DKA: How to avoid a severe complication of insulin deficiency

Sarah J. Swarts, MD

Among the many conditions and complications related to diabetes, one of the most dangerous is diabetic ketoacidosis, or DKA.

To understand DKA, it is first necessary to understand how our body uses glucose for energy and the role that insulin plays in that process. When we eat, food gets broken down into glucose (commonly called sugar), which is then released into the bloodstream. Insulin that is produced by the pancreas in healthy individuals then helps transport the glucose into our cells, where it is used as an energy source.

DKA occurs when the body lacks enough insulin to help the glucose enter the cells, resulting in the glucose getting stuck in the circulatory system. Consequently, the body eliminates the glucose via urine, along with much-needed water and electrolytes such as salt and potassium, ultimately causing dehydration. As a result, the person with DKA is thirsty, urinates frequently and is at risk for severe complications resulting from electrolyte imbalances.

At the same time, the body’s glucose-starved cells resort to burning body fat for fuel. And when that fat is broken down, the chemical byproducts of the fat-burning process – ketones – build up in the blood and urine, which can make the blood more acidic, cause organ dysfunction and ultimately lead to life-threatening complications when the ketones reach abnormally high levels (ketoacidosis). It’s this combination of dehydration and ketoacidosis that is DKA, which can be fatal.

Who is at risk of DKA?

  • Individuals with type 1 diabetes mellitus (T1D), especially children
  • Individuals with T1D who also have eating disorders such as anorexia or bulimia
  • Individuals with T1D who cannot afford their insulin, so skip doses
  • Some individuals with type 2 diabetes mellitus (T2D) who typically either do not know they have diabetes or who might have had diabetes for many years that requires insulin
  • Individuals with diabetes who are on very low carbohydrate diets – those diets work by utilizing fat as a fuel source and generate ketones

What causes DKA?

  • Missing insulin doses or inadequate insulin dosing
  • Insulin pump malfunction/site problems in which the insulin cannot be delivered
  • Major illness (a heart attack for example) or an infection – DKA can develop within hours in these situations
  • A new diagnosis of T1D
  • Insulin that has gone “bad” – for example, if the insulin was left in a car on a hot day or the pen/vial was open too long
    (many insulins “go bad” after being open for 28 days. per the manufacturer’s instructions)

How common is DKA?

According to the Centers for Disease Control (CDC), in 2009 – the most recent year for which information has been released – 140,000 hospital admissions were attributed to DKA, a number that has been increasing steadily since 1988. This translates to four to eight episodes of DKA per 1,000 people each year.

The telltale signs of DKA

The symptoms of a DKA episode usually develop over the course of a 24-hour period. Early warning signs include nausea and vomiting, excessive thirst, frequent urination (polyuria), severe abdominal pain, confusion and a “ketotic” breath, often described as smelling fruity or like nail polish remover. As the condition progresses, additional symptoms can include tachycardia (a fast heart rate), accelerated breathing, blurred vision and, in the most severe cases, coma or even death.

It is not uncommon for people to discover they have diabetes mellitus because of a DKA episode, especially children.

What should I do if I think I have DKA?

  • Check your blood glucose
  • Check your urine ketones if your blood glucose registers over 250 mg/dl twice in a row
  • Take insulin as instructed by your medical team for high blood glucoses (this may be your correction scale or sliding scale or correction bolus)
  • Drink plenty of fluids to keep yourself hydrated
  • Check blood glucoses and urine ketones levels every 4 to 6 hours
  • Do not exercise if you have high blood glucoses and ketones in your urine

When should I seek medical care?

  • If you think you have an infection that caused the DKA
  • If you think you have a major illness that caused the DKA (such as chest pain)
  • If you are vomiting and cannot keep fluids down
  • If your blood glucoses do not come down
  • If your ketones are moderate/high or do not improve within 12 hours or less
  • If you do not get better within 24 hours or less

How is DKA diagnosed and treated?

Generally, individuals with DKA will have blood work done, have their urine tested especially for signs of infection, and may have other tests (such as X-rays or blood cultures) to seek out a cause or a trigger for the DKA.

An episode of DKA is treated by giving insulin and fluids through an intravenous line (IV). You may either be treated in the emergency room or admitted to the hospital. While in the hospital, individuals being treated for DKA may be in the intensive care unit, will likely have their blood drawn frequently and will receive insulin through the IV. Once the patient is feeling better, then they need to start eating again to prevent the formation of more ketones by “starvation.”

Another component to treating DKA is preventing it from happening in the future. For example, if you developed DKA due to missing insulin, a diabetes educator may work with you in the hospital and/or as an outpatient to develop strategies to make sure you get all insulin doses you need.

How can I prevent a DKA episode?

  • Don’t miss insulin doses
  • Once opened, discard your vials/pens/cartridges after the recommended time period
    • Most insulins – 28 days (some 30 days)
    • NPH or pre-mixed insulins with NPH – 10 to 14 days depending on the manufacturer’s instructions
    • Detemir (Levemir) – 42 days
    • Degludec (Tresiba) – up to 8 weeks at room temperature
  • Store your insulin properly
    • Do not let your insulin freeze
    • Do not leave your insulin in the car
    • Store the vials/pens/cartridges that you are not using in the refrigerator
    • Store the vials/pens/cartridges that you are using at room temperature (between 56 and 80 degrees F)
  • If you can’t afford your insulin, talk to your healthcare provider about assistance programs or alternatives to your current prescriptions
  • Check your blood glucoses frequently as instructed by your health care provider
  • If your blood glucoses are running unexpectedly high and you are on an insulin pump, immediately try changing your pump site
  • Always wear a medical alert bracelet or necklace to make sure you get proper medical care in an emergency room
  • Always have ketone strips on hand; individually wrapped strips last longer.
  • Keep extra insulin so that you don’t run out (due to a natural disaster, for example)
  • Have a sick day plan

Sick day rules to prevent DKA

  • Check your blood glucose and urine ketones every 4 to 6 hours
  • Continue to take your insulin as instructed – more insulin than normal will be needed during times of illness
  • Stay hydrated – drink caffeine-free liquids (avoid caffeine as it can dehydrate you even more). Eight ounces per hour would be a good goal.
  • Make sure you are still getting some carbohydrates – for example, you can alternate 8 ounces of sugar-free beverages with 8 ounces of sugar-sweetened beverages. Getting enough carbohydrates will prevent “starvation” ketoacidosis. Easily digested foods include broth, dry toast, saltine crackers, juice, plain ice cream, plain yogurt, applesauce, sports drinks, or popsicles. Fifteen grams of carbohydrates spread over 1 to 2 hours is a good goal.

And always, if you are unsure as to what to do and find yourself not feeling better over several hours, call your healthcare team for advice. Otherwise you might find yourself or your family or friends calling 911. Remember that DKA is a serious condition that needs prompt attention.