogenic anemia from repeated phlebotomy, particularly in small-breed dogs and cats. Journal of Vete…

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