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How to Prevent Diabetic Ketoacidosis

Symptoms can develop within 24 hours, and they are often the first indicators of diabetes

With Caroline Apovian MD

Hyperglycemia, metabolic acidosis, and ketosis are known as the classic triad to cause DKA.

Diabetic ketoacidosis (DKA) is a serious complication of diabetes, characterized by the severe depletion of insulin and the toxic buildup of blood acids called ketones. In the United States, lack of proper insulin management among the under-insured is the principle cause for the development of DKA.

Our body’s primary energy source is glucose (sugars) that we break down from the food we eat. Insulin allows our cells to absorb and utilize these sugars. DKA occurs when the body cannot produce sufficient insulin to absorb glucose and must rely on a secondary energy source. When this happens, hormones are released to break down fats for fuel. As the fat is broken down, acids called ketones are released. In high amounts, these acids are toxic and can cause severe illness. And while treatments for DKA are effective, in some cases the condition can be fatal.

Carolyn Apovian MD, professor at the Boston University School of Medicine, refers to hyperglycemia, metabolic acidosis, and ketosis as the classic triad for DKA.

DKA is primarily a complication of type 1 diabetes, but can sometimes occur in patients with type 2 diabetes.

Who is at risk for diabetic ketoacidosis?

DKA primarily affects people with type 1 diabetes. Frequently missed insulin doses and insulin pump issues are the largest precipitating factors. DKA can also be triggered when illnesses cause your body to produce higher levels of hormones such as adrenaline and cortisol. The most common infections that trigger DKA are pneumonia and urinary tract infections. DKA can also be triggered by:

  • Myocardial infarction
  • Pancreatitis
  • Alcohol abuse
  • Pulmonary embolism
  • Trauma
  • Eating disorders

DKA can also affect people with type 2 diabetes (although rarely), most commonly in children and adults who are newly diagnosed. Obesity and a family history of type 2 diabetes could also increase your chances of developing DKA.

Dr. Apovian notes that when DKA does occur in type 2 diabetes, it is a result of, “impaired insulin secretion or action mimicking type 1 DM with low insulin levels.”

Very rarely, DKA can occur in people without diabetes. In this case, insulin levels fall enough to induce diabetic ketoacidosis, even though blood glucose levels are not elevated.

What are the symptoms of diabetic ketoacidosis?

Diabetic ketoacidosis symptoms can develop quickly (within 24 hours) and for some, they are the first indicators of diabetes.

Common symptoms include:

  • Excessive thirst
  • Frequent urination
  • Nausea and vomiting
  • Abdominal pain
  • Weakness or fatigue
  • Shortness of breath
  • Fruity-scented breath
  • Confusion

Dr. Apovian notes that abdominal pain is often the most common symptom in children with DKA.

Specific signs of DKA include:

  • Hyperglycemia (high blood sugar)
  • High ketone levels in the urine

You can test your blood sugar levels at home using a glucometer. If your sugar levels are higher than your target range, you can test your ketones with an at-home paper test kit. If your ketones are “moderate” or “large” call your doctor.

Seek immediate care if:

  • Your blood sugar level is consistently higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L).
  • You have multiple symptoms of ketoacidosis.


DKA is treated in the hospital. Given proper care, most patients will recover rapidly. Treatments include:

  • Fluids
  • Electrolytes (sodium, potassium, chloride, insulin)
  • Insulin

If an infection has triggered the episode of diabetic ketoacidosis, you will be simultaneously treated for the infection.


Most complications come from the methods used to treat DKA, and may include:

  • hypoglycemia (low blood sugar)
  • hypokalemia (low potassium).
  • swelling in the brain (cerebral edema). 

Insulin will allow your cells to absorb glucose, causing blood sugar levels to drop. If these levels drop too quickly, you can become hypoglycemic.

The combined fluids and insulin can cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles, and nerves. Cerebral edema seems to be more common in children, especially those with newly diagnosed diabetes.

During treatment, you will likely begin potassium supplements to prevent hypokalemia.


The most important thing you can do to prevent DKA is to keep your diabetes well-managed. If you have been diagnosed with type one diabetes, make sure to take monitor your sugar levels, and take your insulin.

Dr. Apovian notes that “omission of insulin is a highly common occurrence in children with DKA.”

Type 1 diabetes is an autoimmune disorder; blood sugar levels cannot be controlled by diet and exercise alone, and it is crucial to be compliant with insulin treatment.

Because the release of certain stress-related hormones, such as adrenaline and cortisol can trigger DKA, extreme stress and trauma are risk factors. Finding ways to cope with stress before it becomes chronic is an important part of prevention.

If you are under increased stress, remember to closely monitor your sugar levels.

To better manage your diabetes:

  • Regular exercise is important in managing stress, as well as in helping to control blood-sugar levels.
  • Keep a balanced diet with regularly scheduled meals to keep from spikes in blood sugar levels.
  • Stay hydrated

DKA is rare in type 2 diabetes, but studies suggest that obesity may increase your risk. Excess weight can contribute to inflammation and an imbalance of hormones. Eating a healthful diet, rich in nutrient dense foods, getting sleep, adequate in quality and quantity, and adding more movement to your day, are all important steps to maintain a healthy weight.

Diabetes ketoacidosis can be quite serious. Knowing your risk, and how to identify symptoms is important for your health.

  • If you know you have type 1 diabetes, make sure you adhere to your insulin treatments and know the signs and symptoms of DKA.
  • During times of increased stress, or during an infection, it is important to monitor your blood-sugar levels more closely, as these can trigger an episode of DKA.
  • For many, an episode of DKA is the first sign of type 1 diabetes, if you begin experiencing symptoms of DKA, such as extreme vomiting, abdominal pains, and a fruity scent to your breath, call a doctor immediately.

Diabetic ketoacidosis can happen rapidly and can be treated successfully. Understanding your risk and knowing the warning signs can be the difference between life and death. Keep your blood sugar levels monitored and focus on living a healthful and balance life.

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