What Is Diabetic Ketoacidosis?

February 22, 2023

Diabetic ketoacidosis (DKA) is an acute hyperglycemic emergency that occurs as a complication of diabetes.¹ It is characterized by a triad of hyperglycemia, metabolic acidosis and ketosis, and dehydration.

CAUSES OF DKA

DKA results from an absolute or relative lack of insulin and a concomitant increase in counterregulatory hormones in both type 1 and type 2 diabetes.^1,2 When the body lacks insulin to utilize glucose as fuel, it begins to break down fat reserves for energy in a process called ketosis.^3,4 Ketones are produced as a byproduct of this process and build up in the blood, causing ketoacidosis. Ketoacidosis causes acidemia (ie, acids in blood) and can lead to serious consequences such as cerebral edema, coma, and even death.⁵

Various factors can precipitate DKA, including 1) lack of insulin 2) use of certain prescription or illicit drugs, and 3) physiological stressors such as infection that increase the need for insulin.¹

Type 1 Diabetes: Two thirds of adult DKA cases occur in those with type 1 diabetes mellitus (T1DM). DKA can be caused by not taking or missing doses of insulin or from insulin pump failure. DKA in children occurs most commonly at the initial diagnosis of T1DM. Pregnant women with pregestational T1DM are also at a greater risk of developing DKA at lower blood glucose levels.⁶

Type 2 Diabetes: DKA can also occur in individuals with poorly controlled type 2 diabetes mellitus (T2DM), with untreated hyperglycemia potentially developing into DKA.^3,4 It can also occur in unrecognized new-onset T2DM or under physiologically stressful conditions (eg, infection or surgical illnesses).

Gestational Diabetes: Pregnancy is associated with physiological changes (eg, relative insulin resistance, hormonal changes, respiratory alkalosis) that can predispose women to DKA.⁷ DKA in pregnancy is most likely to be precipitated by infections, starvation, insulin non-compliance, and hyperemesis gravidarum (a severe form of nausea and vomiting).^6,8 DKA is particularly dangerous during pregnancy as it is associated with high rates of perinatal morbidity and mortality.

SIGNS AND SYMPTOMS OF DKA

Signs and symptoms of DKA vary based on severity, but excessive thirst and urination are common signs.^2,9 If not urgently treated, DKA can lead to coma and even death.

Early Symptoms of DKA:

Excessive thirst
Excessive urination
Weight loss
Fatigue
Nausea and vomiting
Abdominal pain
Dehydration

Late Symptoms of DKA:

Labored breathing
Fruity-smelling breath
Extreme lethargy
Coma

PREVENTION AND TREATMENT OF DKA

It is critical for individuals to be informed of ways to prevent and promptly manage DKA as DKA is one of the leading causes of death in T1DM.¹ It accounts for more than half of all deaths in diabetic children and is associated with significant morbidity as well as with cerebral injury and neurological morbidity especially in children.

Regular monitoring of blood glucose levels and adherence to medication plans are important in DKA prevention.² Especially during times of illnesses, monitor blood glucose levels more frequently and check urine ketone levels every four to six hours if glucose levels measure >240 mg/dL.¹⁰ A blood ketone meter can be highly effective and allow earlier detection of DKA.² Individuals who use insulin pumps are also advised to have a prescription for basal insulin in the case of pump failure.

In the case of DKA, management involves insulin therapy and fluid and electrolyte replacement with the goal of correcting acid-base disturbances, normalizing blood glucose concentrations, and restoring fluid volume.¹ Intravenous administration of fluid and insulin are often required in a hospital setting.

References:
1. Dhatariya KK, Glaser NS, Codner E, Umpierrez GE. Diabetic Ketoacidosis. Nat Rev Dis Primers. 2020;6(1):1-20. doi:10.1038/s41572-020-0165-1
2. Westerberg DP. Diabetic Ketoacidosis: Evaluation and Treatment. Am Fam Physician. 2013;87(5):337-346.
3. Hyperglycemia (High Blood Glucose) | ADA. Accessed July 19, 2022. https://www.diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/hyperglycemia
4. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of Hyperglycemic Crises in Patients With Diabetes. Diabetes Care. 2001;24(1):131-153. doi:10.2337/diacare.24.1.131
5. Fluids and Electrolytes Challenge — Acid–Base Problems in Diabetic Ketoacidosis — NEJM. New England Journal of Medicine. Accessed July 23, 2022. https://www.nejm.org/doi/story/10.1056/feature.2015.01.21.37
6. American Diabetes Association Professional Practice Committee. 15. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes—2022. Diabetes Care. 2021;45(Supplement_1):S232-S243. doi:10.2337/dc22-S015
7. Mohan M, Baagar KAM, Lindow S. Management of Diabetic Ketoacidosis in Pregnancy. Obstet Gynecol. 2017;19(1):55-62. doi:10.1111/tog.12344
8. Tanner HL, Dekker Nitert M, Callaway LK, Barrett HL. Ketones in Pregnancy: Why Is It Considered Necessary to Avoid Them and What Is the Evidence Behind Their Perceived Risk? Diabetes Care. 2020;44(1):280-289. doi:10.2337/dc20-2008
9. Gosmanov AR, Kitabchi AE. Diabetic Ketoacidosis. In: Feingold KR, Anawalt B, Blackman MR, et al., eds. Endotext. MDText.com, Inc.; 2000. Accessed February 14, 2023. http://www.ncbi.nlm.nih.gov/books/NBK279146/
10. CDC. Diabetic Ketoacidosis. Centers for Disease Control and Prevention. Published March 25, 2021. Accessed February 14, 2023. https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html

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