Ketoacidosis: A Diabetes Complication

ketone blood test vialLab tests are required when looking for definitive symptoms of ketoacidosis. (Photo:123rf)

Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes. This hyperglycemic emergency continues to be an important cause of mortality among individuals with diabetes despite the ongoing advances in diabetes management.

The annual incidence rate of DKA estimated from population-based studies ranges from 50-100 events per 1,000 patients with diabetes, making this an unmet need for further diabetes self-management education and ongoing support to reduce the incidence.1 According to the Diabetes Surveillance System of the Centers for Disease Control and Prevention (CDC), overall, age-adjusted DKA hospitalization rates decreased slightly from 2000 to 2009, then reversed direction, steadily increasing from 2009 to 2014 at an average annual rate of 6.3%.

The cause for the increase is not entirely clear, but some possible reasons include changes in how it is defined, new medications that increase the risk for DKA (especially euglycemic DKA – the presence of DKA with glucose levels under 250 mg/dL) and higher admission rates for less serious issues.2 

One item to note is that a slight increase could be due to the introduction of sodium-glucose cotransporter 2 (SGLT2) inhibitors, a class of prescribed medicines used to treat type 2 diabetes, approved in 2013. In 2015, the FDA added a warning to the label that these medications might increase the risk of DKA.

Since individuals with type 1 diabetes were also using this medication “off-label” (had not yet been proven safe and effective by the FDA) and several companies are working on obtaining FDA approval, DKA incidence will continue to be a major risk with or without elevated blood glucose levels. Ketoacidosis can affect anyone with diabetes, however it is quite rare in type 2 diabetes.  It is one of the acute complications of diabetes, often caused by prolonged hyperglycemia in the absence of adequate insulin and/or illness—and one that can be minimized.

Why and How Does Ketoacidosis Occur?

When we talk about basic physiology in the context of how our bodies work, our brain, muscles and nerves all use sugar for fuel.  Insulin is essentially ushers the sugar from our bloodstream to the places that need it.  If there is no insulin or not enough insulin, sugar cannot pass into the brain, muscles or nerves.  Without that fuel, the body starts to break down fat, which produces ketones, chemicals that the body creates when fat is broken down.  As more ketones enter the bloodstream, they make it more acidic, and higher levels lead to acidosis.  

DKA usually develops slowly, but if someone is without any insulin for longer than five hours (if someone is wearing an insulin pump and it is not working or someone with type 1 diabetes stops taking long acting insulin for a few days), ketoacidosis can occur.

Ketoacidosis Symptoms

The first symptoms appear within the first few hours:

  • Thirst or a very dry mouth
  • Frequent urination
  • High blood sugar levels
  • High levels of ketones in the urine

Other symptoms can occur later, including:

  • Ongoing fatigue
  • Dry or flushed skin
  • Nausea, vomiting, or stomach pain (vomiting can be caused by many things (the flu, medications), not just ketoacidosis. But, if it continues for longer than two 2 hours, it is important to contact your healthcare provider)
  • Difficulty breathing (short, deep breaths or cannot catch your breath, even at rest)
  • Fruity breath (presence of ketones)
  • Being confused or having a hard time paying attention

The easiest way to find out if ketones are present is to your urine ketone test strips.  They can be prescribed, but they can also be purchased over-the-counter.  Speak with your healthcare provider regarding when and how to test.  But, generally, it is recommended to test ketones if blood sugar levels have been >240-250 mg/dL for more than one blood sugar test.  If someone is sick, it is recommended to test ketones every 4-6 hours, regardless of blood sugar result.  When someone is sick, ketones can be present with high or low to in-range blood sugar levels.

Ketoacidosis Treatment

if high ketones and vomiting will not go away, it may be necessary to go to the nearest emergency room of your local hospital.  What they will have to do is give you fluids to correct the dehydration, insulin to correct high blood sugars and ketones, possible IV glucose if the blood sugars are too low since glucose is still needed for fuel and insulin is required to bring the sugar into the cells correctly.

Ketoacidosis Prevention

For the most part, DKA can be prevented, but sometimes, being sick just puts you over the edge and there is nothing you can do to reverse it.  But, there are some simple ways to reduce the risk.

If you have not already done so, it is important to see a diabetes educator at least annually for updates on overall diabetes care.  Sick day management is a required part of the information provided to people with diabetes and it is important to have a plan that is specific to you.

Topics should include:

  • When to contact your healthcare provider
  • How to adjust medications during illness to help reduce high blood sugars
  • What should be used to reduce fever and possible infections
  • Types of food to eat during an illness including easily digestible foods containing carbohydrates and salt, like crackers, soups, and pretzels. They will help encourage you to drink fluids as well, to reduce risk of dehydration.
  • Have urine ketone strips in the house. Make sure they are not expired – once you open the bottle, the test strips will only work correctly for
  • Report your illness to the healthcare provider when it causes your blood glucose levels to rise and causes urine ketones.
  • Test blood glucose levels and ketones frequently, about every 2 to 4 hours, until they are normal again.  Based on ketone levels, extra insulin may be required.
  • Get advice from your health care team if your blood glucose levels are above 250 mg/dL for more than 6 hours, if you are unable to take fluids or food for more than 4 hours, if you have a fever (101.5° F), if you are ill for more that 24 hours, or if you have these symptoms we spoke of such as dehydration, severe abdominal pain, or other unexplained symptoms.

    NEVER discontinue taking insulin and to seek professional advice early in an illness.  Continue to take your insulin even if you can't eat solid foods. Your insulin needs will probably increase with illness. If you take pills for diabetes, continue to take them too. If you cannot keep the pills down or if your blood sugars are <70 mg/dL, call your healthcare provider.
  • Continue to try to eat and drink even if your blood glucose levels are high, if you are vomiting or if you have diarrhea. Take some carbohydrate every 3 to 4 hours to prevent low blood glucose. If you can't eat, try carbohydrate containing liquids or soft foods. These include 1/2 cup regular soft drinks, 1 double Popsicle, 1/2 cup regular Jell-O, 1 cup Gatorade, 1 cup soup, 1/2 cup fruit juice, 1 slice toast or 6 soda crackers.
  • To prevent dehydration, drink at least 8 ounces of fluid every hour. If you are vomiting, limit fluid to 1-2 tablespoons every 20 minutes, or suck on a Popsicle. Fluids with electrolytes like potassium and sodium can help prevent dehydration.
  • Limit your activity if your blood glucose levels are above 250 mg/dL and ketones are moderate to large or if blood sugars are >300 mg/dL without ketones.

While the above recommendations are general rules, be sure you work with your healthcare provider and a diabetes educator to create a plan that is right for you.

Updated on: July 25, 2019
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