What Is Diabetic Ketoacidosis? Causes, Symptoms, and Treatment

Diabetic ketoacidosis (DKA) is a life-threatening condition that can develop in people with type 1 diabetes mellitus. It can also develop in people with type 2 diabetes mellitus, that is ketosis-prone. (Find out What Is The Difference Between Type 1 And Type 2 Diabetes?)

DKA occurs when the body doesn’t make as much insulin as it needs. Insulin is a hormone produced by the pancreas. It plays a vital role in regulating blood sugar levels in the body by moving glucose (blood sugar) out of the bloodstream and causing it to enter cells. Sugar (glucose) is the body’s main source of energy.

In people with diabetic ketoacidosis, there isn’t enough insulin leading to too little glucose in the cells. As a result, the body begins breaking down fat to fuel the body’s energy needs. This process causes a buildup of substances called ketones in the bloodstream. Too many ketones make the blood acidic and lead to dehydration. Without treatment, the ketones build up can cause you to develop DKA.

Overview of Risk Factors and Severity

Risk factors for developing DKA include: 

• Type 1 diabetes mellitus.

• Missing your insulin dose frequently if you are receiving insulin.

• Less commonly, DKA affects people with type 2 diabetes (a complication called hyperosmolar hyperglycemic state (HHS) is more common in people with type 2 diabetes mellitus).

• Family history of diabetes or autoimmune diseases (this can put you at risk of type 1 diabetes and new-onset (undiagnosed) diabetes type 1 can lead to diabetic ketoacidosis).

Note: Some people are diagnosed with diabetes for the first time after they become very ill with diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) can make you very unwell very quickly. Without treatment, it can lead to loss of consciousness and even death. If you have diabetes and are at risk of developing diabetic ketoacidosis, it’s important to recognize the signs and symptoms of this condition and get treated quickly. 

However, treatment for diabetic ketoacidosis can also lead to complications, such as:

• Hypoglycemia (low blood sugar) due to insulin therapy. 

• Hypokalemia (low potassium) due to insulin and fluids. Low potassium levels can affect heart, muscle, and nerve function. 

• Cerebral edema (swelling in the brain) due to a rapid adjustment in blood sugar levels. Children with newly diagnosed diabetes are at an especially high risk of this complication. 

Causes of Diabetic Ketoacidosis

Insulin Deficiency

Diabetic ketoacidosis develops due to a lack of enough insulin in the body that is needed to move glucose into cells. People who miss insulin doses can, therefore, develop diabetic ketoacidosis. DKA can also occur from too little insulin from an insulin pump malfunction, such as a kink in the cannula or an empty reservoir. Additionally, using expired insulin or insulin that was not stored properly can result in DKA because the insulin was ineffective.

Illness or Infection

Illnesses and infections such as pneumonia, skin infections, and urinary tract infections put the body under stress. This can lead to elevated levels of certain hormones like cortisol and adrenaline in the body. These hormones counteract the effects of insulin and can lead to diabetic ketoacidosis (DKA), as well as a decompensation in the individual's metabolic balance, raising the risk for this disease.

Other Causes

People with diabetes can also develop diabetic ketoacidosis symptoms in the setting of:

• Heart attack or stroke

• Surgery

• Pancreatitis

• Physical or emotional trauma

• Pregnancy

• Certain medicines, such as corticosteroids, antipsychotic drugs, and diuretics (water pills)

• Substance use (alcohol or drugs, especially cocaine)

Symptoms of Diabetic Ketoacidosis

Common Diabetic Ketoacidosis Symptoms

• Excessive thirst 

• Excessive hunger

• Frequent urination

• Dry mouth

• Headache

• Flushed skin

• Stomach pain

• Nausea and Vomiting

• Weakness or tiredness

More severe symptoms and warning signs include:

• Shortness of breath

• Rapid, deep breathing (Kussumaul breathing)

• Fruity-smelling breath

• Reduced alertness

• Disorientation or confusion

• Loss of consciousness

Signs of Diabetic Ketoacidosis on Home Testing

Diabetic ketoacidosis can be detected by home blood tests and urine test kits, which may show the following: 

• Very high blood sugar above 250 mg/dL

• Ketones in urine (especially if the test for ketones shows above 1.6 mmol/L)

Diagnosis of Diabetic Ketoacidosis

Medical Tests

Doctors diagnose DKA if blood tests and urine tests show the following:

• Very high blood sugar level above 250 mg/dL. DKA is less common if blood glucose is below 250 mg/dL, but can occur (this is called euglycemic diabetes-related ketoacidosis or euDKA).

• Blood pH less than 7.3 (acidosis).

• Bicarbonate less than 18 mEq/L on a blood test.

• Ketones detected on a urine ketone test or blood ketone test.

Your healthcare provider may also order other tests, such as electrolytes, basic metabolic panel, urinalysis, chest X-ray, and electrocardiogram for careful monitoring of your health if you have this serious condition.

Similar Conditions

Some of the medical conditions that can cause signs and symptoms similar to diabetic ketoacidosis include:

• Acute pancreatitis

• Appendicitis

• Alcoholic ketoacidosis

• Lactic acidosis

• Metabolic acidosis

• Hypothermia

• Hypophosphatemia

• Urinary tract infections and bladder infections in females

• Salicylate toxicity

• Septic shock

Treatment Options

Immediate Medical Interventions to Treat Diabetic Ketoacidosis

Diabetic ketoacidosis occurs due to a lack of enough insulin. This leads to dehydration and low electrolyte levels in the body. Therefore, diabetic ketoacidosis is treated with insulin, fluids, and electrolytes in the emergency room or hospital.

• Fluids are given by mouth or intravenously (IV fluids) to replace those lost through frequent urination. 

• Electrolytes (minerals) such as sodium, potassium, and chloride are given to keep the heart, muscle, and nerve cells functioning normally. 

• Insulin is given, usually through a vein, to reverse diabetic ketoacidosis. You can return to regular insulin treatment once your blood sugar level is 200 mg/dL or lower and your blood is not acidic anymore. 

Long-Term Management

People with established diabetes should take a long-acting insulin such as insulin glargine at the dose they were on before they developed diabetic ketoacidosis. People who are on NPH insulin should only take the usual dose after they are able to start eating and keeping food down without vomiting. 

People with newly diagnosed type 1 diabetes require a careful estimation of the dose of long-acting insulin. Healthcare professionals usually start with smaller doses to avoid hypoglycemia (low blood sugar).

Tips for Preventing Diabetic Ketoacidosis

Here are some ways to lower your risk or prevent DKA:

• Take your diabetes medications as prescribed; it is vital to use the correct insulin dose to adequately treat high blood sugar.

• Talk to your healthcare provider and diabetes care team about adjusting the dose of your diabetes medications or taking more insulin if your blood sugar is not in the target range. 

• Check your blood sugar levels exactly as instructed by your doctor, at least 3-4 times daily and more frequently if you are ill or under stress. 

• Manage your diabetes with lifestyle changes such as healthy eating and daily physical activity.

• Check your ketone levels with a home urine test kit, especially if you are ill or stressed. Call your doctor if your blood glucose levels or ketones are high. 

• Learn to recognize the signs and symptoms of diabetes complications like hypoglycemia (low blood sugar) and diabetic ketoacidosis.

• Act quickly and go to the nearest emergency room if you develop early symptoms of DKA (very high blood sugar and positive test for ketones in your urine). DKA is a serious complication that can be fatal.

FAQ on Diabetic Ketoacidosis

What does ketone level 3 mean?

A ketone level 3 is a warning sign of diabetic ketoacidosis and a medical emergency. Ketone levels between 1.6 and 2.9 mmol/L (millimole per liter) are considered high - you may be at a higher risk of diabetic ketoacidosis and should be evaluated by a healthcare provider. If ketones in urine are between 0.6 and 1.5 mmol/L, it is considered borderline high, and you may need to do more than one test (check the test for ketones again in 2 hours).

What are the numbers for diabetic ketoacidosis?

The numbers for diabetic ketoacidosis on home test kits are blood sugar above 250 mg/dL and urine ketones detected or above 1.6 mmol/L. Seek emergency medical care if you have these numbers on home testing.

What does it mean when you have diabetic ketoacidosis?

When you have diabetic ketoacidosis, it means there isn’t enough insulin in your body. This has led your body to break down fats to produce energy. Ketones are a byproduct of this process and have made your blood more acidic. Hence the name diabetic ketoacidosis.

What are the 3 P's of ketoacidosis?

The 3 Ps of ketoacidosis are polyuria, polydipsia, and polyphagia (excessive urination, thirst, and hunger, respectively). These are warning signs of diabetic ketoacidosis.