Diabetic ketoacidosis occurs when a person with diabetes type 1 or 2 has dangerously high levels of ketones in the body. It can be a medical emergency.
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes and, much less commonly, of type 2 diabetes. DKA happens when your blood sugar is very high and acidic substances called ketones build up to dangerous levels in your body.
Ketoacidosis shouldn’t be confused with ketosis, which is harmless. Ketosis can occur as a result of an extremely low carbohydrate diet, known as a ketogenic diet, or from fasting.
DKA only happens when you don’t have enough insulin in your body to process blood sugar into energy. If this happens, your liver starts to process fat into energy, which releases ketones into the blood. High levels of ketones in the blood are dangerous.
It’s less common in people with type 2 diabetes because insulin levels don’t usually drop so low, but it can happen. DKA may be the first sign of type 1 diabetes, as people with this disease can’t make their own insulin.
Symptoms of DKA can appear quickly.
Early symptoms of DKA can include:
- frequent urination
- extreme thirst or dry mouth
- high blood sugar levels, also known as hyperglycemia
- high levels of ketones in the urine
As DKA progresses, more symptoms may appear:
- nausea or vomiting
- abdominal pain
- fruity-smelling breath
- flushed face
- fatigue or weakness
- rapid breathing
- dry skin
- loss of consciousness, also known as fainting or syncope
DKA is a medical emergency. Call your local emergency services immediately if you think you may be experiencing DKA.
If left untreated, DKA can lead to a coma or death. If you use insulin, make sure you discuss the risk of DKA with your healthcare team and have a plan in place.
If you have type 1 diabetes and have a blood sugar reading of over 240 milligrams per deciliter (mg/dL), you should test yourself for ketones using a urine or blood test.
You should also test if you are sick or planning on exercising and your blood sugar is 240 mg/dL or higher.
Call your doctor if moderate or high levels of ketones are present. Always seek medical help if you suspect you are progressing to DKA.
People with type 2 diabetes are usually at lower risk of DKA. But the risk can increase when your body is under strain due to injury, infection, or surgery.
When to get emergency help
If you have any of the following symptoms, and you can’t reach your doctor, the
- a blood sugar level that stays at 300 mg/dL or higher
- breath that smells fruity
- severe vomiting, where you can’t keep food or drinks down
- difficulty breathing
- multiple symptoms of DKA
Get help by calling local emergency services or having someone take you to the nearest emergency room.
The treatment for DKA usually involves a combination of approaches to normalize blood sugar and insulin levels.
If you receive a diagnosis of DKA but haven’t yet received a diagnosis of diabetes, your doctor will create a diabetes treatment plan to keep ketoacidosis from recurring.
Infection can increase the risk of DKA. If your DKA is a result of an infection or illness, your doctor will treat that as well, usually with antibiotics.
At the hospital, your physician will likely give you intravenous (IV) fluids to help your body rehydrate. During a DKA event, you usually lose a lot of fluids, which can reduce the amount of blood flowing through your body.
Fluid replacement helps restore typical blood flow. It also helps treat dehydration, which can cause even higher blood sugar levels.
When your insulin levels are too low, your body’s electrolytes can also become atypically low.
Electrolytes are electrically charged minerals that help your body, including the heart and nerves, function properly. Electrolyte replacement is also commonly done through an IV.
Insulin will likely be administered to you through an IV until your blood sugar level falls below
When your blood sugar and other test readings are within an acceptable range, your doctor will work with you to help you avoid DKA in the future.
DKA occurs when insulin levels are low. Our bodies need insulin to use the available glucose in the blood. In DKA, glucose can’t get into the cells, so it builds up, resulting in high blood sugar levels.
In response, the body starts breaking down fat into a useable fuel that doesn’t require insulin. Turning fat into energy produces ketones. When too many ketones build up, your blood becomes acidic. This is diabetic ketoacidosis.
The most common causes of DKA are:
- missing an insulin injection or not injecting enough insulin
- illness or infection
- a clog in your insulin pump, if you use one
Risk factors for DKA include:
- having type 1 diabetes
- being a younger age, as research suggests 63 percent of DKA cases happen in people below the age of 51
- physiologic shock, a life threatening condition caused by interrupted blood flow
- emotional or psychological stress
- acute cardiovascular disease, such as heart attack or stroke
- acute gastrointestical illness, such as pancreatitis
- having an alcohol use or drug use disorder
- having an eating disorder
- certain endocrine conditions, such as Cushing syndrome and hyperthyroidism
- recent surgery
Certain medications can increase the risk of DKA. These include:
- some antipsychotic medications, such as clozapine (Clozaril), olanzapine (Zyprexa), and risperidone (Risperdal)
- thiazide diuretics
Although DKA is less common in people who have type 2 diabetes, it does occur. Some people with type 2 diabetes are considered “ketosis-prone” and are at a higher risk of DKA. A diagnosis of ketosis-prone diabetes is
- Black (African American, Afro Caribbean, and sub-Saharan African), Asian (Chinese, Indian, and Japanese), and Hispanic people
- people who have overweight or obesity
- people who are middle-aged
It’s best to talk with your doctor about your risk factors to make sure you have the right treatment plan in place.
Testing for ketones is one of the first steps for diagnosing DKA. If you have type 1 diabetes, you should have a supply of home ketone tests. These test either your urine or your blood for the presence of ketones.
You can buy these in drug stores or online.
When to test
According to the American Diabetes Association, you should test for ketones:
- if your blood glucose level is 240 mg/dL or higher
- if you are sick
- if you have any symptoms of DKA
Test your urine or blood every 4 to 6 hours.
How to test
Urine test strips change color to signal the presence of ketones in your urine. You’ll need to pee on the strip or dip the strip into the pee you’ve collected in a container. The indicator on the strip will change color. Compare the test strip to the results chart.
Blood ketone testers are also available. These are usually combination devices that can measure both glucose levels and ketone levels.
Similar to blood glucose testing, you’ll need to apply a small sample of blood to a test strip. The test strip is inserted into a monitor device to test for the presence of ketones in your blood.
A doctor or pharmacist can advise you on when and how to use your home ketone tests.
A doctor will likely do a test to confirm the presence of ketones in your urine. They will usually also test your blood sugar level. Other tests your doctor may order include:
- basic bloodwork, including potassium and sodium, to assess metabolic function
- arterial blood gas, where blood is drawn from an artery to determine its acidity
- blood pressure
- electrocardiogram (ECG)
- chest X-ray or other tests to look for signs of an infection, such as pneumonia
There are many ways to prevent DKA. Prevention means following your diabetes treatment plan carefully and taking some extra care when you’re sick.
Follow your treatment plan
You can lower your risk of DKA with proper management of your diabetes:
- Take your medications as directed, even if you’re feeling fine.
- Follow your meal plan.
- Test your blood sugar consistently, as recommended by your doctor. This will help you get in the habit of making sure your numbers are in range. If you notice a problem, you can talk with your doctor about adjusting your treatment plan.
- Talk with your doctor about adjusting your insulin dosage levels based on your activity level, illnesses, or other factors, such as what you’re eating.
- If you have high blood sugar and your blood or urine test detects ketones, do not exercise. Exercising with high blood sugar can be dangerous when you have diabetes. It’s best to talk with your doctor about how to manage this situation.
- Sometimes the cost of insulin can make it
more difficultto follow a diabetes treatment plan. Read more about how to access insulin at a reduced cost.
When you’re sick
Although you can’t completely avoid illness or infection, you can take steps to help you remember to take your insulin and to help prevent and plan for a DKA emergency.
A “sick day plan” can reduce the risk of DKA:
- Test for ketone levels when you’re sick. This can help you catch mild to moderate ketone levels before they threaten your health.
- Set an alarm if you take your medication at the same time every day, or use a reminder tool like a phone app.
- Ask your doctor or pharmacist if it’s okay to prefill your syringe or syringes in the morning. That will help you easily see if you missed a dose.
- Take the medications advised by your healthcare team to treat fever or infection.
- Have soft or liquid foods available that are easier to eat if you become nauseous.
- If there’s someone helping to care for you when you’re sick at home, make sure they have information about your diabetes treatment plan, including your medication and testing schedules.
Call your doctor if you detect moderate or high ketones in a home test. If you can’t reach your doctor and you suspect you may be progressing to DKA, get emergency help. Early detection is essential.
DKA is serious, but it can be prevented. Follow your diabetes treatment plan and be proactive about your health.
Tell your doctor if something isn’t working for you or if you’re having trouble. They can adjust your treatment plan or help you come up with solutions for better managing your diabetes.