Starvation ketoacidosis: Treatment pitfalls

Dear Editor,

Yeow et al.¹ describe a case of non-diabetic euglycaemic acidosis resulting from post op dysphagia and poor intake of approximately six weeks duration. We have seen a similar case of ‘starvation ketoacidosis’ in a patient undergoing percutaneous endoscopic gastrostomy feeding tube replacement. We think that intravenous (IV) glucose should be the initial treatment, with the addition of insulin only if required. The correspondence from Frise and Mackillop² states this strategy is effective for treating ketoacidosis in pregnancy; however, there are also some other pitfalls in treatment of starvation ketoacidosis which must be considered, and some overlap with alcoholic ketoacidosis.

Unlike patients with diabetic ketoacidosis, patients with starvation ketosis release insulin when carbohydrate is administered. They are also producing high levels of glucose elevating hormones such as glucagon and have depleted glycogen stores. These hormones cause the lipolysis which helps generate ketones for fuel. The addition of exogenous insulin in this state risks hypoglycaemia. Once provided with adequate carbohydrate the insulin levels will rise and counter-regulatory hormone levels will fall, resolving the ketosis.

Alcoholics are another group prone to ketosis (alcoholic ketoacidosis (AKA)) and are particularly prone to hypoglycaemia; administration of insulin to those patients would have to be with caution and literature³ on AKA reports resolution without insulin administration, although there is little evidence outside of case reports.

Starved patients and alcoholics are also both at risk of thiamine deficiency. Depletion of body thiamine stores can occur within four weeks. It is important to consider this, as administration of IV glucose in thiamine deficiency can result in severe lactic acidosis.⁴

Finally, starved patients are at risk of refeeding syndrome. Insulin is a key mediating factor in the pathophysiology of refeeding as it stimulates cellular uptake of phosphate.⁵ The unnecessary addition of exogenous insulin could worsen the risk of this life-threatening condition.

In summary, in starvation ketoacidosis the safest approach to treatment may be to start providing carbohydrate whilst also considering the patient’s risk of other deficiencies and treating accordingly. In cases of treatment failure or hyperglycaemia, IV insulin can be added.