Diabetic ketoacidosis, or DKA, is a serious and potentially life-threatening complication of diabetes that occurs when your body doesn’t have enough insulin to move sugar into cells for energy. Without insulin, your body starts breaking down fat at a rapid pace, producing acidic chemicals called ketones that build up in your blood and make it dangerously acidic. DKA most often affects people with type 1 diabetes, but it can happen in type 2 diabetes as well.
How DKA Develops in Your Body
DKA starts with a simple problem: your cells are starving for energy despite having plenty of sugar in your bloodstream. When insulin levels drop too low, your body can’t use that sugar. In response, your body ramps up production of glucagon and other stress hormones, which signal fat stores to start breaking down rapidly. Your liver converts those released fatty acids into ketone bodies, which are meant to serve as backup fuel.
In small amounts, ketones are harmless. But when fat breakdown goes into overdrive, your liver produces ketones faster than your body can use or clear them. The excess ketones accumulate in the blood and lower its pH, tipping the balance from normal metabolism into full-blown acidosis. This acid buildup is what makes DKA dangerous. It disrupts the way your organs function and, left untreated, can lead to coma or death.
What Triggers a DKA Episode
DKA doesn’t usually come out of nowhere. In a study of patients with type 1 diabetes, infections were the most common trigger, responsible for about 37% of episodes. Missing insulin doses or taking too little insulin accounted for roughly 23%. And for about 27% of patients, the DKA episode was actually the first sign that they had diabetes at all, meaning it can strike before anyone knows there’s a problem.
Other common triggers include major physical stress such as surgery, heart attack, or trauma. Certain medications can also set it off. Emotional stress, heavy alcohol use, and illnesses like pneumonia or urinary tract infections all increase the risk. Any situation that raises your body’s demand for insulin or blocks its effectiveness can push you toward DKA.
Recognizing the Symptoms
DKA typically builds over hours to a day or two, and early symptoms can feel like general illness. You may notice you’re urinating much more than usual, feeling extremely thirsty, or getting dehydrated and developing a headache. Blood sugar readings above 250 mg/dL and elevated ketones on a home test strip are early warning signs.
As the condition worsens, more distinctive symptoms appear: nausea and vomiting, abdominal pain, and a feeling of deep exhaustion. Two hallmark signs set DKA apart from ordinary sickness. The first is fruity-smelling breath, caused by acetone (a type of ketone) being exhaled through your lungs. The second is a pattern of deep, labored breathing called Kussmaul breathing. Your body drives this rapid, heavy breathing on purpose to blow off carbon dioxide, which is one of the acids building up in your blood. If you notice these signs in yourself or someone with diabetes, it’s a medical emergency.
Who Gets DKA
Two-thirds of DKA episodes in adults occur in people with type 1 diabetes, while one-third happen in people with type 2 diabetes. The rate difference is significant: adults with type 1 diabetes experience about 53 hyperglycemic crisis events per 1,000 person-years, compared with 4 per 1,000 person-years in type 2 diabetes.
In the United States, in-hospital mortality from DKA has dropped substantially, falling from 1.1% in 2000 to 0.4% by 2014. That low number, however, depends on timely treatment. Mortality climbs to 8% to 10% in adults aged 65 to 75, largely because of other health conditions. And in low- and middle-income countries where diagnosis and treatment are often delayed, mortality rates from DKA range from 26% to 41%.
DKA With Normal Blood Sugar
One of the trickier forms of this condition is called euglycemic DKA, where blood sugar stays below 250 mg/dL even as dangerous ketone levels and acidosis develop. This can catch people off guard because the most obvious red flag, high blood sugar, is missing.
A class of diabetes medications that work by flushing excess glucose out through your urine are the most common culprits. These drugs lower blood sugar effectively, but they also create a state of carbohydrate depletion that triggers your body to break down fat and produce ketones. They also directly stimulate glucagon release from the pancreas and increase ketone reabsorption in the kidneys, compounding the problem. Estimates suggest these medications raise the risk of DKA about sevenfold in people with type 2 diabetes. Triggers like infection, surgery, fasting, pregnancy, or heavy drinking can push someone taking these drugs into euglycemic DKA. The condition occurs in both type 1 and type 2 diabetes.
How DKA Is Diagnosed
Doctors diagnose DKA using a combination of three lab values. Blood sugar is typically 250 mg/dL (14 mmol/L) or higher, though it can be lower in euglycemic cases. Blood pH falls to 7.30 or below, compared to the normal range of 7.35 to 7.45. And bicarbonate, a natural buffer against acid in your blood, drops to 15 mmol/L or less, though milder cases may show levels between 15 and 18.
Ketone testing plays a central role. Blood ketone meters that measure a specific ketone called beta-hydroxybutyrate are more reliable than urine test strips, which detect a different ketone. Research comparing the two methods found that blood ketone testing led to fewer hospitalizations, faster recovery from DKA episodes, and lower healthcare costs. Many people with type 1 diabetes now keep a blood ketone meter at home for exactly this reason.
What Treatment Looks Like
DKA is treated in a hospital, often in an intensive care or closely monitored setting. The treatment addresses three problems at once: dehydration, insulin deficiency, and electrolyte imbalances.
Fluid replacement comes first. Most people with DKA are severely dehydrated because high blood sugar pulls water out of cells and increases urination. Intravenous fluids are given rapidly in the first few hours to restore circulation. Insulin is delivered through an IV drip at a carefully controlled rate to gradually bring blood sugar down and, more importantly, to stop the overproduction of ketones. Once blood sugar drops below 250 mg/dL, sugar is actually added to the IV fluids so that insulin can continue working to clear ketones without driving blood sugar dangerously low.
Potassium is the electrolyte that demands the most attention. Insulin drives potassium into cells, which can cause blood potassium levels to plummet during treatment. Since low potassium can trigger dangerous heart rhythms and muscle weakness, doctors monitor levels closely and add potassium to the IV fluids for most patients. In the small percentage of patients who arrive with already low potassium, replacement starts before insulin is even given.
Recovery from a straightforward DKA episode typically takes 24 to 48 hours, though some people need longer. The medical team watches for ketones to clear and acid levels to normalize before transitioning from IV insulin back to injections or an insulin pump.
Preventing DKA During Illness
Sick days are the highest-risk time for DKA, because infections and illnesses raise stress hormones that counteract insulin. The CDC recommends a set of practical steps to stay ahead of the problem. Keep taking your insulin even if you’re not eating. Check your blood sugar every four hours. If you can’t eat regular meals, aim for about 50 grams of carbohydrates every four hours through foods or drinks you can tolerate. Drink plenty of water to prevent dehydration, and check your temperature twice a day since a fever may signal an infection that’s worsening your metabolic state.
Test for ketones using a home kit, ideally a blood ketone meter. If ketones are present, contact your healthcare team immediately. If you’re vomiting and can’t keep fluids down, or if ketone levels are rising despite your efforts, that’s the point to head to the emergency room. Most DKA episodes are preventable with early action during illness, which is why people with type 1 diabetes are encouraged to have a written sick-day plan ready before they need it.