What is diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is a serious complication of diabetes where the body is unable to use glucose (sugar) as a source of energy because it lacks insulin (a hormone made by the pancreas that helps to regulate blood glucose levels).

If left untreated, DKA can lead to coma and even death. It more often occurs in people with type 1 diabetes, but it can also occur in people with type 2 diabetes.

Diabetic ketoacidosis is a medical emergency and can be life-threatening if not treated properly.

What are the symptoms of diabetic ketoacidosis?

Diabetic ketoacidosis usually develops gradually, over hours or days.

The symptoms of diabetic ketoacidosis include high blood glucose levels (hyperglycaemia) and high levels of ketones in the urine. It's also important to remember that glucose levels can be near normal in people with type 2 diabetes who take SGLT2 inhibitors.

Symptoms may also include any of the following:

• abdominal pain
• nausea and/or vomiting
• dehydration
• lethargy, tiredness
• feeling very thirsty
• urinating a lot
• weight loss
• rapid, shallow breathing
• acetone smell on the breath
• confusion
• drowsiness which may lead to a coma

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What causes diabetic ketoacidosis?

DKA happens when insulin stops working well. A lack of insulin, or the inability of the body to use insulin, can lead to high blood glucose levels and the body burning fat stores instead of glucose for energy. This process creates by-products called ketones. As ketones build up in the bloodstream, blood becomes acidic. This is known as ketoacidosis.

How does DKA happen in people with type 1 diabetes?

DKA may happen in people with type 1 diabetes for the following reasons.

When someone doesn't know they have type 1 diabetes

DKA can happen if you don't know you have type 1 diabetes and therefore don't take insulin treatment to prevent high glucose and ketone levels which cause DKA. Often people are diagnosed with DKA when they learn they have type 1 diabetes.

Infection

Being unwell with a virus or infection (especially with a high fever) causes a stress response in the body where certain hormones increase. This raises blood sugar levels. Without taking enough insulin to control this, the body will have high glucose and ketone levels, which may result in DKA.

Diarrhea and vomiting

DKA can occur in people with type 1 diabetes who have a gastrointestinal illness with near normal blood glucose levels.

Not taking insulin treatment

DKA can happen if people with type 1 diabetes miss their insulin treatment.

Expired or compromised insulin

DKA can occur if insulin treatment is no longer effective, which can happen if it has expired or been subjected to extreme hot or cold temperatures, including being left in a hot car or a school bag left in the sun, or if it has been put in the freezer.

Insulin pump failure

People with type 1 diabetes can take insulin via a pump. Insulin pumps only use short-acting insulin. This doesn't last long in the body so DKA can happen within a few hours if a pump does not deliver insulin. Insulin pumps can accidentally become disconnected or the connecting tubes can kink or get blocked.

Alcohol or drug abuse

Alcohol and certain drugs, such as cocaine and amphetamines, can interfere with the way insulin works and increase the risk of DKA.

How does DKA happen in people with type 2 diabetes?

DKA may happen in people with type 2 diabetes for the following reasons.

Infection or virus

DKA can happen in people with type 2 diabetes who have low insulin production and get sick with an infection or virus.

SGLT2 inhibitors

There is a small risk that some people who take SGLT2 inhibitor medications will develop DKA.

Usually, glucose in the urine is reabsorbed by the kidneys back into the blood stream. SGLT2 inhibitor medications block the kidneys from reabsorbing glucose. Instead, they send glucose out of the body via urine. This has the effect of lowering blood glucose levels and increases the effectiveness of insulin.

There is a small risk that some people who take SGLT2 inhibitor medications will develop DKA.

People who are more likely to develop DKA when taking a SGLT2 inhibitor are those who have impaired kidney function, are dehydrated, have an infection or have another illness. DKA can also occur with near normal blood glucose levels on SGLT2 inhibitors. It is very important to check your ketone levels if you are sick.

When should I call an ambulance or go to the emergency department?

If you are unable to manage your diabetes or have any of the symptoms listed below, call triple zero (000) or go to the emergency department immediately.

DKA is a medical emergency and can cause death if not treated properly.

• vomiting persistently
• your blood glucose keeps rising despite having extra insulin
• your urine ketones are moderate to high
• blood ketones are more than 1.5mmol/L and do not decrease with extra insulin doses
• feeling drowsy, confused
• difficulty breathing or abdominal pain
• you are too unwell to care for yourself or you don't have adequate support

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How is diabetic ketoacidosis diagnosed?

Diabetic ketoacidosis is diagnosed by assessing symptoms and checking glucose and ketone levels.

It is recommended to test blood ketones via a finger prick using a blood glucose/ketone testing machine. This is an accurate method and shows the level of ketones in the blood to ensure the right treatment. Urine testing can be used as a guide if a blood ketone machine is not available.

How is diabetic ketoacidosis treated?

If you feel unwell or have any signs of infection, it's important to follow your sick-day action plan, even if your blood glucose level is within your target range.

It often doesn't take much to become unwell with DKA because a minor illness can cause a major increase in your blood glucose levels. It only takes a few hours of raised blood glucose levels for your body to start producing ketones. If this happens, you will need extra insulin to reduce the ketones.

Your treatment plan will have advice on what food and fluids to have, when to increase insulin, how often to test glucose and ketones and when to seek help. It's a good idea to let someone know you are sick if you are by yourself.

What are the complications of diabetic ketoacidosis?

Diabetic ketoacidosis can result in coma or death if a person with this condition doesn't get emergency care. The risk of diabetic ketoacidosis increases during pregnancy and it is especially dangerous for the baby.

Can diabetic ketoacidosis be prevented?

There are some things a person can do to reduce their chances of getting diabetic ketoacidosis.

• Keep your diabetes well managed and your blood glucose levels in your target range.
• Know how to adjust your insulin when you are sick.
• Know when to test for ketones and have a supply of tests.
• Follow your sick-day action plan if you are unwell.

Your doctor, endocrinologist or diabetes educator can prepare a sick-day action plan with you, so you know what to do when you are unwell and how to manage your blood glucose levels.