DKA: Diabetic ketoacidosis

You may not have heard of diabetic ketoacidosis if you don’t have diabetes. Perhaps you’ve heard of ketosis, which is a natural metabolic state that happens when you follow a ketogenic diet. But this isn’t the same as ketoacidosis, which, as anyone with diabetes probably already knows, is a potentially serious or even fatal complication of their condition. 

 

What is DKA?

Diabetic ketoacidosis – DKA for short – is when you have a build-up of acids in your blood as a result of having a sugar level that’s been too high for too long. If it isn’t treated quickly DKA can be life- threatening. Yet it’s a common complication of type 1 diabetes, and people with type 2 diabetes can be affected by it too (though this is rare).
 
According to Patient UK, each year nearly four per cent of people with type 1 diabetes experience DKA in this country (i). Experts also believe it’s more common in younger people, and that women are affected by DKA  more than men (ii). Many children with type 1 diabetes develop DKA too.
 
In some adults and children, becoming very unwell with DKA can be the first sign they have type 1 diabetes. Indeed, around six per cent of cases of DKA happen in adults who didn’t previously know they had the condition (i). Meanwhile 30 to 40 per cent of children with type 1 diabetes are diagnosed after developing DKA (iii).
 

How does DKA develop?

When you eat, the sugar (glucose) that’s absorbed into your bloodstream from your food is used as fuel by your body’s cells or stored until it’s needed. This can’t happen without insulin – a hormone made by the pancreas – because insulin helps your cells take in and use the sugar they need. However, people with type 1 diabetes are unable to make much or any insulin.
 
If you can’t produce insulin, the sugar stays in your bloodstream where it can build up and make you very unwell. This is why it’s essential that people with type 1 diabetes take insulin – either as an injection or by using a personal insulin pump – to control their blood sugar level.
 
Find out more about insulin and diabetes by reading our diabetes guide. 
 
Even if you’re already taking insulin there are several reasons why you may not be getting enough of it – see below. When this happens, your blood sugar level keeps rising. At the same time your cells, which are unable to access the sugar in your blood, start burning fat to use as an alternative source of fuel. But when cells burn fat they produce acids called ketones, high levels of which can change the chemical balance of your blood and cause a range of symptoms and complications.
 

What are the complications of DKA?

If you think you may have DKA it’s important to get immediate medical help, since the condition can cause life-threatening complications if it isn’t treated. Some of the main ones include:
 

• Cerebral oedema (swelling of the brain) that can eventually cause a coma (this is more common in children than in adults – according to Patient, up to 80 percent of diabetes-related deaths in children under the age of 12 years are caused by cerebral oedema (i))

• Pulmonary oedema (excess fluid in the lungs) – though this is rare

• Hypoglycaemia (low blood sugar)

• Hypokalemia (low potassium)

• Loss of consciousness

 
The good news is that fewer people die as a result of having DKA these days: 30 years ago the mortality rate was 7.96 percent, but the latest figures from 2013 show it was then around 0.67 percent (i).
 

What causes diabetic ketoacidosis?

DKA develops when someone with diabetes has a lack of insulin in their body. This makes their body’s cells use fat for energy, which can result in high levels of ketones building up in their blood.
 
If you have type 1 diabetes you’ll usually be taking insulin on a regular basis to keep your blood sugar level under control. But several things can happen to cause a lack of insulin in your body (though sometimes there’s no obvious reason). These include:
 

• Skipping meals

• Frequently missing an insulin injection or not using enough of your insulin

• Having an illness or infection (having flu, for instance, or a chest or urinary tract infection)

• High blood sugar levels caused by puberty or a growth spurt

• Having a problem with your insulin pump if you use one (such as if your device becomes clogged)

• Having an injury or surgery

• Taking certain medicines such as steroids, some antipsychotics and some diuretics (water tablets) 

• Being pregnant

• Being under stress

• Using illegal recreational drugs

• Binge drinking 

• Having your period (this can sometimes cause high blood sugar)

• Having heart disease or a stroke 

• Having a blood clot in your lungs

 

What are the warning signs of diabetic ketoacidosis?

Knowing the signs and symptoms to look out for can help you spot early warnings of DKA, which means you can get treatment as quickly as possible. These include:
 

• High blood sugar

• Frequent urination 

• Feeling very thirsty

• Dry mouth

• Feeling and/or being sick

• Blurred vision

• Stomach pain

• Aching muscles

• Facial flushing or dry skin 

• Deep, heavy or rapid breathing 

• Fatigue and weakness 

• Unusual-smelling breath (the smell is often described as fruity, as in pear drop sweets, or like nail polish remover) 

• Confusion 

• Fainting 

 
If you use insulin, your doctor or diabetes specialist will tell you what to look out for and what to do if you suspect you may have any of the symptoms of DKA. If you’re not sure, call your GP or a member of your diabetes team to find out whether or not you need emergency help (call NHS 111 if you cannot get in touch with your care team or your GP).
 

DKA diagnosis criteria

Anyone with type 1 diabetes and some people with type 2 diabetes are at risk of developing DKA. Other things that increase that risk in those living with diabetes – some of which relate directly to the causes of DKA – include the following:
 

• Being younger (researchers suggest 36 percent of cases happen in people aged 30 or younger, compared with only 14 percent in people aged 70 plus (iv))

• Being under emotional or psychological stress

• Having cardiovascular disease (eg heart attack or stroke)

• Having an acute gastrointestinal illness (pancreatitis, for instance)

• Misusing alcohol or drugs

• Having an eating disorder

• Being pregnant

 

How to check for DKA

If you have type 1 diabetes, you’ll already be used to testing your blood sugar level. It’s likely that your GP or specialist will have given you a blood or urine test kit to check for your ketone level too. If you have any of the symptoms of DKA, or even if you simply don’t feel well, the first thing you should do is check your blood sugar level.
 
According to the NHS, if your blood sugar level is 11mmol/L or higher, the next thing you should do is check your ketone level. If your ketone test checks your blood, this is what your result means:
 

• 0.6mmo/L or lower: normal ketones

• 0.6 - 1.5mmol/L: slightly increased DKA risk, test again in two hours and drink plenty of sugar-free fluids in the meantime

• 1.6 - 2.9mmol/L: increased DKA risk, contact your GP or a member of your diabetes care team as soon as possible, as you may need additional fast-acting insulin 

• 3mmol/L or higher: very high DKA risk, get medical help immediately (go straight to A&E or call 999 for an ambulance)

 
If your ketone test kit checks your urine, on the other hand, the number you have to keep in mind is 2+, which means it’s highly likely you have DKA and should get immediate medical help.
 
It’s also a good idea to contact your GP or diabetes team if you feel unwell even if your glucose and ketone levels are only slightly higher than normal, and also if you feel fine but your levels are higher than they are normally. If you can, tell a friend, carer or family member about the warning signs of DKA too, and let them know if you’re feeling ill or if you’re concerned you may be developing DKA.
 
Another thing you should be aware of is that you shouldn’t exercise if your blood sugar and ketones are high, even if you’re feeling well.
 

DKA treatment

DKA is a medical emergency and needs to be treated as quickly as possible, usually in a hospital where you can be given intravenous fluids and insulin. You’ll usually also be given electrolytes – important minerals such as sodium, potassium and chloride – to keep your body including your heart, nerves and muscles working properly.
 
While you’re at hospital doctors will keep an eye out for any other serious problems that may develop, including problems with your lungs, kidneys or brain. 
 

How long does it take to recover from diabetic ketoacidosis?

Most people with DKA stay in hospital for around two days, and are discharged when their ketones have returned to a safe level and when they’re eating and drinking normally again.

 

How can you prevent ketoacidosis?

There are several things you can do to reduce your risk of developing DKA. Knowing as much as you can about the risk factors for DKA and how to monitor your blood sugar and ketone levels is essential. Meanwhile some of the other things you can do include the following:
 

• Take your insulin regularly, as often as your doctor or specialist prescribes, and follow their instructions for increasing your insulin if you’re not well.

• Store your insulin correctly to make sure it doesn’t become damaged or degraded, and check that it hasn’t expired. 

• Make sure your insulin devices – including pens, needles and pumps – are all working properly by following the care and maintenance instructions that come with them. If you think they may be faulty, ask your GP or diabetes team for replacements immediately.

• Check your blood sugar level regularly, as often as your GP or specialist advises, and take steps to reduce it quickly if it starts to rise. If you find it difficult to keep your blood sugar at your target level, ask your GP or diabetes team for advice.

• As well as blood sugar testing equipment, always have a supply of ketone test kits at home (your GP or diabetes team can supply them).

• Whenever you take any new medicines – prescription or over-the-counter remedies – check with your GP or pharmacist before taking them, as some medicines can increase your risk of DKA.

• Stay as healthy as possible by following your GP or specialist’s advice on diet and exercising.

• Drink plenty of fluids – water is ideal but other sugar-free drinks also count towards your daily intake (though avoid having too many caffeinated drinks such as tea, coffee and colas, or too much alcohol).

• Learn everything you can about what you should do when your blood sugar level goes up, when you eat or drink something that may affect it or when you increase your activity levels – you may, for instance, need to take extra insulin on certain occasions, check your blood sugar more often or drink more fluids.
   

 

Sick day rules

Being unwell can affect your risk of developing DKA because you may not be able to follow your usual routines, including those for your diabetes management. Feeling poorly can also raise your blood sugar, as more sugar is released into your bloodstream to help fight illness and infection.
 
Meanwhile some illnesses – vomiting and diarrhoea, for instance – can make your blood sugar drop because you may not feel like eating much and what you do eat may not be very well absorbed.
 
If you have diabetes your GP or a member of your diabetes care team can advise you on what you should do when you’re under the weather, including which medicines you should keep taking (especially insulin) and which ones you should reduce or stop (try using an alarm on your smartphone to remind you to take your insulin, if that helps).
 
You may have to test your blood sugar more often too when you’re ill, plus test for ketones even if your blood sugar is normal. Keep drinking and try to eat if you can face it – stay hydrated by drinking plenty of unsweetened drinks, and try eating little and often if you can’t face proper meals (you may be able to stomach soft or liquid foods if you have just a mouthful or two every now and then). However, if you can’t keep anything down, including fluids, contact your GP or diabetes care team straight away.
 

Natural remedies for diabetes

For further support on keeping your risk of developing DKA as low as possible, you may want to consider taking nutritional supplements that may help support your diabetes management. Note, however, that supplements should never be used as an alternative to conventional diabetes medicines or medical care.

If you have diabetes you should also always check with your GP before taking these or any other supplements, as there’s a risk your blood sugar could dip too low and put you at risk of a serious complication called hypoglycaemia (hypo).

Find out more about hypos in our guide to diabetes
 

Multivitamin

One all-round supplement you may want to try first is a good-quality multivitamin and mineral, as it may help make sure your body is getting all the nutrients it needs to stay healthy. To find out more about multivitamin supplements and the variety of different formulations available, read our guide to multivitamins and daily requirements.

Meanwhile you may also want to consider one or more of the following:
 

Cinnamon

A natural remedy that’s been used in traditional Chinese medicine for centuries, cinnamon is a spice that’s also often recommended by natural therapists for people with type 2 diabetes, as there is some evidence it may help improve blood sugar levels (v).
 

Alpha lipoic acid

There’s also evidence to suggest this fatty acid and powerful antioxidant could help control blood sugar levels (vi) as well as improve insulin sensitivity in people with type 2 diabetes (vii). However, if you have diabetes always consult your GP before taking alpha lipoic acid as it may enhance insulin activity.
 

Magnesium

Some researchers have found that people who have diabetes may have low magnesium levels (viii), possibly because having diabetes or taking the medicines used to treat it may cause magnesium deficiency. Others have also discovered magnesium may even help with blood sugar control (ix).
 

Turmeric

 

Best known as a curry spice, turmeric contains a compound called curcumin that’s believed to have a number of potential health benefits, including the ability to reduce blood sugar levels (though to date most studies have been carried out in animals rather than humans, meaning the available evidence isn’t as strong as it could be). However, one study has found that curcumin may help improve blood sugar level control after investigating its effects in people with diabetic foot ulcers (x). 
 

High-strength fish oils

Omega-3 fatty acids – most notably EPA and DHA, two fatty acids that are found in oily fish such as salmon, trout, sardines and mackerel and fish oil supplements – are widely considered helpful for general health and wellbeing. According to the NHS, a healthy, balanced diet should include at least two portions of fish a week, including one of oily fish (xi). But if you can’t or don’t like eating fish, you could miss out on the benefits. The answer may be to take a high-strength fish oily supplement, or an omega oil supplement derived from marine algae instead of fish if you’re a vegetarian or vegan.
 

Fenugreek

Fenugreek seeds have a long tradition of use in some parts of the world, including in Ayurvedic medicine. There’s some evidence fenugreek seeds may be helpful in controlling type 2 diabetes and reducing insulin resistance – which is when your body cannot use insulin as well as it should – though supporting studies to date are small in scale (xii). However, don’t take fenugreek if you’re pregnant or breastfeeding.
 

Vitamin D

Vitamin D is probably best known for helping the body to absorb calcium. However scientists are frequently discovering new ways in which it’s essential for health. Some, for instance, suggest there’s a link between low vitamin D levels and type 1 diabetes (xiii). Vitamin D deficiency is common, including in the UK. That is why Public Health England advises adults and children over the age of one year old to consider taking a daily supplement containing 10mcg of vitamin D, particularly during autumn and winter (xiv).
 
If your skin is rarely exposed to the sun – if you spend most of your time indoors, for instance, or if your skin is always covered when you’re out and about – you may need to take vitamin D throughout the year. People with dark skin from African, Afro-Caribbean and South Asian backgrounds should consider taking vitamin D all year round too, PHE advises.

The recommended form of vitamin D is vitamin D3 or cholecalciferol, as it’s the natural form of vitamin D that the body makes when it’s exposed to sunlight. Vitamin D3 supplements are available in tablet form, and now you can get them in veggie-friendly drops too. However most vitamin D3 supplements are made from the fat of lamb’s wool, which means they’re unsuitable for vegans. The good news is that vegan vitamin D3 supplements sourced from lichen are now more widely available.
 

High-strength anthocyanidins

Having poorly controlled diabetes over time can damage your blood vessels, leading to a range of complications including problems with the heart, brain, eyes, nerves and kidneys. Anthocyanidins and their derivatives anthocyanins are potent antioxidant compounds found in dark-skinned fruits such as blueberries, cranberries, raspberries, blackberries and red grape, as well as vegetables such as red cabbage, red onions and aubergines. These may be helpful as they may strengthen and repair the walls of blood vessels by protecting collagen in the body (collagen being the structural protein that gives blood vessels their strength).
 
Anthocyanidins are also available in supplement form (choose a product that combines anthocyanidins with vitamin C, as vitamin C supports the body’s ability to produce collagen). 
 

Find out more

Diabetic ketoacidosis is common and can make you quite ill, but there are lots of things you can do to prevent it. Being aware of the warning signs can be a huge help, because the sooner you realise you may be affected by DKA, the quicker you can take steps to nip it in the bud or receive treatment, depending on how close you are to developing it. Treatment, however, usually means a stay in hospital, so it’s well worth learning about what you can do to prevent DKA.
 
If you’re interested in finding out more about diabetes and how to manage it effectively, take a tour around the diabetes section of our pharmacy health library.  
 

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Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

 

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