What is diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is a serious health problem that can occur if you have diabetes. It happens when chemicals called ketones build up in the blood.

Normally, the cells of your body use sugar (glucose) as a source of energy. Glucose moves through the body in the blood. Insulin is a hormone that helps your cells take in the glucose from the blood. If you have diabetes, your cells can’t take in and use this glucose in a normal way. This may be because your body doesn’t make enough insulin. Or it may be because your cells don’t respond to it normally. This is called insulin resistance.

As a result, glucose builds up in your blood and doesn’t reach your cells. Without glucose to use, your body's cells burn fat instead of glucose for energy. When cells burn fat, they make ketones. High levels of ketones can poison the body. High levels of glucose can also build up in your blood and cause other symptoms. DKA also changes the amount of other substances in your blood. These include electrolytes such as sodium, potassium, chloride and bicarbonate. This can lead to other problems.

DKA happens most often in people who have type 1 diabetes. This is a condition where the body doesn't make enough insulin. In rare cases, DKA can happen in people with type 2 diabetes. It can happen when they are under stress, such as when they are sick, or when they have taken certain medicines that change how their bodies handle glucose.

What causes diabetic ketoacidosis?

High levels of ketones and glucose in your blood can cause DKA. This might happen if you:

• Don’t know you have diabetes, and your body is breaking down too much fat.

• Know you have diabetes, but you aren’t managing it well. This includes not taking your medicines as you should.

• Have a sudden health problem, such as a heart attack, a stroke, pancreatitis, pneumonia, or a urinary tract infection.

• Have a physical injury, such as from a car accident.

• Are pregnant and have diabetes. Being pregnant changes how your body processes sugars and other nutrients. Anyone who is pregnant and has diabetes has a higher risk of DKA.

• Take certain medicines, such as prednisone, dexamethasone, or other glucocorticoid medicines. Or if you take a certain class of diabetes medicines called SGLT-2 inhibitors.

• Have an insulin pump that isn't working properly, or you are using expired insulin.

• Take illegal drugs, such as cocaine.

DKA happens mainly from not having enough insulin. It can also happen if your cells don’t respond to insulin normally.

What are the symptoms of diabetic ketoacidosis?

Symptoms often show up quickly over a 24-hour period. They may vary depending on the severity of your DKA and how long you've had it. Symptoms can include:

• Feeling very thirsty and drinking a lot.

• Urinating much more than normal.

• Belly pain.

• Nausea or vomiting.

• Fruity-smelling breath, which comes from the ketones in your blood.

• Trouble breathing.

• Trouble thinking clearly.

• Extreme tiredness (fatigue) and lethargy that can lead to coma.

• Fast heartbeat (especially when standing) and other signs of fluid loss (dehydration).

How is diabetic ketoacidosis diagnosed?

Your health care provider will ask about your health history and your symptoms. You will also have an exam.

You will have blood tests to look for ketones and check your glucose levels. Your urine may also be tested for these things. Also, you may have blood tests to check:

• The number of particles dissolved in your blood (plasma osmolarity).

• The concentration of certain electrolytes in your blood, like sodium and potassium, chloride and bicarbonate. This is called a basic metabolic panel.

• Your kidney function.

You also might need an electrocardiogram (EKG) to check your heart rhythm. This is because changed electrolyte levels in the blood can cause problems with your heart.

How is diabetic ketoacidosis treated?

DKA needs to be treated right away in the hospital. Your health care provider will need to replace the large amount of fluids and electrolytes that you have lost. This is given through an IV (intravenous) line inserted in your arm or hand.

You will also be given insulin. This will let your cells start using more glucose and help lower the levels of both ketones and sugar in your blood. You will likely also be given electrolytes, as these are often low too.

If you have an illness that caused your DKA, your provider will treat that too. For example, you may be given antibiotics for an infection.

You will need to have more blood tests during your treatment. This is so your provider can watch your condition and change your treatment as needed.

What are possible complications of diabetic ketoacidosis?

DKA can cause other problems, such as:

• Low levels of potassium (hypokalemia).

• Swelling inside the brain (cerebral edema).

• Fluid inside your lungs (pulmonary edema).

• Damage to your kidney or other organs from your fluid loss.

• The breakdown of damaged muscle and leakage of muscle cell contents into the blood. This can cause organ damage (rhabdomyolysis).

• Hypoglycemia, or low blood sugar. This is the most common problem caused by DKA during treatment.

Very low potassium levels can cause severe problems. These include muscle weakness and heart rhythm problems. This may cause death. Cerebral and pulmonary edema can also lead to death. Your health care team will work to prevent these severe problems. They will watch you closely and carefully adjust your treatment.

Can I prevent diabetic ketoacidosis?

You can greatly lower your chances of getting DKA by managing your diabetes well. This includes taking all your medicines, including your insulin, as you are instructed. Measure your blood sugar often to make sure it is not too high or too low. If you are sick, you may need to talk with your health care provider about changing your insulin dose for a short time. You might need more insulin than normal when you are sick. Call your provider if your blood sugar is high, or if you have symptoms. This may help prevent more severe DKA.

When should I call my health care provider?

See your health care provider right away if you have symptoms of DKA, such as:

• Feeling very thirsty and drinking a lot.

• Urinating much more than normal.

• Belly pain.

• Nausea or vomiting.

• Fruity smelling breath, which comes from the ketones in your blood.

• Trouble thinking clearly.

• Extreme tiredness (fatigue) and lethargy. This can lead to a coma.

• Fast heartbeat (especially when standing) and other signs of fluid loss (dehydration).

Call your provider right away if your blood sugar readings are higher than expected. When you call, have a list of your recent blood sugar numbers. Also have a list of your insulin history. This includes doses and times you’ve used it. And have a list of all the medicines you take. Your provider may tell you over the phone how to adjust your medicines. Or you may need to go to their office or the emergency room.

Key points about diabetic ketoacidosis

• Diabetic ketoacidosis (DKA) is a dangerous condition that can happen to people with diabetes. It needs treatment right away.

• Ketones and glucose can rise to very high levels in your blood. This can cause a lot of fluid loss and other serious problems.

• DKA happens most often in people with type 1 diabetes. It can also happen to people with type 2 diabetes who have an illness or other health condition.

• Your health care provider can diagnose you with a health history, exam, and blood and urine tests of your sugar and ketone levels.

• Ketoacidosis is treated by replacing fluids and electrolytes and giving insulin.

Next steps

Tips to help you get the most from a visit to your health care provider:

• Know the reason for your visit and what you want to happen.

• Before your visit, write down questions you want answered.

• Bring someone with you to help you ask questions and remember what your provider tells you.

• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are and when they should be reported.

• Ask if your condition can be treated in other ways.

• Know why a test or procedure is advised and what the results could mean.

• Know what to expect if you do not take the medicine or have the test or procedure.

• If you have a follow-up appointment, write down the date, time, and purpose of that visit.

• Know how you can contact your provider if you have questions.