Diabetic Ketoacidosis: Symptoms, Types, Causes and Treatment

Diabetic ketoacidosis (DKA) is a serious, potentially life-threatening complication of diabetes mellitus. It occurs when your body lacks enough insulin to allow glucose into your cells, so it starts breaking down fat for fuel—leading to a dangerous buildup of ketones and acid in your blood. Understanding DKA is crucial for both patients and healthcare providers, as prompt recognition and treatment are essential to prevent severe outcomes. In this article, we’ll explore the key symptoms, types, causes, and treatment strategies for DKA, supported by the latest research and clinical findings.

Symptoms of Diabetic Ketoacidosis

DKA often develops quickly, sometimes within hours, and its symptoms can range from mild to severe. Recognizing these signs early can make all the difference in preventing severe complications. Although some symptoms overlap with other illnesses, certain features are highly suggestive of DKA, especially in people with diabetes or those at risk.

Symptom	Description	Frequency/Prevalence	Source(s)
Polyuria	Excessive urination	83–98%	1 2 5
Polydipsia	Excessive thirst	85–98%	1 2 5
Vomiting	Nausea and frequent vomiting	46–58%	1 3 5
Fatigue	General weakness/tiredness	62–69%	1 2 5
Abdominal pain	Pain/discomfort in the abdomen	32–52%	1 2 3
Dyspnea	Rapid/deep breathing (Kussmaul)	57% (classic, less frequent now)	1 3 5 7
Weight loss	Unintentional weight reduction	81%	1 5
Dehydration	Signs of fluid loss (dry mouth, etc.)	Common	1 3 5 7

Table 1: Key Symptoms of Diabetic Ketoacidosis

Common Symptoms and Their Patterns

Most people with DKA develop a combination of symptoms related to high blood sugar and acidosis. The most prominent are polyuria (frequent urination) and polydipsia (excessive thirst), found in up to 98% of cases. Fatigue and unintentional weight loss are also common, reflecting the body’s inability to use glucose efficiently and the resulting breakdown of fat and muscle for energy. Vomiting and abdominal pain are especially frequent in children and young people but can occur in all age groups 1 2 3 5.

Classic and Less Obvious Features

• Kussmaul Breathing: This deep, rapid breathing is the body's attempt to reduce blood acidity but is becoming less common as DKA is recognized and treated earlier 3 5 7.
• Dehydration: Nearly all patients show signs of fluid loss, including dry mouth, sunken eyes, and poor skin turgor.
• Dyspnea (Shortness of Breath): Sometimes misinterpreted as asthma or pneumonia.
• Altered Mental Status: Severe DKA may cause confusion, lethargy, or even coma, particularly in children 5 7.

Atypical Presentations

DKA can sometimes mimic other conditions, such as gastroenteritis, appendicitis, or even psychiatric disorders due to altered behavior or confusion 2 5 11. Its symptoms can overlap with other metabolic crises, which makes early laboratory assessment essential for diagnosis 1 7.

Types of Diabetic Ketoacidosis

While DKA is classically associated with type 1 diabetes, it can develop in a range of clinical contexts, including type 2 diabetes and, rarely, in people without diabetes. Recent advances have also identified a "euglycemic" form of DKA that can be particularly challenging to recognize.

Type	Description	Typical Scenario	Source(s)
Classic DKA	Hyperglycemia, ketosis, metabolic acidosis	Type 1 diabetes (esp. youth)	1 7 6
DKA in Type 2	Occurs in type 2 diabetes (esp. with stress)	Adults, elderly, infection	3 6 7 13
Euglycemic DKA	Ketoacidosis without marked hyperglycemia	SGLT2i use, pregnancy, etc.	8 9
DKA without DM	Rare, stress-induced in non-diabetics	Alcohol abuse, starvation	9

Table 2: Types of Diabetic Ketoacidosis

Classic DKA

Traditionally, DKA is defined by markedly elevated blood glucose (>250 mg/dL), anion gap metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L), and the presence of ketones in blood or urine 1 7 10. It is most often seen in young people with type 1 diabetes, but can occur at any age 1 5 7.

DKA in Type 2 Diabetes

Although less common, DKA can develop in those with type 2 diabetes, particularly during periods of severe stress, infection, or treatment noncompliance. In some populations, up to 34% of DKA cases occur in type 2 diabetes 3 6 13.

Euglycemic DKA (EDKA)

Euglycemic DKA features the biochemical triad of DKA but with normal or only mildly elevated blood glucose (<250 mg/dL). This form is especially associated with the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors, pregnancy, starvation, or chronic liver disease 8 9. Because blood sugar is not severely elevated, EDKA is often misdiagnosed, leading to dangerous delays in treatment.

DKA Without Diabetes

Rarely, ketoacidosis can occur in people without diabetes, often as a result of severe illness, starvation, alcohol abuse, or metabolic disorders 9. These cases are challenging and require careful evaluation of underlying causes.

Causes of Diabetic Ketoacidosis

Understanding what triggers DKA is fundamental for both prevention and effective clinical management. DKA is almost always precipitated by a combination of insulin deficiency and an increase in counterregulatory stress hormones.

Cause	Mechanism/Trigger	Prevalence/Notes	Source(s)
Insulin Deficiency	Missed doses, pump failure	47–53%	1 3 11
Infection	Increases insulin requirement	38–69%	3 12
New Onset Diabetes	Initial presentation of diabetes	23–40%	2 5 12
Other Illness	MI, stroke, pancreatitis, trauma	Especially in elderly	10 12 14
Medication Effects	SGLT2 inhibitors, steroids	EDKA risk	8 9
Social/Family Issues	Psychosocial stress, non-compliance	Especially in youth	11

Table 3: Common Causes of Diabetic Ketoacidosis

Insulin Deficiency

• Missed Doses: The most common trigger in people with established diabetes. This includes intentional omission (often in teenagers), missed insulin injections, or technical failure of insulin delivery devices 1 3 11.
• Noncompliance: Up to half of DKA episodes in established diabetics are due to poor adherence to insulin regimens.

Infection

Infection is the leading precipitating factor in many studies, accounting for up to 69% of DKA cases 3 12. Common infections include:

• Pneumonia
• Urinary tract infections
• Sepsis

These illnesses increase insulin demand and can tip a person with diabetes into DKA if not rapidly addressed.

Newly Diagnosed Diabetes

DKA may be the first manifestation of diabetes, especially in children and adolescents. Studies report 23–40% of new diabetes cases presenting with DKA 2 5 12. Young age and lack of prior diagnosis are major risk factors for DKA at onset 5.

Other Medical and Social Triggers

• Acute Illness: Heart attack, stroke, pancreatitis, or trauma can all precipitate DKA, especially in older adults 10 12 14.
• Medications: SGLT2 inhibitors are increasingly recognized as a cause of euglycemic DKA. Steroids and certain antipsychotics can also raise blood glucose and ketone levels 8 9.
• Psychosocial Factors: Family stress, school problems, or psychiatric illness, particularly in adolescents, can contribute to poor diabetes management and increased DKA risk 11.

Treatment of Diabetic Ketoacidosis

The management of DKA is a medical emergency and requires a systematic, evidence-based approach. Prompt and aggressive treatment can prevent complications and reduce mortality.

Step	Main Actions/Goals	Key Considerations	Source(s)
Fluid Therapy	Restore volume, correct dehydration	Start with isotonic saline	1 10 16 18
Insulin	Suppress ketogenesis, lower glucose	IV insulin preferred	1 15 16 17
Electrolytes	Correct K+, phosphate, Mg, Na	Monitor closely	10 16 18
Address Cause	Treat infection/MI/precipitating factors	Essential for recovery	1 10 12
Monitoring	Glucose, ketones, pH, electrolytes	Hourly checks	1 10 18
Prevent Recurrence	Patient education, sick-day rules	Discharge planning	1 4 10

Table 4: Main Steps in DKA Treatment

Initial Resuscitation: Fluids First

• Volume Replacement: The first priority is correcting dehydration with intravenous isotonic saline (0.9% NaCl). This helps restore circulation, lower blood glucose, and improve tissue perfusion 1 10 16 18.
• Fluid Deficit: Most patients are 5–10% dehydrated, often requiring several liters of fluid in the first 24 hours.

Insulin Therapy

• IV Insulin: Regular intravenous insulin is the standard of care, started after initial fluid resuscitation. This suppresses ketone production, lowers blood glucose, and corrects acidosis 1 15 16 17.
• Alternative Routes: Subcutaneous rapid-acting analogues are effective for mild-to-moderate DKA but IV insulin remains preferred in severe cases or children 15 17.
• Low-Dose Regimens: Low-dose insulin is as effective as high-dose and has fewer side effects 16 17.

Electrolyte Correction

• Potassium (K+): DKA treatment can rapidly lower blood potassium, risking dangerous arrhythmias. Potassium should be monitored hourly and replaced as needed 10 16 18.
• Phosphate and Magnesium: Deficiencies are common and may require supplementation, especially if the patient is symptomatic 10 16.
• Bicarbonate: Rarely needed unless acidosis is severe (pH <6.9) 10 16.

Treat Underlying Causes

• Infections: Start empiric antibiotics if infection is suspected 1 3 12.
• Other Illnesses: Address myocardial infarction, stroke, or pancreatitis as appropriate 10 12 14.

Monitoring and Prevention

• Frequent Reassessment: Blood glucose, ketones, pH, and electrolytes should be checked hourly initially 1 10 18.
• Complications: Watch for cerebral edema (especially in children), hypoglycemia, and hypokalemia 1 10.
• Education: Before discharge, provide education on sick-day rules, glucose and ketone monitoring, and when to seek help. Most patients with diabetes have insufficient knowledge about DKA prevention, highlighting the need for targeted education 4.

Conclusion

Diabetic ketoacidosis remains a critical and complex medical emergency requiring rapid recognition and comprehensive management. Both healthcare professionals and people with diabetes must be aware of its symptoms, the range of types, contributing causes, and the essential steps in treatment and prevention.

Key Takeaways:

• DKA is characterized by hyperglycemia, ketosis, and acidosis, presenting most often with polyuria, polydipsia, vomiting, fatigue, and abdominal pain 1 2 3 5 7.
• While classically linked to type 1 diabetes, DKA can also occur in type 2 diabetes and even in euglycemic or non-diabetic states, particularly with SGLT2 inhibitor use or severe stress 3 6 8 9.
• The main causes include insulin deficiency (missed doses/noncompliance), infections, new-onset diabetes, and acute medical or psychosocial stressors 1 3 11 12 14.
• Treatment centers on fluid resuscitation, insulin therapy, careful electrolyte management, and addressing precipitating factors, with continuous monitoring to prevent complications 1 10 16 18.
• Patient education is vital to prevent recurrence, yet many patients lack sufficient knowledge about DKA symptoms and management, underscoring the need for ongoing support and education 4 10.

By understanding DKA’s warning signs, risk factors, and management, both patients and clinicians can work together to reduce the risk and impact of this serious diabetic complication.