What is diabetic ketoacidosis (DKA)?

Diabetic ketoacidosis (DKA) is a severe life-threatening condition that means you have too many ketones in your body. Ketones are caused by the breakdown of fat when there isn’t enough insulin to meet your body’s needs. When they build up, the result is acidosis (too much acid in the blood). If not treated, this can lead to death. Usually blood glucose levels are elevated (>250 mg/dL or >13.9 mmol/L) but not always. It is the presence of too many ketones in the blood and urine that defines DKA.

DKA can be caused by insulin lack as well as not giving enough insulin when sick or stressed. This can happen even with normal blood glucose levels.

People with diabetes must NEVER run out of insulin. A pharmacy can give you regular insulin (a vial and syringe) without a prescription if you can prove you have diabetes—bring in an empty vial of insulin or a pen or your meter. You can also go to any urgent-care center or emergency room and tell them you have diabetes and need insulin.

You can give a dose of regular insulin every 6 hours and keep enough insulin in your body.

Causes

Illness is a common precipitating factor in DKA because the body’s response to sickness is to release hormones that can act to counter insulin, raising blood glucose. Also, because a person may not be able to eat, insulin doses at mealtime may not be taken, leading to insulin deficiency. A third factor is dehydration, which can come along with vomiting and inadequate fluid consumption.

Insulin deficiency, and DKA, can also onset rapidly in the event of an insulin pump malfunction. A common cause of DKA in pump users is not using backup insulin (in pens or syringes) when blood glucose is high or ketones are detected in the urine.

Another unfortunate cause of DKA is insulin omission. Some people don’t take insulin because they can’t afford it, they don’t know how to take the medication properly, or they have a fear of insulin. Other people purposefully skip insulin doses for weight management purposes, particularly adolescent girls. DKA is associated with a variety of psychosocial factors, including an unstable or dysfunctional family, language barriers, psychiatric or eating disorders, and financial insecurity. DKA is seen in people who have the highest A1C levels, especially in teenagers and transitioning adults, indicating that an overall lack of adherence with diabetes management can lead to serious acute issues.

Children

Approximately one-third of children with new-onset type 1 diabetes are in DKA when they are diagnosed. Parents often feel guilty that they didn’t realize that something was wrong sooner and worry that they did something to have caused the diabetes. Both of these feelings are natural but are simply not true. Even some healthcare providers have a hard time recognizing symptoms of diabetes in a child and don’t test for diabetes.

Adults

Often DKA in adults occurs either because of an illness that isn’t treated properly with increased insulin doses and carbohydrates or because of a lack of access to medical care, which means patients can’t get their insulin prescriptions refilled and run out of insulin. Sometimes young adults and sometimes older adults simply rebel and stop giving enough insulin.

Sick-Day Rules

Feeling under the weather? Follow these sick-day rules to help prevent dangerous blood glucose highs and diabetic ketoacidosis:

  1. Check blood glucose every 2–3 hours.
  2. Continue taking basal and bolus insulin. If you don’t feel like eating, try to drink your carbs so that you can prevent starvation ketones and continue to take mealtime insulin. If you can’t eat, skip the meal bolus and take the correction bolus if glucose is >200 mg/dL or >11.1 mmol/L.
  3. Check blood or urine ketones frequently with a test strip. Have a plan in place with your provider or call your provider for what to do about any positive results.
  4. Stay hydrated by drinking a cup of fluid every hour, keeping in mind that vomiting and diarrhea increase the risk of dehydration.