Diabetes-Related Ketoacidosis (DKA)

Diabetes-related ketoacidosis (DKA) is a life-threatening complication that affects people with diabetes, including people who don’t know they have it. Without treatment, DKA is fatal.

DKA happens when your body doesn’t have enough insulin (a hormone). Your body needs this hormone to turn glucose (sugar) into energy. Without enough insulin, your liver starts to break down body fat for energy instead. As your liver breaks down fat, it releases ketones into your bloodstream.

A high number of ketones makes your blood acidic, and you get dehydrated. This creates an emergency medical situation.

DKA can develop with:

• Undiagnosed Type 1 diabetes (T1D): For some people, DKA is how they find out that they have T1D. This represents about 20% to 40% of DKA cases.
• Existing T1D: People with T1D can develop this complication at any point if they don’t get enough injected (or inhaled) insulin.
• Type 2 diabetes: It’s not as common, but people with Type 2 diabetes (T2D) who have ketosis-prone diabetes can get DKA. People with T2D are more likely to develop hyperosmolar hyperglycemic state (HHS) than DKA.

Symptoms of DKA

Early signs and symptoms of DKA include:

• Peeing more often than usual
• Extreme thirst
• Intense hunger
• Signs of dehydration, like dry mouth, headache and flushed skin
• High amounts of ketones in your pee or blood (as shown by at-home tests)
• High blood sugar levels (over 250 mg/dL)

More severe symptoms of DKA include:

• Nausea and vomiting
• Abdominal pain
• Rapid, deep breathing
• Fruity-smelling breath
• Feeling very tired or weak
• Feeling disoriented or confused
• Decreased alertness
• Loss of consciousness

If you have any of these symptoms, call your healthcare provider immediately or go to the nearest emergency room.

Diabetes-related ketoacidosis has a severe and sudden onset. It can develop within 24 hours. If you’re vomiting, it could develop much more quickly.

DKA causes

The main cause of DKA is a lack of insulin in your body. The following situations can lead to this:

• New diagnosis of Type 1 diabetes: T1D happens when your immune system attacks the insulin-producing cells in your pancreas. Eventually, this leads to a total lack of insulin.
• Missing one or more insulin doses: If you have insulin-dependent diabetes, forgetting or not taking insulin can cause DKA.
• Insulin pump issues: A kinked cannula or a disconnected site/tubing can prevent insulin from getting into your body. Running out of insulin in your pump reservoir can also lead to this complication.
• Using expired or spoiled insulin: Exposure to extreme heat or cold can prevent your insulin from working as it should. Expired insulin can also become ineffective.

Risk factors

Certain conditions or situations can increase your risk of DKA because they make your body release hormones that lead to insulin resistance. These situations include:

• Illness, especially if it involves vomiting
• Infections, like pneumonia, urinary tract infections (UTIs) and skin infections
• Severe physical injury or emotional trauma
• Surgery
• Heart attack or stroke
• Pregnancy
• Alcohol use disorder or substance use disorder
• Certain medications, like antipsychotic medications, diuretics (water pills), SGLT2 inhibitors and corticosteroids

Complications of this condition

If you don’t get quick treatment, DKA can lead to severe complications, including:

• Very low potassium levels
• Brain swelling
• Fluid inside your lungs
• Cardiac arrest
• Damage to your kidneys and other organs
• Coma
• Death

How doctors diagnose this condition

Healthcare providers diagnose diabetes-related ketoacidosis if:

• Your blood pH is less than 7.3 (acidosis)
• You have ketones in your pee and/or blood
• Your blood bicarbonate level is less than 18 mEq/L
• Your blood sugar level is above 250 mg/dL

You can have DKA if your blood sugar is lower than 250 mg/dL. This is euglycemic diabetes-related ketoacidosis. It’s not as common.

Providers use lab tests to check these levels.

If you have diabetes and call your provider from home about your symptoms, they can usually tell if you have DKA. This is based on specific information you can provide from home test devices, like:

• Urine ketone test: This is usually a strip that’ll turn a certain color depending on the ketone levels in your pee. You can buy these strips at your local pharmacy without a prescription. Follow the instructions on the packaging to make sure you do the test correctly.
• Blood ketone test: Some at-home blood glucose meters can also check blood ketone levels. Other meters only check ketones in your blood.
• Blood sugar checks: Check your blood sugar with a blood glucose meter or use a continuous glucose monitor (CGM).

How is it treated?

If you have diabetes and catch DKA early enough, you may be able to treat it at home with instructions from your healthcare provider. Otherwise, you’ll need to go to the hospital.

If you have DKA symptoms and don’t have a diabetes diagnosis, go to a hospital for treatment.

Hospital treatment

Hospital treatment for DKA can include:

• IV fluids: These help treat dehydration, clear ketones through your pee and fix electrolyte imbalances.
• Insulin: Your healthcare team may give you insulin through an IV or as a needle injection (shot).
• Other treatments: Depending on the severity of DKA, you may need other treatments to help you recover. You may also need treatment for the underlying trigger(s), like antibiotics for a bacterial infection.

At-home treatment

If you have diabetes and your healthcare provider decides that you can treat diabetes-related ketoacidosis from home, follow their instructions. They’ll tell you how much insulin and/or medication to take and other steps to safely get out of DKA.

In general, you should:

• Check your blood sugar often: Try to check your blood sugar every hour to make sure your treatment is working and your glucose level is decreasing safely.
• Check your ketones: Use urine ketone strips or a blood ketone meter to check for ketones as you’re recovering. Your ketone levels should go down, not up.
• Drink fluids to prevent dehydration: Drink water, broth or sugar-free drinks to stay hydrated. This is especially important if you’re sick and/or vomiting.
• Try to eat normally: It’s important to eat as you normally do, especially if you’re sick. If you take insulin, be sure to take the appropriate amount with your meal as directed by your provider.
• Don’t exercise: Physical activity can raise your blood sugar and increase ketones in your body. Your provider will let you know when you can safely exercise again.

What can I expect if I have this condition?

With prompt treatment, DKA recovery typically happens within 24 hours. Full recovery happens when your blood sugar is less than 200 mg/dL and your blood pH is higher than 7.3.

Depending on how severe it is, DKA can take multiple days to treat.

Studies show that the survival rate of DKA continues to improve. With appropriate treatment, the survival rate is over 95%. But certain factors can affect mortality (death) rates. The following factors tend to lead to worse outcomes:

• Getting treatment after you already have a coma, hypothermia and oliguria (low urine output)
• Being over age 65 with coexisting acute conditions, like heart attack, pneumonia or sepsis
• Having brain swelling (especially in younger people)

Can this be prevented?

To help prevent DKA, you can:

• Check your glucose often: Try to at least check your glucose before and after meals and before you go to sleep. Treat high blood sugar as soon as possible.
• Take your insulin and/or medication regularly: Follow your healthcare provider’s instructions for taking your insulin and/or medication.
• Check for ketones: If you have long-lasting high blood sugar, check for ketones using a pee or blood test.
• Check your insulin pump: If you use an insulin pump and have high blood sugar, check your pump for issues like a kinked cannula or a disconnected site/tubing. These issues can prevent you from receiving insulin.
• Have a sick day plan: Talk with your provider about how to manage diabetes when you’re sick.
• Stay educated: Ask your healthcare team about DKA. The more you know about it, the more likely you’ll be able to prevent it or catch it in its early stages.

If you develop DKA despite these efforts, try not to be hard on yourself. Sometimes, the perfect storm of factors triggers DKA — and they’re often outside of your control. The best thing you can do is get help as soon as possible to prevent it from becoming severe.