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What Is Diabetic Ketoacidosis?

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Diabetic ketoacidosis is a serious, potentially life-threatening complication that happens when the body doesn’t have enough insulin. Here's how to recognize early warning signs and prevent DKA. 

First described in the late 19th century, diabetic ketoacidosis (DKA) represents something close to the ultimate diabetes medical emergency.

DKA occurs when the body is short of insulin, which causes ketones to build up in the blood. Too many ketones can harm the brain and other organs. In 24 hours or less, people can experience an onset of severe symptoms, all potentially leading to a coma or death. 

However, the treatment of DKA with insulin also represents one of the great evolutions in diabetes care over the last century. Before the discovery of insulin in 1920, DKA was almost invariably fatal. The mortality rate for DKA dropped to below 30% within 10 years and today, less than 1% of those who develop DKA die from it – provided they get adequate care in time.

Don’t skip over “in time,” because it’s crucial: DKA is treatable, but only as long as it’s promptly diagnosed and treated. The key to avoiding DKA is prevention.

What causes diabetic ketoacidosis?

Insulin plays a critical role in the body’s functioning: it allows cells to absorb glucose in the blood so it can be used for energy. When there’s not enough insulin to take that glucose out of the blood, high blood sugar (hyperglycemia) results.

The body begins to burn fat molecules for energy since it can’t get that energy from glucose. During this process, the liver makes compounds known as ketones, which make the blood more acidic. DKA results when acid levels in the blood get too high due to ketone buildup.

This causes other issues too, as DKA also often leads to an increased release of hormones like glucagon and adrenaline. All symptoms of DKA are signs of the chaos the body is thrown into as it tries to compensate for all these hormonal and chemical imbalances.

What are the symptoms of DKA?

Diabetic ketoacidosis symptoms may begin slowly in some people but can escalate quickly. Early symptoms include:

  • Thirst and dehydration 
  • Dry mouth 
  • Frequent urination
  • Nausea or vomiting 

If untreated, more severe symptoms of DKA occur fairly rapidly (in a few hours after the onset of vomiting). Severe symptoms that require immediate medical attention include:

  • A blood sugar level of 300 mg/dL or higher
  • Elevated blood or urine ketones
  • Fruity-smelling breath
  • Vomiting 
  • Abdominal pain or discomfort 
  • Trouble breathing 
  • Headache
  • Muscle aches or stiffness
  • Confusion and extreme fatigue 

Does DKA occur in both type 1 and type 2 diabetes?

Generally speaking, DKA affects people with type 1 diabetes. It’s less common for people with type 2 diabetes to develop DKA but it can still happen and is something those with type 2 should be aware of. 

According to the latest CDC data, there were more than 200,000 DKA-related hospital admissions in 2020. Type 2 diabetes is estimated to account for up to one-third of DKA causes. 

Can you have DKA without high blood sugar?

There is a special type of DKA that can occur without high blood sugar. Called euglycemic DKA, this is when people are in DKA but have normal or only slightly elevated blood sugar levels. 

Euglycemic DKA can happen if you’re taking SGLT-2 inhibitors, like Jardiance or Farxiga for example. Keep in mind that the absence of high blood sugar does not exclude the possibility of DKA. If you’re experiencing any early warning signs of DKA, it’s always best to perform ketone testing; you can do this with your healthcare provider or at home with a urine ketone test or blood ketone test.

Who is at greater risk for developing DKA?

Certain people have more risk factors for DKA. This includes: 

  • People who are unaware they have diabetes. As many as 30% of children with type 1 diabetes learn they have the disease only after developing DKA. Many people with type 2 diabetes also are diagnosed after experiencing DKA. While things have improved over the years in terms of screening and being able to diagnose diabetes earlier (and thus avoid DKA), this isn’t the case for many people living in under-resourced countries. 
  • People with diabetes who are sick. Illness often increases the need for insulin. It also reduces appetite and as a result, can lead to increased ketone levels. The ADA recommends checking ketones every four to six hours when sick.
  • People with irregular eating habits. Skipping meals or inconsistent insulin regimens can result in heightened ketone levels, which means that people who eat less consistently or have eating disorders are at particular risk.
  • Younger people. According to the CDC, DKA hospitalizations occur at nearly 10 times the rate in people with diabetes ages 0-45 compared to those aged 45 and older.
  • People taking SGLT-2 inhibitors. The U.S. Food and Drug Administration (FDA) and the European Medicines Agency have updated SGLT-2 drug labels to include warnings about euglycemic DKA.

How to prevent DKA

  1. Keep blood sugars in target range: Maximizing your time in range (70-180 mg/dL) can help prevent DKA. The risk of DKA increases substantially when blood glucose levels exceed 240 mg/dL. 
  2. Eat a nutritious diet: Sticking with healthy, regular eating patterns is important for blood sugar management and can help prevent DKA. 
  3. Time your insulin: Because DKA is caused by too little insulin, taking insulin doses at the right times is critical for preventing DKA. If you use insulin and struggle to take it on time, consider getting an insulin pump or using a smart pen to keep track of doses. 
  4. Use a CGM: Careful monitoring of blood sugar with a continuous glucose monitor (CGM) is a great way to stay on top of high (and low) blood sugars and help prevent DKA. CGMs can sound alerts when blood sugar is rising rapidly or when it exceeds a certain level, such as 180 mg/dL or 250 mg/DL. In fact, a large research study found that using a CGM was associated with dramatic reductions in DKA hospitalizations. 
  5. Test for ketones: If you’re sick or your blood sugar is above 240 mg/dL, check your ketones. You can test for ketones with over-the-counter urine test strips or a blood ketone meter.

How is DKA treated?

Call your healthcare provider if your urine ketone levels are moderate to high or your blood ketones are more than 3.0 mmol/L. Be prepared to act quickly to get emergency care. 

Call 911 or go to the closest emergency department immediately if you are experiencing severe DKA symptoms. If you have DKA, you’ll either receive treatment in the emergency room or be admitted to the hospital. Treatment usually involves: 

  • Administration of insulin, which reverses the cause of DKA 
  • Rehydration to replace lost fluids and reduce excess glucose in the blood 
  • Electrolyte replacement (commonly potassium) 
  • Medicine to address any underlying causes of DKA (such as antibiotics to treat an infection) 

What’s next for DKA management?  

Some diabetes technology companies are developing continuous ketone monitoring (CKM) technology as either standalone devices or a combination of continuous glucose and ketone monitoring (CGKM). CKM or CGKM could help prevent DKA in people at higher risk for this serious complication. 

As more people gain access to and insurance coverage for CGMs, recognition and treatment of high blood sugar will likely be easier and earlier – with less DKA. Meanwhile, greater population-wide screening can help identify people at high risk of developing diabetes before DKA has a chance to happen. 

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