Diabetes-Related Ketoacidosis (DKA)

What is diabetes-related ketoacidosis (DKA)?

Diabetes-related ketoacidosis (DKA) is a life-threatening complication that affects people with diabetes or undiagnosed diabetes. It requires immediate medical attention.

DKA happens when your body doesn’t have enough insulin (an essential hormone). Your body needs insulin to turn glucose (sugar), your body’s go-to source of fuel, into energy. If there’s no insulin or not enough insulin, your liver starts breaking down body fat for energy instead. As your liver breaks down fat, it releases ketones into your bloodstream.

A high number of ketones causes your blood to become acidic (your blood pH is too low) and you experience dehydration. This creates an emergency medical situation. Without treatment, DKA is fatal.

Who does DKA affect?

Diabetes-related ketoacidosis can develop with:

• Undiagnosed Type 1 diabetes: For some people, DKA is how they find out that they have Type 1 diabetes (T1D). T1D typically develops during childhood or adolescence but can also develop in adulthood. You can get T1D even if you don’t have a family history of it. Approximately 20% to 40% of DKA cases affect people who are newly diagnosed with T1D.
• Existing Type 1 diabetes: People with T1D can develop DKA 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 develop DKA. People with T2D are more likely to develop hyperosmolar hyperglycemic state (HHS) than DKA.

What are the symptoms of DKA?

Early signs and symptoms of DKA include:

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

Although it’s not as common, you can be in DKA even if your blood sugar is lower than 250 mg/dL.

More severe symptoms of DKA include:

• Nausea and vomiting.
• Abdominal pain.
• Rapid, deep breathing (Kussmaul 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.

How long does it take for DKA to develop?

Diabetes-related ketoacidosis is an acute complication, meaning it has a severe and sudden onset. DKA can develop within 24 hours. It begins relatively slowly but can rapidly get worse. If you’re vomiting, it could develop much more quickly.

It’s essential to call your healthcare provider or go to the hospital as soon as you experience symptoms to get treatment before the DKA becomes more severe.

What causes DKA?

The main cause of DKA is an insufficient amount of insulin in your body. The following situations can cause a lack of insulin:

• New diagnosis of Type 1 diabetes: Type 1 diabetes happens when your immune system attacks the insulin-producing cells in your pancreas, eventually leading to a total lack of insulin. Oftentimes, people have DKA when they’re first diagnosed with T1D because they missed the early signs of T1D.
• Missing one or more insulin doses: If you have insulin-dependent diabetes, forgetting to take or not taking insulin, especially with a meal, can cause DKA.
• Insulin pump issues: If you use an insulin pump, a kinked cannula or a disconnected site/tubing can prevent the insulin from getting into your body. Running out of insulin in your pump reservoir can also lead to DKA.
• Using expired or spoiled insulin: Exposure to extreme heat or cold can prevent your insulin from working as it should. Be sure to read the instructions for how you should store your type of insulin when it’s not in use. Expired insulin can also become ineffective.

Certain conditions or situations can contribute to developing DKA because they cause your body to release certain hormones (like cortisol and adrenaline) that lead to insulin resistance. This means you need more insulin than usual. These situations include:

• Illness. Vomiting from an illness can also trigger DKA due to dehydration.
• Infection. The most common infections that can lead to DKA include pneumonia, urinary tract infections (UTIs) and skin infections.
• Severe physical injury or emotional trauma.
• Surgery.
• Heart attack or stroke.
• Pregnancy.

Other triggers of DKA include:

• Pancreatitis: Some cases of pancreatitis can cause lower-than-normal levels of insulin, which could trigger DKA.
• Alcohol use disorder or substance use disorder: Alcohol and substance use, especially cocaine, can make your body produce hormones that make it difficult to use insulin properly. In addition, you’re more likely to miss doses of insulin and/or medication if you use substances.
• Certain medications: Some antipsychotic medications, diuretics (water pills), SGLT2 inhibitors and corticosteroids can lead to DKA.

How is DKA diagnosed?

Healthcare providers diagnose diabetes-related ketoacidosis if you have the following four conditions:

• Your blood glucose (sugar) level is above 250 mg/dL. It’s possible to have DKA if your blood sugar is lower than 250 mg/dL. This is euglycemic diabetes-related ketoacidosis (euDKA). It’s not as common.
• 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.

What tests are used to diagnose DKA?

In the hospital, healthcare providers may use the following tests to diagnose DKA:

• Blood glucose test.
• Ketone testing (through a urine or blood test).
• Arterial blood gas (ABG).
• Basic metabolic panel (BMP).
• Blood pressure measurement.
• Osmolality blood test.

If you have diabetes and call your provider from home about your symptoms, they can usually determine if you have DKA based on your history, blood sugar levels and pee and/or blood ketones. You can take a few at-home tests to see if you could have DKA, including:

• Urine ketone test: This measures the number of ketones in your pee. It’s usually a strip that’ll turn a certain color depending on the ketone levels in your pee. You can buy urine ketone tests at your local pharmacy without a prescription. Follow the instructions on the packaging to be sure you’re doing the test properly.
• Blood ketone test: Some at-home blood glucose meters can check blood ketones as well as blood sugar levels with a drop of blood. Some meters just check ketones in your blood.
• Blood sugar checks: High blood sugar (above 250 mg/dL) is a sign that you could have DKA. Checking your blood sugar with a blood glucose meter or using a continuous glucose monitor (CGM) are the only ways to know for sure if you have high blood sugar.

What is the treatment for DKA?

If you have diabetes and identify DKA early enough, you may be able to treat it from home with specific instructions from your healthcare provider. If you think you might be developing DKA, call your provider immediately. They’ll determine if you’ll be able to treat it from home or if you’ll need to go to the hospital.

People with symptoms of DKA and undiagnosed diabetes must go to a hospital for treatment.

Hospital treatment of DKA

Hospital treatment of DKA includes:

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

At-home treatment of DKA

If you have diabetes and your healthcare provider has determined that you can treat DKA from home, be sure to do the following:

• Follow your provider’s instructions: They’ll tell you how much insulin and/or medication to take and other steps to safely get out of DKA.
• Check your blood sugar often: Try to check your blood sugar every hour to be sure your treatment is working and your blood sugar is decreasing safely.
• Check your ketones: Use urine ketone strips or a blood ketone meter to check for ketones as you’re recovering. The level of ketones in your body should be decreasing, not increasing.
• 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 increase your blood sugar and increase ketones in your body. Your provider will let you know when you can safely start exercising again.

How long does it take to recover from diabetes-related ketoacidosis?

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

Depending on the severity of DKA, it could take multiple days before it’s fully treated.

How can I prevent DKA?

If you have diabetes, taking the following actions can help prevent DKA:

• Checking your blood sugar often: Checking your blood sugar with a glucose meter and/or using a CGM is crucial to managing diabetes and preventing complications. Try to at least check your blood sugar before and after meals and before you go to sleep. It’s important to treat high blood sugar as soon as possible to prevent DKA.
• Taking your insulin and/or medication regularly: Follow your healthcare provider’s instructions for taking your insulin and/or medication. Missed doses can lead to DKA.
• Checking for ketones: If you’re experiencing sustained high blood sugar, check for ketones using a pee or blood test to be sure you’re not close to developing DKA.
• Checking your insulin pump: If you use an insulin pump and are experiencing high blood sugar, be sure to check your pump for issues like a kinked cannula or a disconnected site/tubing. These issues could be preventing you from receiving insulin.
• Having a sick day plan: Talk with your provider about how to manage diabetes when you’re sick. Illness can trigger DKA, so it’s important to know what to do if you get sick before it happens so that you’re prepared.
• Seeing your diabetes provider regularly: It’s important to see your diabetes provider regularly to be sure that your diabetes management plan is working.
• Staying educated: Don’t be afraid to ask your healthcare team about DKA. The more you know about DKA and your diabetes management, 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.

What is the prognosis (outlook) for someone with DKA?

With prompt treatment, most people recover from diabetes-related ketoacidosis within a day. Sometimes, it takes longer.

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

• Very low potassium levels (hypokalemia).
• Brain swelling (cerebral edema).
• Fluid inside of your lungs (pulmonary edema).
• Cardiac arrest.
• Damage to your kidneys and other organs.
• Coma.
• Death.

What is the survival rate of DKA?

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).

What’s the difference between diabetes-related ketoacidosis (DKA) and ketosis?

Even though they sound alike, diabetes-related ketoacidosis and ketosis are two different things.

Ketosis happens when you have ketones in your blood and/or pee but not enough to turn your blood acidic. It usually happens if you:

• Are eating a low-carbohydrate (keto) diet.
• Aren’t eating for long periods (fasting).
• Have consumed excessive alcohol.

Ketosis isn’t harmful.

Diabetes-related ketoacidosis (DKA) happens when your blood turns acidic because there are too many ketones in your blood due to a lack of insulin. Diabetes-related ketoacidosis is life-threatening and requires immediate treatment.

A note from Cleveland Clinic

Diabetes-related ketoacidosis (DKA) is one of the scariest complications of Type 1 diabetes. That’s why it’s important to recognize its signs and triggers so you can act quickly if it arises. While there are many steps you can take to prevent DKA, it’s sometimes unavoidable. Try not to think of it as a failure — diabetes is a tough condition to manage. If you’re struggling with management or have questions about complications, don’t hesitate to ask your healthcare provider for help.