Diabetic Ketoacidosis

Diabetic ketoacidosis is a serious and life-threatening emergency that can happen when your body doesn’t have enough insulin to use blood sugar for energy. Instead, your body breaks down fat too quickly, creating harmful acids called ketones that build up in your blood and make it too acidic.

Table of contents

• What is diabetic ketoacidosis?
• Who can develop diabetic ketoacidosis?
• What happens in your body during diabetic ketoacidosis?
• Warning signs and symptoms
• What causes diabetic ketoacidosis?
• How doctors diagnose diabetic ketoacidosis
• Treatment in the hospital
• Possible complications
• How to prevent diabetic ketoacidosis
• Testing for ketones at home
• When to seek emergency help

What is diabetic ketoacidosis?

Diabetic ketoacidosis, often called DKA, is a serious health emergency that can happen as a result of diabetes. It can be life-threatening and requires immediate medical care^[1]. The condition develops when the body cannot make enough insulin, which is a hormone that helps blood sugar (also called glucose) enter cells in the body to be used for energy^[1].

Without enough insulin, the body begins to break down fat as fuel. This causes a buildup of acids in the blood called ketones^[1]. When too many ketones are produced too fast, they can build up to dangerous levels in your body, making your blood too acidic^[2]. This condition is called ketoacidosis. If it’s not treated, the buildup can lead to diabetic ketoacidosis and eventually cause coma or death^[1].

Who can develop diabetic ketoacidosis?

Diabetic ketoacidosis most commonly occurs in people with type 1 diabetes, though it can also occur in people with type 2 diabetes^[2]. Type 1 diabetes usually develops during childhood or adolescence but can also develop in adulthood^[7]. For some people, DKA is how they find out that they have type 1 diabetes, and approximately 20% to 40% of DKA cases affect people who are newly diagnosed^[7].

People with existing type 1 diabetes can develop DKA at any point if they don’t get enough injected insulin^[7]. While less common, people with type 2 diabetes can also develop DKA, particularly those who have a condition called ketosis-prone diabetes^[7].

Sometimes DKA is the first sign of diabetes in people who haven’t yet been diagnosed, particularly in children^[2].

What happens in your body during diabetic ketoacidosis?

Your body needs insulin to use blood sugar for energy. Normally, when you eat, your body breaks down food into blood sugar, and insulin helps move that sugar into your cells. When there isn’t enough insulin in your body, blood sugar can’t enter cells to be used for energy^[2].

When this happens, your body looks for another source of fuel. Your liver starts breaking down body fat for energy instead^[7]. As your liver breaks down fat, it releases ketones into your bloodstream. Ketones are normally produced when the body breaks down fat after it has been a long time since your last meal^[3]. However, when ketones are produced too quickly and build up in the blood, they can be toxic by making the blood acidic^[3].

At the same time, without insulin, blood sugar levels rise very high because the sugar can’t get into cells. This causes the body to lose water through increased urination, leading to severe dehydration^[4]. A high number of ketones causes your blood to become acidic (your blood pH is too low) and you experience dehydration, creating an emergency medical situation^[7].

Warning signs and symptoms

Diabetic ketoacidosis symptoms often come on quickly, sometimes within 24 hours^[1]. DKA usually develops slowly at first, but it begins relatively slowly and can rapidly get worse. If you’re vomiting, it could develop much more quickly^[7].

Early symptoms of DKA include^[2]:

• Being very thirsty
• Urinating a lot more than usual
• High blood sugar levels (over 250 mg/dL)
• High amounts of ketones in your urine or blood

If untreated, more severe symptoms can appear quickly, such as^[2]:

• Feeling a need to throw up and throwing up
• Having belly pain or stomach pain
• Being weak or tired
• Being short of breath or fast, deep breathing
• Having fruity-scented breath (like pear drop sweets or nail polish remover)
• Dry skin and mouth
• Flushed face
• Headache
• Muscle stiffness or aches
• Being confused or feeling disoriented
• Decreased alertness or loss of consciousness

For some people, these symptoms may be the first sign of diabetes^[1].

What causes diabetic ketoacidosis?

Very high blood sugar and low insulin levels lead to DKA. The main cause of DKA is an insufficient amount of insulin in your body^[7]. The two most common causes are^[2]:

• Illness. You may not be able to eat or drink as much as usual, which can make blood sugar hard to manage
• Missing insulin shots, a clogged insulin pump, or the wrong insulin dose

Other causes of DKA include^[2]:

• Heart attack or stroke
• Physical injury, such as from a car accident
• Alcohol or drug use
• Certain medicines, such as some diuretics (water pills) and corticosteroids (used to treat inflammation in the body)

Common precipitating factors for DKA include non-compliance with insulin treatment, new-onset diabetes, and other acute medical illness^[4]. The most common types of infections that trigger DKA are pneumonia and urinary tract infections^[4].

Some newer medications called SGLT2 inhibitors can also increase the risk of DKA. These medications promote increased blood sugar in urine and may decrease urinary removal of ketone bodies, leading to an increase in plasma ketone levels^[4].

How doctors diagnose diabetic ketoacidosis

A physical exam and blood tests can help diagnose diabetic ketoacidosis^[11]. If you think you have DKA, test for ketones using urine strips or a blood ketone meter. If ketones are present, contact your provider right away^[3].

Blood tests used in the diagnosis of diabetic ketoacidosis measure^[11]:

• Blood sugar level. Without enough insulin, the blood sugar level rises, a condition called hyperglycemia
• Ketone level. When the body breaks down fat and protein for energy, it makes acids called ketones that go into the blood
• Blood acidity. A blood ketone level that’s too high causes the blood to become acidic, which can change how organs work throughout the body

Other tests may include blood electrolyte tests, urinalysis, chest X-ray, and an electrocardiogram to check the heart’s electrical activity^[11]. Tests can also help find health issues that might have led to diabetic ketoacidosis, such as infections^[11].

Treatment in the hospital

DKA is a medical emergency. If you have diabetic ketoacidosis, you will need to go to the hospital for urgent treatment^[5]. You may be treated in the emergency room or admitted to the hospital, possibly to the intensive care unit^[3].

Treatment most often involves^[11]:

• Fluids. Fluids replace those lost by urinating a lot. They also lower blood sugar. You can get fluids by mouth or through a vein (called IV fluids)
• Insulin therapy. You will receive insulin through a vein to help lower blood sugar levels and stop the body from making more ketones
• Electrolyte replacement. Electrolytes are minerals in the blood, such as sodium, potassium and chloride, that carry an electric charge. Too little insulin can lower the level of several electrolytes in the blood. You get IV electrolytes to help keep the heart, muscles and nerve cells working as they should

You’ll be monitored for complications, as DKA can sometimes affect your brain, heart or lungs^[5]. Providers will also search for and treat whatever other problem caused the DKA, such as an infection^[3].

Once your ketones are at a safe level and you can eat and drink normally, you’ll be able to go home^[5]. Most people respond to treatment within 24 hours, though sometimes it takes longer to recover^[3].

Possible complications

If DKA is not treated, it can lead to severe illness or death^[3]. Health problems that may result from DKA include^[3]:

• Fluid buildup in the brain (cerebral edema)
• Heart stops working (cardiac arrest)
• Kidney failure

Cerebral edema, which is fluid buildup in the brain, is one of the most serious complications of diabetic ketoacidosis and occurs more commonly in children and adolescents than in adults^[4].

How to prevent diabetic ketoacidosis

DKA is a serious condition, but you can take steps to help prevent it^[2]:

• Check your blood sugar often, especially if you’re sick. Keep your blood sugar levels in your target range as much as possible
• Take medicines as prescribed, even if you feel fine. Don’t stop taking insulin, even if you’re not eating, and don’t skip insulin doses
• Talk to your doctor about how to adjust your insulin based on what you eat, how active you are, or if you’re sick
• Follow the treatment plan agreed with your diabetes care team, including adjusting your insulin dose when you need to
• Ask your care team about getting a continuous glucose monitor or flash monitor if you don’t already have one

When you are sick, special care is needed^[21]:

• Take your insulin and diabetes medicines even if you are vomiting and having trouble eating or drinking. Your blood sugar may go up because you are sick
• Drink extra fluids to prevent dehydration, including water, broth, and sugar-free drinks
• Try to eat as you normally do, with a focus on healthy food choices
• Check your blood sugar at least every 3 to 4 hours
• Check your temperature and pulse often. If your temperature goes up, call your doctor
• Test for ketones when your blood sugar is high

If you’re concerned about DKA or have questions about how to manage your diabetes, talk to your diabetes care team. Ask them for a referral to diabetes self-management education and support for individual guidance^[2].

Testing for ketones at home

Anytime you’re sick or your blood sugar is 240 mg/dL or above, you’ll need to test for ketones^[2]. Use an over-the-counter ketone test kit to check your urine or a meter to test your blood every 4 to 6 hours. You can get kits to test for ketones free from some health services, or buy them from a pharmacy^[5].

If you use a meter to test for ketones in your blood^[5]:

• Under 0.6 mmol/L is normal
• 0.6 to 1.5 mmol/L is slightly high – test again in 2 hours
• 1.6 to 3 mmol/L means you’re at risk of DKA and should speak to your diabetes care team for advice
• Over 3 mmol/L is high and means you may have DKA and should call emergency services or go to the emergency room

If you use strips to test for ketones in your urine, over 2+ is high. This means you may have DKA and should call emergency services or go to the emergency room^[5].

These ketone levels are a guide. Normal blood ketone levels can be different for different people. Your diabetes care team will advise you on what levels to look for^[5].

When to seek emergency help

If you feel ill or stressed or you’ve had a recent illness or injury, check your blood sugar level often. You also might need to check for urine ketones^[1].

Contact your healthcare professional right away if^[1]:

• You’re throwing up and can’t keep down food or liquid
• Your blood sugar level is higher than your target range and doesn’t go down after treatment at home
• Your urine ketone level is moderate or high

Call emergency services (999, 911, or your local emergency number) or go to the emergency room if^[5]:

• You have a high level of ketones – over 3 mmol/L in your blood, or over 2+ in your urine
• You do not know your ketone levels but have symptoms of diabetic ketoacidosis, such as feeling thirsty and needing to urinate more often, feeling sleepy or confused, and breath that smells fruity
• You have symptoms of diabetic ketoacidosis and have not been diagnosed with diabetes
• You have decreased consciousness, trouble breathing, fruity breath, or nausea and vomiting

Diabetic ketoacidosis can be life threatening, so it’s important to get treatment quickly^[5]. Do not drive yourself to the emergency room. Ask someone to drive you or call for an ambulance^[5].