fatigue
Fatigue is one of the symptoms of diabetic ketoacidosis.
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  • Diabetic ketoacidosis (DKA) is a serious complication that occurs in people with diabetes when the body is unable to break down glucose and starts metabolizing fat instead, which increases ketones in the blood.
  • Ketones are a byproduct that develops when the body burns fat for energy, and if they are elevated you may be at risk of symptoms like abdominal pain, confusion, excessive thirst, frequent urination, nausea, shortness of breath, and fatigue.
  • This article was medically reviewed by Jason R. McKnight, MD, MS, a family medicine physician and clinical assistant professor at Texas A&M College of Medicine. 
  • Visit Insider’s Health Reference library for more advice.

Diabetic ketoacidosis, or DKA, is a life-threatening condition that develops when the body is unable to break down blood sugar appropriately and begins breaking down large amounts of fat instead. 

It is a complication of type 1 diabetes, although in rare cases it can occur with type 2 diabetes as well. The CDC reports that in 2000, about 2% of people with diabetes were hospitalized for DKA. By 2014, that number had increased to 3%. 

Learn more about diabetic ketoacidosis causes, symptoms, and treatment options.

What causes diabetic ketoacidosis? 

What causes diabetic ketoacidosis is extremely high levels of ketones in the blood. Ketones are a byproduct that your body produces when it burns fat for energy.

 

Typically, your body breaks down glucose for energy, and the hormone insulin helps with that process.  However, when neither enough glucose nor insulin is present, your body starts metabolizing fat instead, which produces ketones. 

"It's when the insulin levels are extremely low or zero that you get this uncontrolled process of ketone production," says Irwin Brodsky, MD, a physician who specializes in endocrinology and diabetes at Maine Medical Center.

DKA occurs when your body is breaking down fat so quickly that ketones build up in your blood to dangerously high levels.

Normally, most people have little to no ketones in their blood, so levels above 1.6 mmol/L (or approximately 29 mg/dL) may indicate you are at risk for ketoacidosis. Levels can change and will vary depending on the person, so if they are at all elevated you may be at risk.

Extremely low levels of insulin will typically only happen in someone with diabetes because their body either doesn't interact properly with or produce insulin on its own. 

High blood sugar is a symptom of diabetic ketoacidosis

Sometimes, high blood sugar is a sign of DKA. If no insulin is present but a person is still eating normally, glucose can build up in the blood, causing high blood sugar. Brodsky says people with diabetes should aim to keep their blood sugar level between 70 mg/dL and 180 mg/dL. 

 

If your blood sugar is very high, around 380 mg/dL, you should consider checking your urine for ketones, Brodsky says. You can purchase ketone test strips that measure ketone levels in the urine (which are also an indication of how much are in the blood) at the pharmacy without a prescription.

However, you might also have DKA with low blood sugar if you are experiencing a major stressor, like a serious illness or a heart attack. Brodsky says in this case, your body releases stress hormones, which cause a lot of fat to be released and broken down, resulting in high ketone levels.

It is important to note that low insulin, not high blood sugar, is the actual cause of DKA, says Brodsky. If you have type 1 diabetes and have neither eaten anything nor taken insulin, you will have low blood sugar but are still at risk for DKA because insulin levels will also be dangerously low. 

More signs and symptoms of diabetic ketoacidosis

According to the Mayo Clinic, the major symptoms of diabetic ketoacidosis include:

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

How quickly symptoms develop depends on how quickly DKA develops and what is causing it, says Brodsky. 

 

For example, a person with type 1 diabetes who is eating normally but who either hasn't taken insulin or whose insulin isn't working for some reason, the first signs will be those of high blood sugar, which include extreme thirst and excessive urination. High blood sugar may happen almost immediately after eating, and symptoms such as loss of appetite, nausea, and vomiting, may appear over a few hours. 

Treatment

DKA is a medical emergency. If you think you are developing DKA, you should seek medical attention immediately. Although some cases of extremely mild DKA can be treated outside the hospital, it's best to seek medical attention to be sure. Severe cases of DKA may result in death.

Take your insulin

For instance, if you realize your insulin pump broke and you have been without insulin for a few hours, your doctor may have you administer insulin at home, although it will likely be a larger dose than normal.

"People with DKA are under so much stress, and the body is so geared up, that it takes more insulin than usual to reverse it," Brodsky says. 

Drink fluids

Diabetic ketoacidosis also makes you dehydrated, so it is important to drink fluids. If you can't keep fluids down because you are vomiting, you should go to the hospital, says Brodsky. 

Seek medical aid

Your doctor will also probably want you to go to the hospital if you don't know what is causing your DKA, if it has been developing for longer than a few hours, or if you have multiple symptoms. You may need to remain in the hospital for observation and treatment for 1-3 days.

Treatment will generally involve an IV of fluids to combat dehydration and insulin injections so that your cells can start metabolizing glucose instead of fat, which will lower your blood sugar levels, lower your ketone levels, and work to get your metabolism back to a more normal state.

Doctors will also keep a close eye on your potassium levels, Brodsky says. This is because the standard amount of insulin required to treat DKA may lead to potassium levels to drop to dangerous levels, so you may be given potassium as part of your DKA treatment. Small doses of insulin are standard for normal, day to day treatment and do not pose a severe risk for low potassium

Takeaways

Brodsky says the people most at risk for developing diabetic ketoacidosis are people who have undiagnosed type 1 diabetes. 

"If you don't know you have diabetes, you can't prevent [DKA]," says Brodsky. "If you know you have diabetes, it's really about making sure you don't omit insulin doses. Take all of them."

Although most cases of DKA are in people with type 1 diabetes,  it can also occur in people with type 2 diabetes. Additionally, it's important to remember that high blood sugar is an indication of risk for DKA, but it is possible to have DKA without high blood sugar. Anyone who is experiencing symptoms of DKA should check their urine for ketones, and seek medical attention immediately.

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