Diabetic Ketoacidosis

A Preventable Crisis

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Diabetic Ketoacidosis

People who have had diabetic ketoacidosis, or DKA, will tell you it’s worse than any flu they’ve ever had, describing an overwhelming feeling of lethargy, unquenchable thirst, and unrelenting vomiting.

“It’s sort of like having molasses for blood,” says George. “Everything moves so slow, the mouth can feel so dry, and there is a cloud over your head. Just before diagnosis, when I was in high school, I would get out of a class and go to the bathroom to pee for about 10–12 minutes. Then I would head to the water fountain and begin drinking water for minutes at a time, usually until well after the next class had begun.”

George, generally an upbeat person, said that while he has experienced varying degrees of DKA in his 40 years or so of having diabetes, “…at its worst, there is one reprieve from its ill feeling: Unfortunately, that is a coma.”

But DKA can be more than a feeling of extreme discomfort, and it can result in more than a coma.

“It has the potential to kill,” says Richard Hellman, MD, past president of the American Association of Clinical Endocrinologists. “DKA is a medical emergency. It’s the biggest medical emergency related to diabetes. It’s also the most likely time for a child with diabetes to die.”

DKA occurs when there is not enough insulin in the body, resulting in high blood glucose; the person is dehydrated; and too many ketones are present in the bloodstream, making it acidic. The initial insulin deficit is most often caused by the onset of diabetes, by an illness or infection, or by not taking insulin when it is needed.

Ketones are your brain’s “second-best fuel,” Hellman says, with glucose being number one. If you don’t have enough glucose in your cells to supply energy to your brain, your body breaks fat down into small pieces so that it can be used as fuel. Ketones are formed during that process. Everybody has ketones in their bloodstream at some point, even people who don’t have diabetes. Your body sometimes uses them for fuel when you restrict your food intake, when you haven’t eaten for a while — even overnight, in very tiny amounts — and when you exercise.

The problem comes when you have diabetes and lack sufficient insulin to move glucose from your bloodstream into your body’s cells. Your body believes it isn’t getting enough food, so it reacts in two ways: It instructs the liver to turn glycogen (stored glucose) into glucose and release it into the bloodstream, and it begins to use fat for energy. The higher your blood glucose rises, the more fat is used — and the more ketones are formed.

“When you run out of insulin, ketone production becomes excessive,” Hellman says. “It takes approximately two hours after you run out of insulin for excessive ketone accumulation to occur.”

Ketones accumulate in your blood and, from there, go into the urine. That causes excessive urination, which is added to the increased urine production from high blood glucose. You then begin to become dehydrated.

At the same time, the increase in ketone production begins to change your body’s chemistry, and it becomes more acidic. The increased acidity changes the delicate mechanisms that regulate your body — changes that can affect your heart and, perhaps, your brain. In addition to urinating more, your body also tries to get rid of the excess acid by exhaling it, so your breathing becomes shallow and rapid and smells like acetone, or fingernail polish remover. Badly needed fluids may not be retained because of vomiting. Because your body isn’t getting the “food” it needs for energy, you have an overwhelming feeling of sleepiness. And you experience abdominal pain. In fact, Dr. Hellman says, DKA is sometimes misdiagnosed as appendicitis.

The treatment can be as simple as restoring fluids and insulin to the body, or as complicated as doing that plus bringing the body’s chemistry back into balance, something that can only be done in a medical setting such as an emergency room or hospital.

Not just for Type 1 diabetes

Historically, DKA was thought of as a condition experienced only by people with Type 1 diabetes, but some research is noting that DKA can occur in people with Type 2 diabetes as well, although it is generally not as severe in people with Type 2.

“A significant proportion of DKA occurs in patients with Type 2 diabetes,” said one study, published in the September 27, 2004, issue of Archives of Internal Medicine. In that study, conducted in Dallas, Texas, nearly 22% of people with DKA who were identified as having diabetes had Type 2 diabetes.

Another study, conducted in the Bronx, New York, and published in the February 2007 issue of Metabolism, found that 32% of the subjects studied had Type 2 diabetes. This study focused on hospital admissions for DKA among ethnic minorities, primarily African-Americans and Hispanics. It concluded that African-Americans with Type 2 diabetes may be particularly susceptible to developing DKA. (For information about hyperosmolar hyperglycemic state, another condition characterized by very high blood glucose levels, click here.)

How to check for ketones

Either a blood test or a urine test can check for ketones. The American Diabetes Association recommends that doctors use a blood test. Blood ketone testing equipment also is available for home use.

Why test blood rather than urine? First of all, because ketones enter the bloodstream first and then travel to the urine, ketones can be measured earlier in the blood. In addition, there are three types of ketones: acetoacetic acid, acetone, and beta-hydroxybutyric (b-OHB) acid. Urine ketone strips measure only acetoacetic acid and acetone, while blood ketone tests measure b-OHB, “the strongest and most prevalent acid in DKA,” according to the 2004 ADA position paper “Hyperglycemic Crises in Diabetes.”

Among people who are accustomed to checking their blood glucose, measuring blood ketones is widely accepted, according to a study published in the March 2006 issue of the British journal, Diabetic Medicine. In the study, 123 people 3 to 22 years old and their families were educated on sick-day care. Some were then given a meter that can measure blood ketones, and others were given urine ketone strips. While more than 90% of the subjects reported checking for blood ketones during illnesses, stress, or when blood glucose was elevated, only slightly more than 61% measured ketones in their urine. Hospital visits among those who checked for blood ketones were nearly half that of those who checked for urine ketones.

Two home meters are available to measure ketones in the blood: Nova Diabetes Care’s Nova Max Plus and CardioChek, which is made by Polymer Technology Systems, Inc. The Nova Max Plus can also be used to check blood glucose levels, and CardioChek can also measure glucose, lipid, and creatinine levels.

While testing blood for ketones is the preferred method, the test strips are more costly than urine ketone strips, and it requires a meter that can check for blood ketones.

Urine ketone testing is done by dipping a reagent strip in urine, urinating on the strip, or, in the case of very young children, pressing the strip against a wet diaper. After a specified amount of time, the color on the strip is compared to a color chart on the container to determine the amount — if any — of ketones present. Ketones in the urine are measured in terms of the amount present: negative (no ketones), trace, small, moderate, or large.

Several brands of urine ketone strips are available, including Ketostix, Keto-Diastix (which also check for glucose in the urine), and Clinistix. Ask your pharmacist if ketone strips are available individually wrapped in foil packets. While the initial cost is higher, they last longer than the ones that are loosely packaged in vials. However, they may need to be specially ordered.

When to check for ketones

Don’t wait for an emergency to happen before learning when to check for ketones and what to do if you detect ketones in your blood or urine. Talk to your doctor or diabetes educator in advance. In general, ketones should be checked for in the following situations:

  • You have an unexplained blood glucose level over 250 mg/dl two times in a row.
  • You are sick (with a cold, a sore throat, the flu, a stomach virus, suspected food poisoning, or anything else that makes you feel ill).
  • You are planning to exercise and your blood glucose level is over 250 mg/dl.
  • You have symptoms of DKA, such as increased urination, a stomachache, and dry mouth. (Click here for more about symptoms of DKA.)
  • Your insulin pump has malfunctioned, causing an interruption in insulin delivery.
  • You have experienced a traumatic stress.
  • You are pregnant, in which case you should check for ketones every morning before breakfast and any time your blood glucose level is over 250 mg/dl. Pregnant women who have ketones in the morning are advised to eat more carbohydrate late in the evening or during the night.

If you detect ketones in your blood or urine, general treatment guidelines include drinking plenty of water or other calorie-free fluids to help flush ketones out of the body, taking insulin to bring your blood glucose level down, and rechecking both your blood glucose level and ketone level every three to four hours. Additional insulin may be needed to bring your blood glucose level down if ketones are present.

If ketone levels are not coming down, or are going up, treat the incident as a medical emergency and go to a hospital.

With proper vigilance, having ketones appear in your blood or urine won’t escalate into a medical emergency, and your life won’t be in peril.

Originally Published November 19, 2009

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