🚨 Diabetic Ketoacidosis (DKA): Warning Signs, Causes, and Emergency Treatment

Diabetic ketoacidosis (DKA) is one of the most serious emergencies in diabetes. It can develop rapidly — sometimes within hours — and if left untreated, it can lead to coma and even death. While DKA is most commonly associated with Type 1 diabetes, it can also occur in Type 2 diabetes under conditions of severe stress, infection, or when certain medications are involved. Dr. Ravi Sishir Reddy explains what DKA is, the early warning signs, and exactly what to do if you suspect it.

1. What Is Diabetic Ketoacidosis?

DKA occurs when there is a severe shortage of insulin in the body. Without insulin, glucose cannot enter cells to be used for energy. The body, thinking it is starving, begins to break down fat at an accelerated rate. This fat breakdown produces ketones — acidic compounds that build up in the blood. As ketones accumulate, the blood becomes dangerously acidic, causing a cascade of metabolic disturbances that can be fatal if not treated promptly with intravenous fluids, insulin, and electrolyte replacement.

DKA is usually triggered by an event that increases the body's demand for insulin, such as an infection, missed insulin doses, or a new diagnosis of Type 1 diabetes. It can also be caused by certain medications — notably SGLT2 inhibitors (like dapagliflozin and empagliflozin), which can rarely trigger a form of DKA even with normal blood sugar (euglycemic DKA).

2. The Early Warning Signs of DKA

DKA does not usually come out of nowhere. There are often recognizable symptoms that develop over hours to a day. Dr. Reddy emphasises that recognising these early signs can make the difference between a brief hospital stay and a life‑threatening emergency. Early symptoms include:

• Excessive thirst (polydipsia) and a very dry mouth.
• Frequent urination (polyuria), often in large volumes.
• High blood sugar readings — typically above 250 mg/dL, and often much higher. However, in euglycemic DKA, blood sugar may be under 200 mg/dL.
• Fatigue, weakness, and lethargy.
• Blurred vision.

As DKA progresses, more alarming signs appear:

• Nausea and vomiting — this is often the tipping point that requires hospitalisation, as it makes oral hydration impossible.
• Abdominal pain — can be severe and mimic appendicitis or other acute abdomen conditions.
• Deep, rapid, gasping breathing (Kussmaul breathing) — the body's attempt to blow off excess acid.
• Fruity‑smelling breath — a distinctive acetone odour from the ketones. This is a classic sign that family members may notice.
• Confusion, drowsiness, difficulty concentrating.
• Flushed, dry skin.
• In severe cases, loss of consciousness and coma.

3. What Triggers DKA?

• Missed or inadequate insulin doses: The most common cause in people with known Type 1 diabetes.
• Infection: Urinary tract infections, pneumonia, or any severe illness increase the body's stress hormones, which raise insulin requirements.
• New onset of Type 1 diabetes: DKA is the presenting feature in about 25‑30% of children and adults newly diagnosed with Type 1 diabetes.
• Heart attack, stroke, or major surgery.
• Certain medications: SGLT2 inhibitors (can cause euglycemic DKA), corticosteroids, and certain antipsychotics.
• Pregnancy: Especially during the third trimester or during labour.
• Alcohol or drug abuse.

4. A Special Warning: Euglycemic DKA (Normal Blood Sugar)

In euglycemic DKA, the blood sugar may be below 200 mg/dL — sometimes even normal. This can happen in people taking SGLT2 inhibitors, during pregnancy, or in those who are fasting. Because the blood sugar is not alarmingly high, patients and even doctors may not suspect DKA, delaying treatment. If you are on an SGLT2 inhibitor and develop nausea, vomiting, or abdominal pain, seek medical attention and ask for ketone testing, even if your glucometer shows normal numbers.

5. What to Do If You Suspect DKA

1. Do not wait. DKA is a medical emergency that requires hospitalisation for intravenous insulin, fluids, and electrolyte management. If you are vomiting, unable to keep fluids down, or have deep laboured breathing, go to the emergency room immediately.
2. Check your blood sugar and ketones. If you have a urine ketone test strip or a blood ketone meter, use it. Moderate to large ketones in the presence of high blood sugar confirm the diagnosis. But even if you cannot test, go to the ER if you have symptoms.
3. Do not stop your basal insulin (long‑acting) without medical advice, even if you are vomiting. The body needs insulin to clear ketones.
4. Stay hydrated with small sips of water if you can tolerate it, but do not delay seeking care.
5. If you are on an insulin pump and suspect a pump malfunction, disconnect it, take a correction dose with a pen or syringe, and change the infusion set. Seek medical attention.

6. How to Prevent DKA

• Never skip your insulin doses — even when you are sick and not eating, your body still needs basal insulin.
• Have a "sick‑day plan" that you have discussed with your doctor: how often to check glucose and ketones, how to adjust insulin, and when to call for help.
• Keep ketone test strips (urine or blood) at home, especially if you have Type 1 diabetes.
• During illness or stress, check your blood sugar more frequently — every 2‑4 hours — and check ketones if glucose is above 250 mg/dL.
• Be aware of SGLT2 inhibitor risks: If you are on one of these drugs and become unwell, are fasting, or are on a very low‑carb diet, discuss temporarily stopping the medication with your doctor.
• Attend regular follow‑up appointments to ensure your insulin regimen remains appropriate.