In diabetic ketoacidosis management, when should insulin therapy be started?

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In diabetic ketoacidosis, the priority is to restore circulating volume and then manage electrolytes before starting insulin. Begin with vigorous isotonic IV fluids to correct deficit and improve perfusion, as this supports kidney function and helps ketone clearance. Next, check the potassium. Although total body potassium is depleted, serum K guides safety of insulin therapy. If potassium is above 3.3 mEq/L, start insulin after fluids are begun to suppress ketogenesis and correct hyperglycemia. If potassium is below 3.3, hold insulin and correct potassium first, then resume insulin once K is at least 3.3. Insulin will lower glucose and drive potassium into cells, risking hypokalemia, so addressing potassium first is crucial. Acidosis will improve with insulin, so you don’t need to wait for full acidosis resolution to start therapy.