Diabetic ketoacidosis

Also called DKA

Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when your body produces high levels of acids called ketones in the blood.

Diabetic ketoacidosis can be life threatening. This situation can happen very quickly. If you have diabetes, learn the warning signs of diabetic ketoacidosis and know when to seek emergency care (below).

Contact your doctor or diabetes nurse without delay if:
  • your urine or blood ketone levels are high
  • your ketone levels are not coming down once you have started treating yourself
  • you are feeling very unwell (drowsy, rapid breathing, pain in your abdomen or nausea and vomiting)
  • you are unable to look after yourself
  • you don't know how much extra insulin to take
  • you are unable to drink fluids
  • you have a temperature or an obvious sickness that is not improving

What is diabetic ketoacidosis?

Diabetic ketoacidosis is a condition which can affect people with diabetes, usually type 1 diabetes. It happens when your body does not have enough insulin to help it use sugar for energy. Instead, your body starts burning fat for energy, which releases ketones. A build-up of ketones in your body causes it to become acidic. This is why it is called 'ketoacidosis'.

Because diabetic ketoacidosis upsets the chemical balance in the body, and can quickly make you sick, it requires immediate medical attention. Left untreated, diabetic ketoacidosis can be fatal. If picked up early, it can be treated with extra insulin, glucose and fluid. 

What causes diabetic ketoacidosis?

Diabetic ketoacidosis is triggered by low insulin levels. This is most commonly caused by:

  • Missed doses of insulin
  • Insulin therapy not being given correctly which may be because of problems with your insulin pen, insulin cartridge or insulin pump
  • An illness or hormonal change – insulin in the body may not work well in the presence of infection, stress/trauma, or pregnancy. This is due to your body producing higher levels of other hormones, such as adrenaline or cortisol, which reduce the effect of insulin. You are at risk of diabetic ketoacidosis if you have an infection such as gastroenteritis (tummy bug), urinary tract infection, chest infection or skin infection.

Other causes include:

  • A heart attack.
  • Alcohol or drug abuse, in particular, cocaine.
  • Certain medications, such as corticosteroids and some diuretics.

What are the warning signs of diabetic ketoacidosis?

If you take insulin to control your diabetes, you should keep an eye out for signs and symptoms of diabetic ketoacidosis.

Early signs and symptoms of diabetic ketoacidosis can include:
  • passing large amounts of urine
  • feeling very thirsty
  • dry mouth
  • feeling sick or vomiting
  • abdominal (tummy) pain
  • tiredness, weakness, fatigue
  • shortness of breath
  • unusual or fruity-smelling breath
  • confusion
  • an increase in your blood sugar and/or ketone levels.

How to test for ketones?

Ketones are very easy to test for. The best way is to use a blood ketone meter. If you have type 1 diabetes you can get a blood ketone meter and two boxes of ketone testing strips on prescription from your doctor. You can also test for ketones in the urine but this is not as accurate because it reflects your ketone levels a few hours ago rather than right away. 

Monitoring blood ketone at home allows you to detect oncoming ketoacidosis early, so that you can give yourself insulin therapy and potentially  prevent a trip to hospital.

When to test for ketones?

You should test for ketones if you feel unwell and your blood glucose is increasing or you have any symptoms of ketoacidosis. 

Monitoring blood glucose and ketones levels when you are sick is especially important. During minor illness or injury, blood glucose levels might increase but ketones may remain negative. However during serious illness, such as high temperature or infections, blood glucose levels are often raised and ketones are present. Monitoring blood glucose and ketones during sickness will help you decide if extra insulin is required. Read more about blood glucose testing and diabetes and sick days

What to do if my ketones are raised?

Whatever your ketone levels, it is important to never stop taking your background insulin.

If your ketones are raised, adjust your insulin dose as outlined in your diabetes sick day plan. If you are unsure about how to adjust your insulin dose, contact your diabetes care provider or emergency service. Measure your blood glucose levels and ketone levels at frequent intervals, as outlined in your diabetes sick day plan. If they remain high contact your doctor, diabetes clinic or emergency service. Diabetic ketoacidosis can be life threatening, and the situation can happen very quickly, so it is important to seek medical advice promptly. 

How to prevent diabetic ketoacidosis

If you have diabetes, there's lots you can do to prevent diabetic ketoacidosis.

  • Take control of your diabetes. Take your medicines, including insulin as directed. Don't skip insulin doses. Be aware of how diet and exercise affect your blood glucose levels.  If you suspect that your insulin pen or pump is not working, get it checked out.
  • Be prepared — work with your diabetes care provider to make a sick-day plan. Know  how to manage your diabetes when you are unwell, such as what your target blood glucose level should be during an illness, how often to check your blood glucose and your ketone levels, how to adjust your insulin dose and timing and when to contact your doctor for help. Read more about diabetes sick day plan.

Learn more

The following links provide further information on sick day planning in people with diabetes. Be aware that websites from other countries may contain information that differs from New Zealand recommendations.

High blood glucose (hyper) & type 1 diabetes Diabetes New Zealand
Diabetic ketoacidosis NHS choices

Credits: Health Navigator Editorial Team. Reviewed By: Rab Burtun, Waitemata DHB (3 July 2017)