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What Is Diabetic Ketoacidosis?

Symptoms, Causes, Diagnosis, and Treatments

For those with Type 1 Diabetes, this is an insulin emergency, developing in mere hours and having life-threatening consequences. Scary? Yes. Can you prevent it? Absolutely. We’re here to empower you with clear answers to all your pressing Qs. 

In This Article: 
Definition Causes | Symptoms | Complications | Diagnosis and Treatments | Fast Facts | Frequently Asked Questions | Support 

Featured Voices:
Elena Christofides MDDavid Klonoff MD, and Guillermo Umpierrez MD

What is diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is a condition resulting from high blood sugar (a.k.a. hyperglycemia) and acid buildup, primarily affecting people with type 1 diabetes.

Despite significant improvement in diagnosis and treatment, DKA is still the number one cause of death in children, adolescents, and young adults with type 1 diabetes, according to Dr. Umpierrez. Overall, mortality is low, but its occurrence is common, and the number of diabetics with DKA has increased with the cost of insulin, which has risen 1200 percent since its initial price of $21 per vial in 1996. As of 2019, that same vial cost $275.

Though diabetic ketoacidosis is most common and serious with type 1 diabetes, it can also strike people with type 2 diabetes who are skipping or can’t afford insulin, have prolonged uncontrolled blood sugar, or are very sick with a co-occurring illness or infection, according to Dr. Umpierrez.

Diabetic Ketoacidosis Fast FactsInfographic by Lauren Hunter

What are the causes of DKA?

Let’s split the causes into two buckets—the biological ones, and those triggered by behavioral/societal forces.

First up, what’s actually happening in the body to trigger DKA? 

  1. DKA is brought on by a lack of insulin, the hormone generated by your pancreas to help your body produce glucose. That glucose is the stuff that provides energy to your muscles.
  2. Without insulin, your body begins to break down fat in attempt to get the energy it needs, a process that ultimately results in a dangerous buildup of acids, known as ketones, in your bloodstream.
  3. When this happens, your body can go into shock, and the acid buildup causes swelling in the brain. Clearly, this requires emergency care, as it can induce a coma and even become life-threatening.

So, what about those other forces we mentioned? To put it bluntly, many people can’t afford insulin.

 “When someone has economic concerns, they might chronically underdose their insulin, thinking that they’re preserving it or stretching it out, but underdosing insulin is just as bad as not taking it at all,” says Dr. Christofides. In fact, the number one risk factor for DKA is a lack of health coverage resulting in an inability to afford insulin.

Stress, trauma, sickness, or drug and alcohol abuse can also alter insulin intake, triggering DKA. If you suffer from type 1 diabetes, it’s important not to skimp on insulin via lower dosage or skipping cycles entirely, no matter what else is going on in your life. It’s even more important to maintain a consistent dosage when you’re stressed or not feeling 100%. 

“You could be perfectly well-controlled and actually doing just fine with your insulin, but get very sick from some other illness or stressor, which can push you into DKA risk territory,” says Dr. Christofides. “So even a type 1 diabetic who feels that they’re doing well, in general, can get tipped over the edge from some sort of stressor, whether it’s physical or emotional.”

What Causes Diabetic KetoacidosisDiabetic ketoacidosis is caused by a lack of insulin in the body which can lead to life-threatening results.

What are the symptoms of DKA?

Beware the “fruity breath.” This tell-tale sign of diabetic ketoacidosis is caused by the body breaking down ketones, which become acetone (yes, just like in nail-polish remover) which we then excrete through breathing. “If you see someone who’s breathing rapidly and their breath smells like fruit or a nail salon, they probably have DKA,” says Dr. Klonoff.

Heavy breathing, known as Kussmaul breathing, is a reflex to try to bring up the pH that has gotten to be too low, according to Dr. Klonoff. It’s named after Adolph Kussmaul, a German physician who first observed it in his patients with severe diabetes in 1874. “You could be breathing really hard, and not even realize necessarily that you’re doing it,” Klonoff says.

Diabetic ketoacidosis affects the brain, making it work through what feels like mental “sludge,” according to Dr. Christofides. Confusion and irritability are major signs to watch out for.

As a result of your brain swelling, DKA can make you feel as if you’re drunk and act just as irrationally. “I’ve seen situations where people have gotten into fights, or have become a risk to themselves physically, or had an intervention by law enforcement while driving because they appear to be acting drunk or are incoherent when stopped,” says Dr. Christofides.

People in the middle of a DKA episode can seem emotionally unstable, or lash out, because it physically alters the way your brain functions,” says Dr. Christofides. “If you know someone who has diabetes, and they’re acting weird, you want to be concerned that their sugars might be quite high. You want to not react to what they’re saying, but rather think about what might be happening to them internally that’s causing the abnormal behavior.” Diabetics who are breathing heavily and seem to be acting drunk or incoherent could be totally sober and instead suffering from DKA.

The main warning signs of DKA are:

  • Heavy breathing
  • Fruity-smelling breath
  • Confusion and irritability

Other symptoms to look out for:

  • Excessive thirst
  • Nausea and vomiting
  • Abdominal pain
  • Persistent need to urinate
  • Blurred vision
  • High blood-sugar levels

If symptoms aren’t clear or severe enough to be certain, home testing kits for urine can show for sure whether you have high ketone levels in your body. Blood sticks can also check your glucose levels.

The three Ps of DKA:

  • Polydipsia—thirst
  • Polyuria—urination
  • Polyphagia—appetite

These common symptoms are known as the “three Ps” of diabetic ketoacidosis. When you have a sudden bout of excessive thirst, urination, and appetite, you could be suffering from DKA.

How is DKA diagnosed and treated?

If you’re suffering from acute DKA, you’ll be admitted to the ICU for frequent glucose and vital-sign monitoring, and to begin the process of restoring electrolytes via fluid IV. You’ll also have constant insulin infusions until the levels of ketones are reduced and your blood-sugar levels return to normal. Once this treatment is underway, recovery is rapid. A typical hospital stay for DKA is only a few days.

Are there any possible complications from DKA?

As DKA is life-threatening, it’s important to seek emergency care as soon as you suspect you’re suffering from the condition. Fluid loss from DKA can lead to kidney and organ damage, brain swelling that can eventually cause a coma, and fluid buildup in your lungs. The sooner you’re treated for DKA, the less likely you are to suffer from these major complications.

What can I do to lessen my chances of suffering from DKA?

The number one protection against DKA is to maintain your proper insulin intake.

  • If you’re dealing with illness or trauma that could cause levels of insulin to drop, make sure you drink lots of water or other fluids.
  • If you can’t afford your prescribed level of insulin, talk to your healthcare provider to see about assistance programs or samples they can give you to keep your dose at the right level.
  • If you’re worried about being unable to afford your treatment plan long-term, let your doctor know so they can offer you an alternative cheaper insulin plan (see https://www.healthcentral.com/slideshow/affording-insulin-options-and-advice).

Where can I find support?

Since DKA is a common and life-threatening condition, it’s important to seek out diabetes support in your community. Here are a few nonprofits and groups to check out:

Founded in 2008 by Anna Norton, who was diagnosed with type 1 diabetes as a teenager, the organization is a social support network for women suffering from the disease.

This telemedicine initiative matches you one-on-one with a peer to connect you with someone who can really relate to the same issues and obstacles that you’re going through in your own journey with diabetes.

An entire database of education and support groups through the ADA’s Diabetes Self-Management Education and Support (DSMES) network to help you find the right one for you.

FAQs: Frequently Asked Questions

Can DKA recur?

Yes, DKA will happen whenever insulin levels are too low and not enough glucose is being produced to provide energy to your muscles and other tissues. If you miss a dose, underdose, or suffer from trauma or illness that depletes your insulin, DKA can recur.

Can DKA cause a heart attack or stroke?

Complications of DKA can include a heart attack or stroke because of the buildup of ketones in your body, so take it seriously and get emergency treatment as soon as you recognize the signs.

What causes a coma in DKA?

When blood-sugar levels become too low, triggering hypoglycemia, severe dehydration can then cause a diabetic coma.

How long does it take to recover from diabetic ketoacidosis?

Finally, some good news! Once you’re safely admitted to the hospital for DKA, recovery is usually complete in one to three days.

Diabetic Ketoacidosis (DKA) Fast Facts

  • The number 1 risk factor for DKA is lack of health coverage
  • 200,000 cases in the US every year
  • DKA can develop in only a few hours
  • DKA is more common in women, young adults, and children
  • In 20 percent of cases, DKA is the first sign of type 1 diabetes
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