The Danger of Diabetic Ketoacidosis

DIABETIC KETOACIDOSIS is a dangerous complication for people with diabetes. DKA occurs when the body lacks insulin for too long, causing blood sugar to spike. DKA can quickly become a medical emergency. Fortunately, DKA responds to prompt treatment.

DKA is preventable. Keeping blood sugar under control is the challenge. For people with Type 1 diabetes, in particular, staying on top of insulin regimens, whether through multiple daily injections or an insulin pump, is vital.

However, rising insulin costs and shifting insurance coverage make it harder. Between 2012 and 2016, the price of common insulin products nearly doubled, according to a January 2019 report from the Health Care Cost Institute.

Average point-of-sales prices for insulin rose from 13 cents to 25 cents per unit. “That translates to an increase of $7.80 a day in 2012, to $15 a day in 2016 for someone using an average amount of insulin,” according to HCCI figures.

This week, Congress opened hearings on expensive prescription drugs, including remarks from lawmakers on spiking insulin prices forcing patients to risk their health by rationing insulin.

What Causes Diabetic Ketoacidosis?

When the body has too little of the hormone insulin, blood sugar rises far above normal as the body loses its ability to use sugar for energy. In ketoacidosis, the body becomes acidic as it instead uses fat for energy, causing acids called ketones to form. These ketones accumulate in the blood and spill into the urine.

Normally, insulin is produced in the pancreas. In Type 1 diabetes, people need outside sources of insulin to survive.

About 3 million people in the U.S. have Type 1 diabetes, says Dr. Guillermo Umpierrez, a professor of medicine in the division of endocrinology, metabolism and lipids at Emory University School of Medicine, and chief of diabetes and endocrinology at Grady Memorial Hospital in Atlanta.

“Diabetic ketoacidosis results from the significant or complete lack of insulin,” Umpierrez says. “Therefore, it’s much more common in patients with Type 1 diabetes. In the United States, we believe about one-third of the patients with diabetic ketoacidosis have Type 2 diabetes and two-thirds have Type 1 diabetes.”

Patients with Type 2 diabetes can develop ketoacidosis when they have an infection, are under stress or are taking certain medications. Long-term, poorly controlled diabetes may be one of the most important risk factors for patients with Type 2 diabetes to develop DKA, Umpierrez says.

At its worst, DKA can be fatal. However, mortality is strongly related to precipitating causes. In someone who is newly diagnosed with diabetes, or who has stopped taking insulin and develops ketoacidosis, mortality is less than 1 percent, Umpierrez says. However, if DKA occurs in the context of a heart attack or other serious medical condition, that risk rises.

Onset of DKA

For people who don’t know they have diabetes, the first DKA episode often leads to diagnosis. For those with known diabetes, DKA means blood sugar is spiraling out of control.

Blood sugar levels vary throughout the day. Fasting blood sugars, after waking and before eating, tend to be lower. A fasting blood sugar of less than 100 milligrams per deciliter is considered normal. A random blood glucose level of at least 200 mg/dL indicates diabetes.

With DKA, glucose usually surpasses 250 to 350. “The average blood glucose in a patient with diabetic ketoacidosis is about 600 mg/dL – or six to eight times the normal blood glucose level in a nondiabetic person,” Umpierrez says.

Early DKA Symptoms

To turn rising blood glucose levels around, patients must recognize early DKA symptoms:

  • Increased thirst.
  • Frequent urination.
  • Unexplained weight loss.
  • Fruity-smelling breath.
  • Nausea.
  • Fatigue.
  • High blood glucose.
  • Elevated urine ketones.

DKA Emergency

Health care providers need to be aware of these progressing DKA symptoms and signs of dehydration:

  • Abdominal pain and cramping.
  • Vomiting.
  • Decreased perspiration.
  • Cool, dry skin.
  • Behavior changes (not acting right).
  • Vision changes.
  • Confusion.
  • Lethargy.

DKA and Kids

DKA is highly dangerous for children, says Dr. Arleta Rewers, an associate professor of pediatrics-emergency medicine at the University of Colorado School of Medicine and a physician at Children’s Hospital Colorado. “About 50 percent of kids who have DKA are admitted to the ICU,” she says. “They require very extensive treatment with fluids and insulin.”

Two basic scenarios bring children to the hospital, says Rewers, a contributor to the updated publication Diabetes in America from the National Institute of Diabetes and Digestive and Kidney Diseases. The first is kids who are developing diabetes but aren’t yet diagnosed, who suddenly begin showing symptoms.

In kids known to have diabetes, missed insulin treatments or brewing infections can predispose them to developing DKA. “Also, kids on insulin pumps can have DKA,” Rewers says. “Sometimes there’s a malfunction and it’s not recognized early enough.”

Complications extend beyond the crisis. “DKA also has long-term consequences,” Rewers says. “It changes brain development and brain functioning for a long time. Kids who had DKA can show memory and learning problems going on for several years.”

Once diabetes is diagnosed, DKA wipes out remaining insulin-producing beta cells in the pancreas, Rewers says, thus reducing any ‘honeymoon period’ and increasing kids’ lifelong struggle with glucose control. “It leaves a permanent mark on the child.”

Up to 1 percent of kids who come to the hospital with DKA may develop cerebral edema, or swelling in the brain, Rewers notes. Cerebral swelling can be fatal or leave the child with catastrophic health consequences.

Team Approach

Working closely with your endocrinologist, diabetes educator, dietitian and primary care provider will help you stay in control of diabetes and prevent DKA. Monitoring blood glucose is the most proactive way to prevent DKA, says Cara Schrager, a registered dietitian and certified diabetes educator at Joslin Diabetes Center in Boston.

Continuous glucose monitoring systems, which are worn on the body, make it easier for users to know how their glucose is doing in the moment. CGM technology checks the wearer’s glucose every few minutes. Most monitors also have trend arrows.

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