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Diabetic Ketoacidosis: Symptoms, Causes, and Emergency Treatment
Diabetic ketoacidosis, or DKA, is a medical emergency caused by severe insulin deficiency and a dangerous buildup of ketones and acid in the blood. It is more common in type 1 diabetes, but it can also occur in type 2 diabetes, during pregnancy, or with certain medicines. Because DKA can worsen within hours, recognizing the warning signs and acting early can save a life.
What Is Diabetic Ketoacidosis?
The correct medical term for the condition often called “diabetic acidosis” is diabetic ketoacidosis. DKA is a specific type of metabolic acidosis. It develops when there is too little effective insulin for the body to use glucose normally.
Without enough insulin, the liver releases more glucose and the body breaks down fat for energy. This produces acidic chemicals called ketones. At the same time, excess glucose and ketones spill into the urine, pulling water and electrolytes with them. The combination of ketone accumulation, dehydration, and electrolyte loss makes the blood dangerously acidic and disrupts organ function.
The body tries to compensate by breathing more deeply and rapidly to remove carbon dioxide. This pattern is called Kussmaul breathing, but it is a sign of significant illness—not a successful treatment. Without prompt medical care, DKA can progress to shock, coma, organ injury, or death.
Symptoms of Diabetic Ketoacidosis
DKA can develop over several hours to a few days. In insulin-pump users, it may progress especially quickly because the pump supplies only rapid-acting insulin.
Early warning signs
- increased thirst or very dry mouth;
- frequent urination;
- high or rising glucose;
- positive blood or urine ketones;
- unusual tiredness or weakness;
- headache or difficulty concentrating.
Signs of worsening DKA
- nausea, repeated vomiting, or abdominal pain;
- deep, rapid, or labored breathing;
- fruity or acetone-like breath;
- marked dehydration or very little urine;
- confusion, severe drowsiness, or difficulty waking;
- collapse or loss of consciousness.
Children may first present with new bed-wetting, weight loss, vomiting, abdominal pain, rapid breathing, or marked sleepiness. DKA can be the first sign of previously undiagnosed type 1 diabetes. Pregnancy also requires a lower threshold for urgent assessment because DKA may occur with less dramatic glucose elevation and can threaten both mother and baby.
When Should You Get Emergency Help?
Seek emergency care immediately if any of the following applies:
- you are vomiting repeatedly or cannot keep fluids down;
- your breathing is deep, rapid, difficult, or unusual;
- you are confused, severely drowsy, faint, or difficult to wake;
- your breath smells fruity and you feel ill;
- blood ketones are 1.6 mmol/L or higher, or ketones are high and rising;
- urine ketones are moderate or large, particularly with symptoms;
- glucose or ketones do not improve after the insulin and hydration steps in your written sick-day plan;
- you have DKA symptoms while taking an SGLT2 inhibitor, even if glucose is below 200–250 mg/dL;
- a child, teenager, or pregnant person has suspected DKA.
A glucose number alone cannot rule DKA in or out. For a broader guide to urgent glucose situations, see dangerous blood sugar levels and when to act.
What Causes DKA?
DKA develops when insulin is absent or insufficient for the body’s needs. Common triggers include:
- missed, delayed, spoiled, or inadequate insulin;
- insulin-pump interruption, such as a blocked cannula, empty reservoir, disconnected tubing, site leak, or device failure;
- infection, including urinary, chest, skin, or other infections;
- new, previously unrecognized diabetes, especially type 1 diabetes;
- acute illness or major stress, such as heart attack, stroke, pancreatitis, trauma, or surgery;
- vomiting, dehydration, or prolonged fasting;
- pregnancy;
- SGLT2 inhibitor treatment, especially with illness, dehydration, fasting, surgery, reduced insulin, or a very-low-carbohydrate diet;
- medicines that can markedly increase glucose or reduce insulin effectiveness, including corticosteroids in susceptible people;
- difficulty obtaining insulin, fear of hypoglycemia or weight gain, an eating disorder, depression, or another barrier to taking insulin safely.
Vomiting does not mean insulin should automatically be stopped. Illness hormones often increase insulin needs even when you cannot eat normally. People using intensive insulin therapy should not omit basal insulin; instead, follow an individualized sick-day and correction plan.
Euglycemic DKA and SGLT2 Medicines
SGLT2 inhibitors include medicines such as empagliflozin, dapagliflozin, and canagliflozin. They can provide important heart, kidney, and glucose benefits for appropriate patients, but they also carry an uncommon risk of DKA.
Because these medicines increase glucose loss through the urine, DKA can occur with glucose below the level many patients expect—sometimes below 200 mg/dL (11.1 mmol/L). This is called euglycemic DKA. Nausea, vomiting, abdominal pain, rapid breathing, unusual fatigue, or positive ketones must not be dismissed simply because the glucose meter does not show a very high number.
When and How to Check Ketones
If you are at risk for DKA, keep unexpired ketone-testing supplies at home and know how to use them before an illness. Blood ketone testing measures beta-hydroxybutyrate and is generally preferred because it reflects the main ketone in DKA more directly. Urine strips can still be useful when a blood ketone meter is unavailable.
Check ketones according to your personal plan, especially when:
- you are sick, feverish, vomiting, dehydrated, or unable to eat normally;
- you have nausea, abdominal pain, rapid breathing, or other DKA symptoms;
- glucose is repeatedly above your team’s threshold—often 200–250 mg/dL;
- you missed insulin or suspect a pump or infusion-site problem;
- you are pregnant and have diabetes;
- you take an SGLT2 inhibitor and feel unwell, regardless of glucose.
| Blood ketone result | General meaning | What to do |
|---|---|---|
| Below 0.6 mmol/L | Usually within the expected range. | Continue glucose monitoring and your sick-day plan if you are unwell. |
| 0.6–1.5 mmol/L | Above normal; DKA may be developing, especially with symptoms. | Follow your written ketone plan, hydrate if able, take insulin only as directed, recheck within the advised interval, and contact your diabetes team if you feel unwell or the value rises. |
| 1.6 mmol/L or higher | High risk requiring urgent assessment; ADA patient guidance advises immediate emergency care. | Seek emergency medical care, especially with vomiting, abdominal pain, breathing changes, drowsiness, or rising ketones. |
Thresholds on your meter, strip instructions, or diabetes plan may differ. Symptoms always take priority. Urine ketones can lag behind changes in blood ketones, so they may underestimate DKA early and remain positive while recovery is underway.
How to Reduce DKA Risk During Illness
- Never stop basal insulin on your own. Ask in advance how illness should change rapid-acting, meal, and correction doses.
- Check glucose more often. Many sick-day plans recommend at least every 4–6 hours, with more frequent checks when results are changing quickly.
- Check ketones. Test during illness, after missed insulin, with pump failure, or when symptoms appear—even if an SGLT2 medicine keeps glucose lower.
- Drink fluids if you can. Use the type and amount recommended in your plan. Vomiting or inability to drink needs urgent help.
- Inspect pump equipment. Check the infusion site, tubing, reservoir, and delivery history. Use your backup injection plan if instructed.
- Do not exercise with elevated ketones. Exercise may increase ketone production when insulin is deficient.
- Know whom to call. Keep daytime, after-hours, pharmacy, and emergency contact numbers available.
A sick-day kit can include a glucose meter and strips, blood ketone meter or urine ketone strips, insulin and backup delivery supplies, a thermometer, fluids, written insulin instructions, medication list, and emergency contacts. Check expiry dates regularly.
How Doctors Diagnose DKA
A home glucose or ketone test can signal danger, but it cannot confirm the complete diagnosis. Current international consensus criteria require all three components:
| Component | Hospital assessment | Why it matters |
|---|---|---|
| Diabetes or hyperglycemia | A known history of diabetes or glucose generally at least 200 mg/dL (11.1 mmol/L) | DKA can still occur below 200 mg/dL when diabetes is present, particularly with SGLT2 use, pregnancy, fasting, or reduced intake. |
| Ketosis | Blood beta-hydroxybutyrate at least 3.0 mmol/L or, when blood testing is unavailable, substantial urine ketones | Blood beta-hydroxybutyrate is the preferred marker of clinically important ketonemia. |
| Metabolic acidosis | Venous pH below 7.3, bicarbonate below 18 mmol/L, or both | This confirms that ketone accumulation is disrupting the body’s acid-base balance. |
The hospital team also checks sodium, potassium, kidney function, hydration, and other blood chemistry. A venous blood sample is commonly sufficient; an arterial sample is not automatically required. Tests may be ordered to identify infection, heart problems, pancreatitis, pregnancy, medication effects, or another trigger.
How Is DKA Treated?
Treatment belongs in a monitored medical setting. The main goals are to restore circulation and hydration, stop ketone production, correct electrolyte abnormalities safely, and treat the underlying cause.
- Fluids: intravenous fluids replace water and improve circulation. The type and rate depend on blood pressure, sodium, kidney and heart function, age, and severity.
- Insulin: insulin stops ketone production and lowers glucose. Intravenous insulin is common; selected mild, uncomplicated cases may be treated with carefully monitored subcutaneous rapid-acting insulin.
- Potassium and other electrolytes: potassium can fall rapidly once insulin begins, so it is measured repeatedly and replaced when indicated.
- Dextrose when needed: glucose-containing fluid is added as blood glucose falls so insulin can continue until ketones and acidosis resolve.
- Treatment of the trigger: this may include antibiotics for a confirmed or strongly suspected bacterial infection, treatment for a heart problem, pump replacement, or another specific intervention.
Not everyone with DKA needs an intensive care unit, and not everyone needs antibiotics. The level of care depends on acidosis, ketone level, blood pressure, mental state, other illnesses, age, pregnancy, and response to treatment. Clinicians monitor closely for hypoglycemia, low potassium, fluid overload, kidney injury, and other complications.
DKA Compared With Hyperosmolar Hyperglycemic State
| Feature | DKA | HHS |
|---|---|---|
| Main problem | Significant ketones and metabolic acidosis caused by insulin deficiency | Extreme hyperglycemia, hyperosmolality, and profound dehydration with little or no significant ketoacidosis |
| More common in | Type 1 diabetes, but possible in type 2 diabetes | Usually type 2 diabetes, especially older adults |
| Typical development | Hours to a few days | Several days to weeks |
| Glucose | Often high, but may be below 200 mg/dL in euglycemic DKA | Usually extremely high |
| Emergency? | Yes | Yes |
DKA and HHS can overlap, so the emergency team uses laboratory results rather than symptoms alone. Learn more from our diabetes complications guide.
After DKA: Preventing Another Episode
Before leaving the hospital, ask what triggered the episode and how your plan should change. I encourage my patients to review:
- basal and mealtime insulin doses and timing;
- pump settings, infusion-site technique, alarms, and backup injections;
- how often to check glucose and ketones during illness;
- the exact correction-insulin and hydration instructions;
- SGLT2 sick-day, fasting, and surgery precautions;
- access to insulin, prescriptions, supplies, refrigeration, and emergency contacts;
- screening for infection, depression, diabetes distress, or an eating disorder when relevant;
- follow-up with a diabetes clinician and diabetes self-management education.
If DKA was the first sign of diabetes, the diabetes type may need further evaluation after recovery. Some people who initially appear to have type 2 diabetes may have autoimmune or ketosis-prone diabetes and require insulin.
Frequently Asked Questions
Can someone with type 2 diabetes develop DKA?
Yes. DKA is more common in type 1 diabetes but can occur in type 2 diabetes during severe illness, marked insulin deficiency, missed insulin, pregnancy, or treatment with an SGLT2 inhibitor. It can also be the first presentation of diabetes.
Can DKA happen with normal or only moderately high glucose?
Yes. Euglycemic DKA can occur with glucose below 200 mg/dL, particularly with SGLT2 inhibitors, pregnancy, reduced food intake, alcohol-related illness, or insulin taken before testing. Symptoms and ketones matter, not only the glucose value.
Are ketones always an emergency?
No. Small ketone amounts may occur during fasting, but rising or high ketones in a person with diabetes can be an early warning of DKA. High ketones, symptoms, vomiting, breathing changes, or inability to drink require urgent or emergency assessment.
Should I stop insulin if I am vomiting and not eating?
Do not stop basal insulin on your own. Illness can increase insulin needs even when you are not eating. Follow your written sick-day plan and contact your diabetes team promptly for dose and fluid instructions.
Can I exercise to lower high glucose when ketones are present?
No. Exercise can worsen ketone production when insulin is insufficient. Stop exercise, follow your ketone plan, and seek urgent care if ketones are high, rising, or accompanied by DKA symptoms.
How quickly can pump failure cause DKA?
DKA may develop within hours because most pumps deliver rapid-acting insulin without a separate long-acting insulin depot. Check the infusion set and ketones promptly, and use the backup plan provided by your diabetes team.
Can DKA be treated at home?
Suspected DKA needs immediate clinical assessment. A person who is stable may sometimes manage early, mildly elevated ketones using a clinician-written plan, but vomiting, inability to drink, breathing changes, confusion, high or rising ketones, or failure to improve requires emergency care.
Related Questions
Related Resources
References
- American Diabetes Association: Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises—Standards of Care in Diabetes 2026
- Hyperglycemic Crises in Adults With Diabetes: 2024 International Consensus Report
- American Diabetes Association: DKA—Signs, Symptoms, and Treatment
- American Diabetes Association: Managing Ketones With Diabetes
- American Diabetes Association: Diabetes and Planning for Sick Days
- Centers for Disease Control and Prevention: Diabetic Ketoacidosis
- American Diabetes Association: Diabetes Care in the Hospital—Standards of Care in Diabetes 2026