What Is Diabetic Ketoacidosis?

Diabetic ketoacidosis (DKA) is an emergency medical condition that causes you to have extremely high blood sugar levels, which can lead to severe pH changes in your body. These pH changes can be life-threatening if left untreated. Diabetic ketoacidosis can affect people with type 1 or type 2 diabetes.

Your body is like a car engine, whose “gas” is glucose (your blood sugar). Without enough insulin, your body can’t use blood sugar and starts to break down fats to use as energy. When these are broken down, your body releases ketones. Ketones are chemicals that can upset the pH balance in your body, causing it to become very acidic. In this way, high ketones levels are like poison to your body.

If you have diabetes, educating yourself on the risks and possible causes of diabetic ketoacidosis can be important for preventing and recognizing the condition. 

Types of DKA

There are two types of diabetic ketoacidosis: hyperglycemic and euglycemic. Hyperglycemic means that you have high blood sugar levels, and euglycemic means you do not.

Hyperglycemic DKA

In most instances, diabetic ketoacidosis will lead to very high blood sugar. Your body can usually only handle blood sugar levels of about 180 to 200 milligrams per deciliter (mg/dL). When your blood sugar levels are higher than this, your kidneys can’t handle the extra sugar, and your kidneys start releasing extra water and electrolytes. This leads to dehydration and many of the symptoms diabetic ketoacidosis can cause.

Euglycemic DKA

It’s possible to have diabetic ketoacidosis without extremely high blood sugar. Euglycemic diabetic ketoacidosis means you have a normal to slightly high blood sugar level, but are still experiencing other symptoms, such as high blood acid levels. 

Euglycemic acidosis will usually occur if you take medications called sodium-glucose transport protein 2 (SGLT2) inhibitors. Examples of these medicines include Invokana (canagliflozin), Farxiga (dapagliflozin), and Jardiance (empagliflozin). If you take these medicines, your prescribing doctor may recommend checking your urine ketones regularly.

Symptoms of Diabetic Ketoacidosis

Diabetic ketoacidosis symptoms can vary. Sometimes, you may have symptoms that seem like when your blood sugar is too high. These include:

• Being thirstier than usual 
• Nausea 
• Unexplained weight loss 
• Urinating more frequently
• Stomach pain 
• Weakness  

However, diabetic ketoacidosis can also cause severe symptoms. These include:

• Confusion 
• Lethargy 
• Passing out 
• Problems breathing 

Causes

When you have diabetes, your body already experiences an imbalance of insulin and glucose or blood sugar. Diabetic ketoacidosis results when you don’t have enough insulin in your body.  

Having diabetes can make you more vulnerable to diabetic ketoacidosis, especially in one of the following circumstances:

• Infection or illness, such as pneumonia, urinary tract infection (UTI), or COVID-19
• New diabetes diagnosis 
• Not following your insulin therapy plan 
• Malfunction of an insulin pump or insulin delivery device 

If you take sodium-glucose co-transporter 2 (SGLT2) inhibitors, you may also be at greater risk for euglycemic diabetic ketoacidosis. Other potential causes for euglycemic ketoacidosis include pregnancy and prolonged fasting.

Diagnosis

A healthcare provider will consider your symptoms and blood test results to determine if you could have diabetic ketoacidosis. 

Physical symptoms may include:

• Rapid heart rate 
• Dry mouth 
• Fruity odor to your breath 
• Confusion, or changes in mental status 
• Kussmaul respirations, which are rapid, deep breaths 

Laboratory results may include:

• Blood sugar levels higher than 250 mg/dL (sometimes are much higher) 
• Serum bicarbonate level less than 18 mmol/L
• Arterial blood pH less than 7.30 
• Elevated white blood cell counts
• Presence of ketones in your urine 

A healthcare provider will take these results and assessments into consideration when making a diagnosis. Prompt recognition and treatment of DKA can be vital to recovery. 

Treatment for Diabetic Ketoacidosis

If you have diabetic ketoacidosis, you will need to stay in the hospital for treatment and observation. Treatments will work toward multiple goals. Examples of these goals are:

• Lower blood sugar: Your healthcare provider will likely prescribe an intravenous insulin drip to slowly and carefully correct your high blood sugar levels. Trying to decrease your blood sugar by more than 50 to 70 mg/dL in the first hour could cause harmful side effects. A healthcare professional will likely check your blood sugar every hour at first to make sure the level is going down. 
• Reduce dehydration: You will likely receive intravenous fluids to reduce dehydration that comes with diabetic ketoacidosis. 
• Correct electrolyte imbalances: Diabetic ketoacidosis can reduce the amount of electrolytes in your body, such as potassium, sodium, and chloride. You will get some of these electrolytes in your intravenous fluids, but a healthcare provider may prescribe more electrolytes, such as potassium, if your levels are very low. 
• Treat the underlying causes: If you have an infection or other known cause that could lead to DKA, your doctor may prescribe antibiotics or other treatments that could help. 

Prevention 

Diabetic ketoacidosis can be a life-threatening condition. Preventing it can keep you well and out of the hospital. 

One of the most important ways you can prevent diabetic ketoacidosis is to regularly monitor your blood sugar and follow your diabetes treatment regimen. This includes injecting insulin if your healthcare provider prescribes it. It is important to keep your blood sugar levels as balanced as possible, working with your prescribing doctor to adjust your insulin if your exercise level or diet changes.

Comorbid Conditions

An estimated 25-40% of people may know they have diabetic ketoacidosis first before being diagnosed with type 1 diabetes while another 34% may have DKA first before receiving a type 2 diabetes diagnosis. The condition is one of the leading causes of death in those with diabetes.

Having a history of chronic kidney disease may also increase your risk for diabetic ketoacidosis. Having chronic kidney disease may make giving intravenous fluids more difficult to manage dehydration because your kidneys may not filter the fluid as well. Always tell your healthcare provider if you have chronic kidney disease.

Living With Diabetic Ketoacidosis 

The invention of insulin as a diabetes treatment has improved treatment outcomes for those with diabetic ketoacidosis. If you have diabetes or other risk factors, talk to your doctor about ways to reduce your risks and how you can recognize if you could be in diabetic ketoacidosis. Studies have shown that education and reduction of risk factors can help to reduce the incidence of diabetic ketoacidosis.