STICH Protocol for DKA Management

Editor’s Note: Recently a more robust protocol for mitigating diabetic ketoacidosis (DKA) risk in people with type 1 diabetes using SGLTs—the STOP DKA Protocol—was published. STOP DKA Protocol builds on steps outlined in STICH protocol.

With sodium-glucose co-transporter (SGLT) inhibitors increasingly being used off-label to treat type 1 diabetes, it is vital that patients on these drugs know when and how to treat for ketones.

What does STICH stand for?

STop SGLT inhibitor treatment
Insulin administration
Carbohydrate consumption
Hydration with water or sugar-free electrolyte drink

What is an SGLT inhibitor?

Sodium–glucose co-transporter inhibitors are among very few existing “adjunct therapy” options for people with type 1 diabetes. SGLT1 and SGLT2 inhibitors work to excrete more glucose in the kidneys through urination (SGLT1) and delay glucose from being absorbed into the bloodstream as it passes through the intestines (SGLT2).  Benefits of SGLT therapy include lower blood sugar, lower insulin requirements and lower blood pressure. Dual SGLT 1/2 inhibitors are now also being considered as a treatment for type 1 diabetes.

Some SGLT inhibitors have recently been approved in Europe to treat people with type 1 diabetes who meet other criteria, including a body mass index (BMI) ≥ 27 kg/m².  The FDA declined to approve one such treatment in March of 2019. Product names include Zynquista (sotagliflozin) and Farxiga (dapagliflozin). To learn more about SGLT inhibitors and their use in type 1 diabetes, check out Beyond Type 1’s resource on the subject.

DKA + SGLT inhibitors

One of the dangerous risks of SGLT inhibitor therapy in type 1 diabetes is diabetic ketoacidosis (DKA). Additionally it is more likely that a person taking an SGLT experience euglycemic DKA—DKA without the typical accompanying hyperglycemia. Causes for euglycemic DKA include concentrated ketone molecules in the bloodstream due to frequent urination (less fluid = more concentrated ketones).

Passing more glucose out of the body through urination can actually result in lowering blood sugar, which is generally a good thing, but taking less insulin is another factor that contributes to euglycemic DKA. Insulin requirements that lie below the threshold at which the body produces ketones can result in ketosis, a precursor to diabetic ketoacidosis.

Implementing STICH

It’s always important to pay close attention to DKA, but even more so if an SGLT inhibitor is involved. Patients with type 1 diabetes (T1D) who are taking SGLT inhibits should be checking for ketones every day, as they may experience asymptomatic DKA. That’s why the steps for treating DKA using STICH protocol are a little different than the usual approach.

Patients with high ketones or who may be in DKA should always seek immediate medical advice. STICH protocol is helpful advice to be used under the care and guidance of a healthcare professional.

If you have high ketones or might possibly be in DKA, work with your healthcare team to follow these steps:

1. STop SGLT inhibitor treatment right away (this one is pretty self-explanatory). Treatment can resume once ketone levels have returned to normal. Discuss with your SGLT inhibitor-prescribing doctor situations in which you might choose not to take your dose in order to avoid DKA: instances of strenuous exercise, undergoing surgery, drinking a lot of alcohol, or when you can otherwise predict becoming dehydrated or not eating on a normal schedule. The next step is to take an…
2. Insulin injection or a bolus. Consult with your provider to understand the proper amount of insulin to take. The bolus should be accompanied by a small amount of…
3. Carbohydrates (30g or less) to give your body some glucose to break down. Yes, drinking water is still important to flush out ketones, so you must
4. Hydrate. Adults should have one full glass (8 ounces) of fluid every 30-60 minutes.

If your healthcare provider decides that home-treatment is not an option, go to the nearest hospital/ emergency room and make sure you inform the staff that you are taking SGLT inhibitors and may not be exhibiting “typical” symptoms of DKA.

This piece is part of Beyond Type 1’s resources on DKA + managing ketones—find the complete collection of resources here.

This article was verified for accuracy by Julia Blanchette PhD(c), RN, CDE.

WRITTEN BY Katie Doyle, POSTED 06/18/19, UPDATED 11/10/22

Katie Doyle is a writer and videographer who chronicles her travels and diabetes (mis)adventures from wherever she happens to be. She’s written about dropping her meter off of a chairlift in the Alps, wearing her pump while teaching swim lessons on Cape Cod and the many road trips and fishing expeditions in between—she’s up for anything and will tell you the story about it later. Check out www.kadoyle.com for more.