Nonsevere Diabetic Ketoacidosis and Adrenal Insufficiency: Exploring the Impact of Glucocorticoid Replacement on Metabolic Outcomes and ICU Length of Stay

Background: There is a paucity of clinical data on corticosteroid replacement in patients with adrenal insufficiency who present with nonsevere noncomplicated diabetic ketoacidosis. Case Summary: We analyzed five consecutive admissions for diabetic ketoacidosis of mild/moderate severity due to insulin omission in a 21-year-old man with type 1 diabetes and stable Addison disease. Despite similar presentations, the approach to steroid replacement differed: maintenance/moderate doses of hydrocortisone (< 60 mg/d) or high stress-doses (≥ 120 mg/d). Resolution of diabetic ketoacidosis and ICU and hospital length of stay were prolonged when high-dose versus maintenance/moderate glucocorticoids were provided: 45.5, 47.0, and 63.0 versus 12.0, 24.5, and 31 hours, respectively. Conclusions: Although our findings remain hypothesis-generating, our case study raises awareness on the importance of categorizing diabetic ketoacidosis by severity and complication status when deciding on the intensity of steroid replacement in patients with stable Addison disease. Excessive glucocorticoid administration may delay the resolution of nonsevere and otherwise noncomplicated diabetic ketoacidosis and prolong ICU and hospital stays.