Why consider IV Thiamine infusion in DKA !

Back when I was a scared little resident, an ER doc told me an useful mnemonic to consider in patients brought in unresponsive: “Do the ‘DON’T‘ “. (D – Dextrose, O – Oxygen, N – Narcan/Naloxone, T – Thiamine ! Every clinical Tom, Jane & Harry – and possibly their grandmas – know about giving an IV Thiamine push before starting Dextrose-containing IV fluids in chronic alcoholics. They tend to have low Thiamine levels due to inhibited absorption & lack of good oral intake. A glucose infusion results in rapid thiamine utilization and level drop.

Interestingly, diabetics too have a significantly high incidence of thiamine deficiency from large renal losses. In this study,for example, here is a sample of thiamine levels in diabetics compared to non-diabetic control. When one starts Insulin drip in a DKA (Diabetic Ketoacidosis) patient, it rapidly kickstarts glucose consumption for Glycolysis and Kreb’s cycle (aka TCA or citric acid cycle) which uses Thiamine as a essential co-factor. If Thiamine levels are low, Pyruvate accumulates & converts to Lactic Acid instead. Indeed case reports like this and studies like these show elevated lactic acid levels related to thiamine deficiency. Here is an ongoing study listed on ClinicaTrials.Gov looking specifically into this.

Low thiamine levels can contribute to fatigue, deconditioning & falls in patients. A 2021 paper also argues that a link between thiamine deficiency in diabetes & diabetic neuropathy is very likely but large studies are missing – Why? Because Money!
The author notes:

“Unfortunately, it is non-patentable, and neither industry nor independent donors are interested in investing in large-scale randomized controlled clinical trials to investigate its potential in diabetes and its complications”

Reference: Thiamine and diabetes: Back to the future ?

So the next time you have a patient with DKA – especially the ones with lactic acid elevation and those who look undernourished or haven’t been eating well for some days before admission, consider Thiamine supplementation (IV first, then oral ) when you initiate insulin drips. Thiamine levels might take time to result, and time is of essence in DKA, doesn’t hurt to give a 200mg IV Thiamine infusion after drawing blood for Thiamine levels without waiting for results first!

💡 P.S: ATP generation in the same Glycolytic and Kreb’s cycle pathway is the reason phosphorous levels can dip low on Insulin drips.
💡 Diabetic patients should have Thiamine levels checked. Thiamine supplements are cheap – Thiamine on Amazon (#AdLink).