Diabetic Ketoacidosis: What It Is + What to Do About It

Diabetic ketoacidosis (DKA) is a complication of diabetes that can be serious and life-threatening. DKA is most common when someone is first diagnosed with type 1 diabetes (T1D), but it can also occur after someone has been managing T1D for a long time.

People with type 2 diabetes (T2D) can also develop ketones and, therefore, be at risk for DKA, but the American Diabetes Association (ADA) says this is rare.

How does DKA happen?

When the body is not receiving enough insulin to break down glucose, it forces it to start breaking down fat for fuel—this is when ketones form and are released into your body’s bloodstream. This is the start of DKA.

In small amounts—like the amount that develops during a ketogenic diet—ketones are not dangerous. (There’s a difference between ketosis and ketones.) However, in people with diabetes (PWD) who may not have enough insulin in their system, ketone levels can rise to life-threatening levels and need to be treated immediately.

Causes of DKA

If your ketone levels are high enough and turn into DKA, they can lead to a coma or even death.

The most common causes of DKA include:

• An Illness: An infection or illness, like the flu or a urinary tract infection, are the most common causes of DKA. When a person’s body is under stress from an illness, it releases certain hormones that work against the effect of insulin. 
• Too little insulin: Missed insulin doses, not taking enough insulin, and insulin delivery device malfunctions are also associated with DKA risk. 

Less Common: 

• Stress
• Pregnancy
• Certain medications like steroids  and SGLT2is

Warning signs of DKA

Early signs of DKA include:

• Nausea 
• Abdominal pain
• Extreme fatigue
• Blood glucose (blood sugar) higher than 200 mg/dL (or a level recommended by your doctor)
• Thirst or very dry mouth
• Flushed skin

More extreme warning signs of DKA include:

• Rapid or heavy breathing
• Confusion or difficulty concentrating
• Vomiting
• Shortness of breath
• Fruity smell on the breath

As soon as you notice these signs, it’s important to take action. Take the first step and test for ketones. 

Pro tip: Call someone and let them know you suspect ketones. Being alone while experiencing DKA can be dangerous. Do not drive or walk alone. 

How to Test for Ketones

Although urine strips are the most common and available method to test for ketones, you have another option that’s more accurate. Whatever your choice, have one of these handy at all times.  

• Blood ketone meter test: The most accurate method is using a blood ketone meter, which measures BHB, the main ketone present during DKA. Using a blood ketone meter is similar to checking your blood sugar—you take a small blood sample. These meters usually cost between $30 and $60, and the test strips cost about $1 each. You can find them at stores like Walmart or online on Amazon. 
• Urine ketone test strips: A less accurate method is using urine ketone test strips, which detect ketones in urine. These strips are inexpensive—around a quarter each—and are available at drug stores. Keep in mind that urine tests are less dependable because ketone levels take longer to appear in urine, and hydration levels can influence the results. 

Some diabetes technology manufacturers are even exploring ways to integrate continuous ketone monitoring (CKM) into continuous glucose monitoring (CGM) sensors to make things easier on PWD.

When to test for ketones

If you’re unsure whether to test for ketones, follow this simple checklist to make your decision. Test for ketones if:

• You are experiencing any of the symptoms listed above: ketones can sneak up on you, so don’t take any of the signs lightly
• You have the flu or any other virus: in this case, the standard recommendation is to test every four to six hours, though your doctor may tell you to check it even more often—every two to three hours
• Your blood sugar levels are consistently higher than 13.3 mmol/L (240 mg/dL): use your CGM, if you have one, to check your time in range—this can be a helpful indicator to see how long you’ve been out of range

If your test shows high ketone levels—or if you experience severe symptoms—contact a healthcare provider immediately. It’s always better to test for peace of mind and be wrong than to skip testing and have ketones present. Make sure a ketone testing option is part of your daily diabetes care kit, just in case. It’s better to have one and not use it than not to have it if you need it.

Reducing the Risk of  DKA

To reduce the risk of DKA, be sure to take precautions such as:

• Drink lots of water: this is an underrated, usually accessible and affordable option to include in your day-to-day diabetes management. Lots of people are dehydrated. Don’t be one of them! Create a habit out of filling up a jug of water first thing in the morning.
• Take the appropriate doses of insulin as instructed by your healthcare provider: never skip doses! If you’re finding it hard to keep up, talk openly with your doctor about ways to take your medication better and stick to a diabetes strategy that feels manageable.
• Eat what you can when you’re ill: if you’re having a sick day, it’s better to eat something than nothing. Talk to your doctor about foods that are easier on your stomach and your diabetes when you’re feeling off.
• Check your blood sugar often: CGMs are a great choice for many PWD. They help keep track of blood sugar levels without needing to use a blood glucose meter (BGM) all the time. 
• Test for ketones: if you think something’s off, test so you can rest! It’s always better to be aware than to hope for the best. With diabetes, you can never be too careful.

The Reality of DKA

The effects of DKA are profound, no matter how you cut it. Fortunately, with modern medicine, technology, healthcare and education, it is avoidable. 

Still, the reality shouldn’t be pushed aside:

• According to the International Society for Pediatric and Adolescent Diabetes (ISPAD), DKA usually occurs at the onset of T1D. It is seen in about 15% to 70% of cases in Europe and North America.
• Several studies documented a rise in DKA and severe DKA cases at diabetes diagnosis during the COVID-19 pandemic. 
• Another study reported that 28% of older adults with T1D had experienced DKA in their lifetime.
• The same study indicated that DKA can lead to dementia in people with T2D and lower cognitive functioning in people with T1D.

You can get ahead of  DKA

If you think you might have DKA, talk to your doctor right away. If you feel you’re in immediate danger, go to the emergency room. Knowing about DKA is the first step in preventing or managing it. These situations can be scary, but remember—diabetes doesn’t own you!

DKA is not inevitable, and your diabetes doesn’t have to define you through fear or anxiety. Complications exist, but many PWD are thriving and living happy, healthy lives. By following guides, your healthcare provider’s advice and getting support from the diabetes community, you’re sure to feel that way, too.

Want to help raise awareness of the signs of diabetes and prevent others from experiencing DKA? Join our #SeeTheSigns ambassador program and make a difference in your area!

This educational resource is made possible through the support of Abbott Diabetes Care. Beyond Type 1 retains complete, independent editorial control over all content.