Diabetic Ketoacidosis

Diabetic Ketoacidosis

Also called: DKA, Ketoacidosis


Diabetic ketoacidosis (DKA) is a dangerous condition that can occur when a severe lack of insulin causes the body to break down fats instead of glucose (blood sugar) for energy. This process causes acidic waste products called ketones to build up in the blood.

If untreated, DKA can lead to diabetic coma or death. However, with proper medical treatment, patients can recover from DKA and prevent it from recurring.

Ketoacidosis may develop because of an infection or illness. This condition may also develop when people fail to control their diabetes, as a result of pregnancy complications or from an eating disorder.

DKA is most common with type 1 diabetes, although it can also affect those with type 2 diabetes or other forms of diabetes. The American Diabetes Association estimates that DKA is responsible for 10 percent of all diabetes-related deaths for diabetic individuals under the age of 45.

DKA develops because of three factors:

  • A severe lack of insulin
  • Very high levels of glucose (severe hyperglycemia)
  • Very high levels of ketones (severe ketosis)

The typical treatment options for DKA are intravenous (I.V.) treatments and replacement of lost insulin. Patients can reduce their risk of DKA by:

  • Adhering to their prescribed diet
  • Taking insulin and other medication as prescribed
  • Monitoring glucose and performing ketone tests
  • Following a prescribed sick-day plan
  • Taking precautions against infections and injuries
  • Ensuring caregivers’ education

About diabetic ketoacidosis

Diabetic ketoacidosis (DKA) can develop when the body is unable to break down the glucose in the bloodstream because of a severe lack of insulin. This forces the body to break down fats, which produces acidic waste products known as ketones. Excessive levels of ketones (ketosis) can lead to ketoacidosis and have life-threatening consequences.

DKA develops primarily because of infection or illness, or when people fail to control their diabetes, such as missing or skipping insulin doses. Ketoacidosis may also develop as a result of complications of pregnancy, and it may be caused by eating disorders.

DKA may lead to diabetic coma or even death, if untreated. Immediate emergency treatment is required. With proper medical treatment, patients can completely recover and prevent DKA from occurring again.

DKA most commonly affects people with type 1 diabetes, but it may affect those with type 2 diabetes or other forms of diabetes. According to the American Diabetes Association (ADA), women have a 50 percent higher risk for DKA than men. The ADA estimates that this condition is responsible for about 10 percent of all diabetes-related deaths in patients under the age of 45. Sometimes DKA occurs in people whose diabetes has not yet been diagnosed.  

Diabetic ketoacidosis develops because of the combination of three factors:

  • A severe lack of insulin
  • Very high levels of glucose (severe hyperglycemia)
  • Very high levels of ketones (severe ketosis)

Normally, the body forms energy by breaking down glucose, which is moved through the bloodstream by insulin. However, in type 1 diabetes, the pancreas no longer produces insulin. When insulin is not available, the body will find other sources to transform into energy. This lack of energy causes muscle cells to starve, and the body is forced to use fat, and not glucose, to form energy. The breakdown of fat leaves ketones as a waste product.

Some ketones are released through the urine, but many remain. These extra ketones build up in the blood, causing ketoacidosis. However, only when ketoacidosis is caused by complications related to diabetes is it referred to as diabetic ketoacidosis. There are other forms of ketoacidosis, including alcohol ketoacidosis, brought on by high consumption of alcohol, and starvation ketoacidosis, caused by a lack of food. Diets low in carbohydrates can cause ketosis by forcing the body to burn fats rather than glucose for energy, but dietary ketosis in nondiabetics rarely leads to ketoacidosis.

People with diabetes can check their level of ketones with a simple urine test involving a test strip (like a blood testing strip). Some glucose meters also monitor ketones. The ADA recommends that people with diabetes monitor their ketones:

  • When sick or under stress
  • During pregnancy
  • When blood glucose is high, typically:
    • Above 240 milligrams per deciliter (mg/dL) with type 1 diabetes
    • Above 300 mg/dL with other forms of diabetes
    • Or as advised by their physician

It is important for pregnant women to test their ketone levels every day. When diabetic patients are sick and their glucose level is higher than 240 mg/dL, the ADA advises that ketones be checked every four to six hours. Ketone buildup can cause nausea, and it can easily be mistaken as being caused by illness. Parents of children with diabetes should check their children’s ketone levels when they complain of a stomachache.

Though physical activity is normally an important part of managing diabetes, people should not exercise when their levels of ketones and glucose are high, according to the ADA. Instead they are advised to call their physician.

Diabetic individuals are advised to have their physician create a sick-day plan for them in advance of potential problems. When people with diabetes become sick, glucose can rise and ketosis may develop, and they can become even sicker. It is important to monitor glucose and ketones more than usual when sick, as these higher levels may require additional insulin.

Although DKA develops slowly, once vomiting occurs the condition may worsen in a matter of hours. Without treatment, DKA can lead to a number of potentially life-threatening complications, including:

  • Cerebral edema. Swelling of the brain.
  • Cardiac arrhythmia (or dysrhythmia). An abnormal heart rhythm.
  • Hyperkalemia. High level of potassium in the blood. This can cause arrhythmia or even cardiac arrest, in which the heart stops beating.
  • Hypokalemia. Low level of potassium in the blood. This can cause arrhythmia, muscle weakness or cramping, extreme thirst (polydipsia) and possibly even paralysis of the lungs.
  • Arterial thrombosis. Blood clot in an artery.
  • Disseminated intravascular coagulation (DIC). A reduction of blood-clotting factors.
  • Adult respiratory distress syndrome (ARDS). A rare condition affecting smokers and involving rapid respiratory failure.
  • Pneumomediastinum. Air found in the mediastinum, the area between the lungs in the chest.
  • Pulmonary embolus. A sudden blockage affecting the lungs, such as a blood clot.
  • Pulmonary edema. An accumulation and swelling of fluid in the lungs.
  • Subcutaneous emphysema. A condition in which gas is present within the tissue under the skin covering the chest wall. It results in a crackling bulge under the skin’s surface.
  • Heart attack.
  • Kidney failure.
  • Rhabdomyolysis (a breakdown of muscle fibers.) This releases the muscle fibers’ contents into circulating blood. This content may be toxic and damage the kidneys.
  • Shock.
  • Infection.

People with diabetes may also be at risk for a condition known as hyperosmolar hyperglycemic nonketotic state (HHNS), which occurs when severe hyperglycemia is combined with dehydration, typically without ketosis. HHNS is usually found in elderly individuals. Unlike diabetic ketoacidosis, HHNS occurs more often in patients with type 2 diabetes and is uncommon in those with type 1 diabetes. The mortality rate from both conditions has plunged in recent decades, according to the U.S. Centers for Disease Control and Prevention.

Risk factors and potential causes of diabetic ketoacidosis

Diabetic ketoacidosis (DKA) may result when a person with diabetes, especially type 1 diabetes, does not follow proper medical care. This condition sometimes developes in people even before a diagnosis of diabetes is made. A severe lack of insulin causes the body to break down fats because it cannot use the glucose (blood sugar) circulating in the bloodstream. This metabolism of fats produces waste products known as ketones.

Many ketones are eliminated from the body in urine. But if too many ketones are released, the body cannot eliminate them quickly enough and they build up in the blood (ketosis). Over time, this can lead to ketoacidosis.

Factors that can raise ketone levels include:

  • Infections, trauma and infarctions. Those with type 1 diabetes can develop DKA as a result of various conditions that can cause insulin treatments to fail. These include:
    • Acute infections, such as a urinary tract infection, yeast infection, skin infection or  bone infection (osteomyelitis)
    • Injury or trauma
    • Infarctions (tissue death caused by obstructions in the blood supply), such as a heart attack
    • Surgery
    • Cold or flu

  • Missed or skipped insulin. People with diabetes who miss or skip their normal dose of insulin are at risk of a lack of insulin. Insulin doses may be skipped by mistake, inconvenience, or because of social or psychological pressure.
  • Illness or stress. When people with diabetes are sick or are under extreme stress, insulin levels may drop.
  • Insulin reaction (hypoglycemia). Diabetics should check for insulin reactions, which are excessively low glucose levels, typically defined as below 50 milligrams per deciliter (mg/dL). As it is possible to have a reaction to insulin while sleeping, performing a ketone test in the morning is recommended. High levels of ketones may mean that a reaction has occurred.
  • Damaged or spoiled insulin. Make sure to use insulin as directed. An insulin supply that is damaged or spoiled may not be effective. It is vital to throw out any insulin that looks unusual or is expired. People with diabetes should follow the guidelines on the package for using and storing insulin, which includes not exposing insulin to temperatures of 80 degrees Fahrenheit (26 degrees Celsius) or higher or at freezing level or below.
  • Malfunction of an insulin pump. A malfunctioning insulin pump can cause insulin levels to drop and ketone levels to rise. It is important that diabetic patients using insulin pumps have their pumps checked as often as recommended by their physician or the pump’s manufacturer.
  • New onset of diabetes. DKA may be the first indication that a person has diabetes, usually type 1. This is because symptoms of DKA are severe enough to cause people to seek medical attention.
  • Pancreatitis. An inflammation of the pancreas.
  • Stroke. An event in which blood flow to the brain is blocked, resulting in tissue damage or death.
  • Shock. This includes hypovolemia, a type of shock that results when the heart fails to supply sufficient blood.
  • Lack of food. Missing a meal can result in low blood glucose, the breakdown of fat and elevated ketone levels in the blood.
  • Eating disorders. Young women have eating disorders more often than men and older women, and the resulting uncontrolled blood glucose may cause DKA.
  • Pregnancy. During pregnancy, women’s bodies burn fat quicker, and DKA can occur at much lower glucose levels.
  • Hyperthyroidism. Untreated hyperthyroidism (excess thyroid hormones) can lead to ketoacidosis. 
  • Alcohol abuse. The liver processes alcohol before it processes excess glucose because alcohol is a toxin. Alcohol consumption can cause hypoglycemia and lead to ketoacidosis.
  • Medications. Drugs including corticosteroids (a class of anti-inflammatory immunosuppressives), diuretics, beta blockers, some antibiotics, antidepressants, antipsychotics, estrogens, anticonvulsants and protease inhibitors (HIV medications) may temporarily raise glucose levels.

Signs and symptoms of diabetic ketoacidosis

Generally, diabetic ketoacidosis (DKA) develops slowly. However, when it develops, immediate medical attention is required. If left untreated, DKA may result in pneumonia, shock, diabetic coma and even death. Small children may also develop swelling of the brain (cerebral edema), with a headache as the earliest symptom. Certain signs and symptoms of DKA appear earlier than others. These include:

  • High levels of glucose (blood sugar). Hyperglycemia is an important warning sign of DKA. Levels above 250 mg/dL are typically considered high, but individuals are advised to consult their physician about what level of glucose is considered excessive for them.
  • Higher-than-normal levels of ketones in urine.
  • Extreme thirst (polydipsia) or dry mouth.
  • Frequent urination (polyuria). In children, this may take the form of bedwetting.
  • Breathing difficulties. People with DKA may experience fast, deep or labored breathing, known as Kussmaul breathing or air hunger. However, as the level of ketones increase, the breathing may become deeper and slower.

Other DKA signs and symptoms may develop later. These include:

  • Fatigue.
  • Warm, dry or flushed skin.
  • Nausea and vomiting. It is important to notify a physician if vomiting lasts longer than two hours. DKA may develop within a matter of hours after vomiting.
  • Abdominal pain. This may also include tenderness and a lack of bowel sounds.
  • A sweet, fruity odor on the breath.
  • Confusion or difficulty paying attention.

People with diabetes should notify their physician if they develop any of these signs or symptoms. If levels of ketones and glucose are high, diabetic individuals are advised to avoid exercising, as the body does not have enough insulin to supply the muscles with fuel. As a result, fat, and not glucose, is used for fuel, and additional ketones are formed. DKA may be life-threatening, so prompt treatment is crucial.

Diagnosis methods for diabetic ketoacidosis

A diagnosis of diabetic ketoacidosis (DKA) generally begins with a medical history and a physical examination. In addition, a number of blood tests may be performed, including:

  • Glucose test. Measures the level of glucose (blood sugar) in a patient’s blood.
  • Electrolyte panel. Measures blood levels of minerals that may be depleted when DKA occurs, such as potassium and sodium. Potassium is an essential mineral important for cellular, neurological and muscular health. Sodium helps the body maintain necessary levels of acids and fluids.
  • Ketone blood test. Measures blood levels of ketones, waste products produced when the body is forced to break down fat to make energy. If people with diabetes have excess ketones in their urine (which can cause nausea and vomiting), it is important for a physician to examine the blood, especially if the patient has vomited more than twice in four hours. Some ketones are released through the urine, but many remain, and these extra ketones build up in the blood and act as a poison to the body.

When checking for ketone levels, the findings are categorized as “small,” “moderate” or “large.” Patients with “moderate” or “large” amounts of ketones and/or high blood glucose should contact their physician. Findings in the negative range are considered normal.

CategoryKetone Ranges
Small< 20 mg/dL
Moderate30 to 40 mg/dL
Large> 80 mg/dL

Missed doses of insulin are a common cause of DKA, so physicians are likely to ask questions about the frequency and consistency of doses. When patients regularly take their insulin without skipping any doses, DKA may be caused by a number of underlying illnesses or infections. Additional blood and urine tests may also be taken to diagnose these underlying conditions.

People with diabetes are often advised to monitor their own ketone levels at home, so that DKA can be avoided or diagnosed as soon as possible. Home ketone monitoring involves a urine or blood test. Some glucose meters check ketone levels.

The American Diabetes Association recommends that all pregnant women with diabetes check their ketone levels every day and that all men, women and children with diabetes who are sick have their ketones checked every four hours.

Treatment options for diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is usually treated by replenishing insulin through intravenous (I.V.) treatments. The I.V. replaces lost fluids, electrolytes and insulin (regular insulin), so glucose, and not fat, is used to produce energy. Typically, patients receive an initial dose of 15 to 20 units of insulin, followed by continuous infusion of about 7 units per hour (0.1 unit per kilogram). The I.V. treatments generally take about three to four hours for maximum effectiveness.

In most cases, treatment will return ketone levels to normal in 12 to 24 hours, although some diabetic individuals may have higher levels for days. Glucose levels should return to normal in several hours. The physician will continue to monitor glucose, fluid levels and vital signs, and may also recommend supplements of potassium. Patients can expect to be hospitalized for several days.

Use of some medications, including antidiabetic agents, may have to be reduced or suspended during episodes of diabetic ketoacidosis. Alpha-glucosidase inhibitors, biguanides, DPP-4 inhibitors, meglitinides, sulfonylureas and thiazolidinediones should not be used to treat DKA, according to the U.S. Food and Drug Administration.

If prompt medical treatment is received, patients can expect to quickly and completely recover from DKA. However, it is vital to continue to monitor blood and urine.

Prevention methods for diabetic ketoacidosis

The best way to prevent diabetic ketoacidosis (DKA) is to follow a proper plan for diabetes health. It is helpful to have one main physician to oversee a care plan. There are other steps that diabetic individuals can take to lessen their risk of developing DKA, including:

  • Monitoring ketone levels. Above-normal ketone levels are dangerous. They can signal a blood imbalance and lead to DKA. Patients can check their ketone levels regularly with a simple urine test or blood test.
  • Eating a proper diet. Missed meals can result in ketones forming from the breakdown of fats. A physician or registered dietitian may prescribe a carbohydrate-restricted diet, such as one incorporating the glycemic index. However, patients are advised not to start low-carb diets on their own because these plans can trigger ketosis. 
  • Ensuring insulin dose and safety.
    • Take insulin doses on time and in the recommended dosage.
  • When sick or under extreme stress, adjust insulin levels accordingly, as recommended by the physician. The body may require extra insulin at these times.
  • Test ketone levels in the morning. While sleeping, people with diabetes may experience insulin reactions (hypoglycemia), excessively low glucose (blood sugar) levels (below 50 mg/dL [milligram per deciliter]).  High ketone levels may signal a reaction.
  • Throw out any expired insulin or any insulin that does not look normal, as a supply of insulin may be ineffective or spoiled. Never expose insulin to temperatures of 80 degrees Fahrenheit or higher or at freezing level or below.
  • Ensure that insulin pumps are working properly.

In addition, several organizations train dogs to detect ketoacidosis and other diabetic emergencies, but the demand for these assistance animals outstrips the supply.

Questions for your doctor regarding DKA

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about diabetic ketoacidosis (DKA):

  1. What could cause me to develop diabetic ketoacidosis?
  2. At what point would a high level of ketones (ketosis) in me be considered ketoacidosis?
  3. How would DKA be diagnosed in me?
  4. Can DKA happen to anyone with diabetes? Am I at high risk?
  5. Should I check my ketone levels at home? How often? Under what circumstances should I perform ketone tests more frequently?
  6. What symptoms of DKA should I watch out for?
  7. Should I avoid exercising if my ketones and blood sugar are high? Should I eat something or avoid eating?
  8. What action should I take if DKA may be developing? Should I be transported to a hospital? Will I need to be treated with intravenous insulin?
  9. What complications could DKA cause me?
  10. Do I need to stop taking antidiabetic agents or any other medications when experiencing DKA?
  11. Am I likely to make a full recovery? How soon will I be back on my feet?
  12. How can I reduce my risk of diabetic ketoacidosis?
  13. Will you devise a sick-day plan to help me prevent DKA and other diabetic complications?
  14. Can I help manage my diabetes with a controlled-carbohydrate diet without risking DKA?
  15. If my child has diabetes, what else do I need to know about diabetic ketoacidosis?
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