Diabetic ketoacidosis is a serious condition that can occur as a complication of diabetes. People with diabetic ketoacidosis (DKA) have high blood sugar levels and a build-up of chemicals called ketones in the body that makes the blood more acidic than usual.

Diabetic ketoacidosis can develop when there isn’t enough insulin in the body for it to use sugars for energy, so it starts to use fat as a fuel instead. When fat is broken down to make energy, ketones are made in the body as a by-product.

Ketones are harmful to the body, and diabetic ketoacidosis can be life-threatening. Fortunately, treatment is available and is usually successful.

Symptoms

Ketoacidosis usually develops gradually over hours or days. Symptoms of diabetic ketoacidosis may include:

• excessive thirst;
• increased urination;
• tiredness or weakness;
• a flushed appearance, with hot dry skin;
• nausea and vomiting;
• dehydration;
• restlessness, discomfort and agitation;
• fruity or acetone smelling breath (like nail polish remover);
• abdominal pain;
• deep or rapid breathing;
• low blood pressure (hypotension) due to dehydration; and
• confusion and coma.

See your doctor as soon as possible or seek emergency treatment if you develop symptoms of ketoacidosis.

Who is at risk of diabetic ketoacidosis?

Diabetic ketoacidosis usually occurs in people with type 1 diabetes. It rarely affects people with type 2 diabetes.

DKA may be the first indication that a person has type 1 diabetes. It can also affect people with known diabetes who are not getting enough insulin to meet their needs, either due to insufficient insulin or increased needs.

Ketoacidosis most often happens when people with diabetes:

• do not get enough insulin due to missed or incorrect doses of insulin or problems with their insulin pump;
• have an infection or illness, such as a urinary tract infection or heart attack;
• suffer physical or emotional trauma, such as a car accident or burns; or
• consume large amounts of sugar or alcohol.

During times of illness or stress, extra insulin is needed because the hormones that your body produces in response to stress oppose the action of insulin.

Self-monitoring for ketones

Early detection of ketones in the body and rapid treatment can help avoid severe ketoacidosis. So, in addition to regular monitoring of blood sugar levels, people with type 1 diabetes should occasionally test their blood and/or urine for ketones. Blood testing for ketones can be done with some blood glucose meters. Urine testing uses urine test strips.

Testing for ketones is recommended when you:

• are unwell or stressed;
• have noticed your blood sugar levels are rising (especially if they are not responding to correction doses of insulin); or
• have any symptoms of ketoacidosis.

Contact your doctor as soon as possible or seek emergency treatment if you develop ketones in your blood or urine, or if you develop any of the symptoms of ketoacidosis.

Tests and diagnosis

Your doctor will ask about your symptoms, and if you have known diabetes, they will ask about your recent blood sugar levels and whether you have recently been unwell or stressed. They will perform a physical examination looking for signs of ketoacidosis.

Tests will include blood tests to find out your blood sugar level and blood ketone concentration. Your doctor will also test the acidity (pH) of your blood and test your urine glucose and ketone levels.

Your doctor may also recommend tests to see what may have triggered the ketoacidosis.

If it is likely that you have or are developing diabetic ketoacidosis, your doctor will refer you for emergency specialist treatment in hospital. Ongoing monitoring of your glucose and ketone levels will be done in hospital.

Treatment of ketoacidosis

Diabetic ketoacidosis should be treated in hospital as a medical emergency.

The aim of treatment for diabetic ketoacidosis is to:

• reduce the acidity of the blood;
• stop the production of ketones and clear them from the body; and
• normalise blood sugar levels.

You will be given fluids via a drip to treat dehydration and replace the loss of electrolytes such as potassium and sodium. Glucose levels will need to be monitored closely and an insulin infusion given via a drip into a vein to stabilise your blood sugar level.

Even after the blood glucose level has reduced, insulin treatment should continue. This is to stop the formation of ketones while the acidosis gets better. At this point you will also be given glucose via a vein, so that the insulin infusion can continue without causing low blood sugar levels (hypoglycaemia).

Specific treatment may be recommended if an infection or other illness has triggered the episode of ketoacidosis.

What’s the difference between ketosis and ketoacidosis?

Ketosis is the process where excessive amounts of ketones are produced in the body.

Ketosis can happen if you have not eaten for several days or more (called fasting ketosis or starvation ketosis) or if you have prolonged, uncontrollable vomiting (for example, due to severe morning sickness). When ketones start to build up in your body it can be a risk to your health.

Mild ketosis can happen if you are eating a very-low carbohydrate diet or a ketogenic diet to help treat various medical conditions. That’s because when you eat these diets, your body starts to use fats (instead of sugars) for fuel and produces ketones. A healthy low-carb diet should not result in harmful levels of ketones in the body, but a ketogenic diet requires medical supervision. Talk to your doctor before starting any special diets to find out their risks and benefits.

Ketoacidosis is a dangerous condition where the level of ketones in the body is high enough that the blood becomes overly acidic. Diabetic ketoacidosis is ketoacidosis plus high blood sugar levels (hyperglycaemia) due to insufficient insulin. Alcoholic ketoacidosis is another form of ketoacidosis, caused by a combination of excessive alcohol intake and lack of food intake. Ketoacidosis is a dangerous condition regardless of the cause.

Prevention

In people who have been diagnosed with diabetes, careful monitoring and management of blood sugar levels is important to prevent diabetes complications such as ketoacidosis.

Make sure you have a management plan for your diabetes, developed in consultation with your GP, endocrinologist (diabetes specialist) and diabetes educator. The plan should include what to do if your blood glucose levels start to rise and how to manage your insulin needs on days when you are sick.

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