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 a few 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).