Diabetic Ketoacidosis: Do I Have It?

Medically Reviewed by Zilpah Sheikh, MD on December 19, 2023
Written by Kristin Mitchell, WebMD Editorial Contributor, Nechama F. Sammet Moring
12 min read

Diabetic ketoacidosis, also known as DKA, is a serious complication of diabetes that happens when your body doesn't have enough of a hormone called insulin, which usually creates energy by letting blood sugar into your cells. Instead, your body starts to break down fat for energy, causing ketones to develop in your blood. If your body makes too many ketones at once, the buildup damages your body and makes your blood too acidic, which is called ketoacidosis.

If you don’t get medical help in time, DKA can be life-threatening. Symptoms of DKA often build up slowly, so it’s important to know the warning signs, as it can usually be prevented and treated if discovered early.

Ketoacidosis blood sugar levels

When you don’t have enough insulin, the sugars you eat can’t get out of your blood and into your cells. This makes the sugar build up in your blood, causing high blood sugar. During diabetic ketoacidosis, your blood sugar will be very high and your insulin levels will be low.

If your blood sugar is over 240 mg/dL, you should check your ketones using a urine ketone test or a glucometer (blood ketone test) every 4-6 hours. Ketoacidosis is generally considered to start at 250 mg/dL. Talk to your doctor if your blood sugar level is outside of your target range.

Go to the emergency room if your blood sugar is 300 mg/dL or more and won’t go down or if you have any symptoms of DKA, including frequent throwing up, tiredness, or difficulty breathing.

 Ketoacidosis vs. ketosis

Ketoacidosis and ketosis sound similar but are different processes. 

Typically, your body uses sugar (glucose) for energy. With ketosis, you don’t eat many carbohydrates (foods like bread, pasta, or other starches), which usually turn into sugar quickly, so your body starts burning fat to create energy. Ketones are released into your blood as fat is broken down.

Your body makes ketones, but not enough to make your blood too acidic, so ketosis isn’t dangerous. With ketosis, your body has enough insulin and it's working properly.  

In diabetic ketoacidosis, ketones build up too fast, and your blood becomes acidic. Diabetic ketoacidosis is life-threatening.

Diabetic ketoacidosis symptoms can appear quickly and may even be your first warning sign that you have diabetes. The first signs of DKA can include:

  • Urge to pee a lot more than usual
  • High ketones amount
  • Strong thirst
  • Severe headache
  • Dehydration
  • High blood sugar levels (more than 250 mg/dL)

If you don’t get medical help, you can have more DKA symptoms, including:

  • Nausea or throwing up (vomiting)
  • Weakness, muscle aches, or stiffness
  • Dry mouth and dry skin
  • Fatigue/feeling very tired
  • Confusion (feeling foggy, or less alert than usual)
  • Flushed face (your face is redder or feels sweaty or hot)
  • Headache
  • Breath that smells sweet or fruity
  • Pain in your stomach
  • Breathing problems including breathing fast, having trouble catching your breath, or shortness of breath

Diabetic ketoacidosis can be very dangerous and even life-threatening. You should go to the emergency room right away if:

  • Your ketones are moderate or high and you have any DKA symptoms
  • You have more than one symptom of DKA, even if you haven’t tested your ketones yet
  • Your blood sugar is 300 or more, and it isn’t going down
  • You’re throwing up and you can’t keep food or water down, or you’ve been throwing up for more than 2 hours
  • Your breath smells sweet or fruity
  • Your blood sugar stays higher than your target range, even when you do your usual home treatments
  • You’re very tired, woozy, or confused (foggy feeling)
  • You feel queasy or your belly hurts
  • It’s hard to breathe

If you have the symptoms described above, you should go to the emergency room or call 911, even if you haven’t been told you have diabetes.

HHS vs. DKA

Another condition that can sometimes seem like diabetic ketoacidosis is hyperosmolar hyperglycemic state, also called HHS. HHS and DKA have similar symptoms, including feeling very thirsty, having to pee more than usual, dry mouth, and feeling confused or less alert, weak, or nauseous. Both HHS and DKA can happen when your blood sugar is too high. 

With HHS, very high blood sugar over a long period makes you dehydrate (lose water), causing your blood to get too concentrated. This can harm your brain, kidneys, heart, and other parts of your body. HHS is more likely to happen to people with type 2 diabetes. Symptoms of HHS that usually don’t happen with DKA include blurry vision or suddenly losing your ability to see, trouble moving your body, especially on only one side, and seeing things that aren’t usually there (hallucinations).

A big difference is that with HHS, your body doesn’t make too many ketones. HHS also takes longer than DKA to develop, and your blood sugar is usually higher (600 or above) than it is in DKA. People who develop HHS are more likely to die from it (about 10 or 20 of every 100 people). On the other hand, only about 1 to 8 in 100 people who get DKA die from it.

 

Diabetic ketoacidosis usually happens because your body doesn't have enough insulin. Your cells can't use the sugar in your blood for energy, so they use fat for fuel instead. Burning fat makes acids called ketones. If the process goes on for a while, they could build up in your blood. Having too many ketones can change the chemical balance of your blood and throw off your entire system.

Certain things can make your blood sugar go up and your insulin go down, which makes your body more likely to start burning fat and building up ketones. These include:

  • Missing insulin doses and diabetes mismanagement. If you miss doses of insulin or other medications a lot, or if your doctor prescribed the wrong dose, etc., your blood sugar might be further away from your target. You are at higher risk for DKA when your diabetes is not well-managed.

  • Timing of diabetes diagnosis. People who don’t know they are diabetic and people who just found out that they have diabetes are more likely to get DKA. This is probably because they don’t have as much experience managing theirdiabetes.

  • How you take your insulin. People who give themselves shots of insulin are more likely to get DKA than people who use an insulin pump. However, if you use an insulin pump and it gets clogged or stops working, you’re at risk for DKA because your body won’t get the amount of insulin you need until your pump gets fixed.

  • Using expired insulin. If your insulin is spoiled or expired, it might not work as well as it should.

Other things that could lead to DKA include:

  • Being sick or stressed. When you’re sick or under a lot of stress, your body makes more stress hormones, including adrenaline and cortisol. These hormones can get in the way of insulin and stop it from helping sugar get inside your cells. Talk to your doctor about whether you’ll need higher doses of insulin if you’re sick.
  • Infections. Common sicknesses that sometimes lead to DKA are urinary tract infections (also called UTIs or bladder infections) and pneumonia.
  • Trauma to your body. Getting hurt or needing surgery also makes your body send out stress hormones that get in the way of insulin, which can lead to DKA.
  • Heart attacks, strokes, and blood clots. These problems with your heart, lungs, and blood flow can all cause DKA.
  • Pancreatitis (inflammation in your pancreas). This can lead to DKA, and it can also be a symptom of it. Many people with pancreatitis have bad stomach pain.
  • Pregnancy. Being pregnant changes how your body processes sugars and other nutrients. Pregnant people who have diabetes are at higher risk of DKA.
  • Alcohol, drugs, and certain medicines. Drinking alcohol and using drugs such as cocaine can put you at higher risk of DKA. Some medications, such as corticosteroids, water pills (diuretics), and those used to treat serious mental health conditions can also lead to DKA. Make sure your doctor or health care provider knows you have diabetes whenever they prescribe you a new medication. Talk to your doctor or a mental health professional if you or other people in your life are worried about your alcohol or drug use.

Anyone who has diabetes can get diabetic ketoacidosis. Some people find out that they have diabetes only after they get DKA. However, certain things make you more likely than other people with diabetes to get DKA. These risk factors include:

  • Type of diabetes. People with type 1 diabetes are more likely to get DKA, and it’s often more serious than it is in people with type 2 diabetes. Type 1 diabetes means that your body doesn’t make insulin, or just makes a very small amount. People with type 2 diabetes can still get DKA if the insulin they do make isn’t enough to stop their body from making ketones.
  • Age. Older adults are more likely to get complications from diabetes, including DKA, and it can be even more serious than it is in younger people. Among children with diabetes, kids under 5 are more likely to get it. Children assigned female at birth are more likely to get it around the age of puberty. 
  • Access to insulin. In the U.S., about 1 in 5 people with diabetes who need insulin don't take their insulin as often as their doctor wants them to, take smaller doses than they need, or go without because insulin costs too much. If you can’t afford to take as much insulin as you need, you have a higher risk of getting DKA. Talk to your doctor about programs to help people afford insulin.
  • Missing meals. Not eating regularly can cause your body to start making too many ketones.
  • Family history of diabetes or autoimmune diseases. This can put you at risk of getting type 1 diabetes. Undiagnosed Type 1 diabetes can lead to DKA.

 Your doctor will figure out if you have DKA by doing a physical exam and asking you about your symptoms, experiences, and medical history. They’ll check your blood sugar, ketones in your pee and/or blood, and your blood pH and bicarbonate levels.

Your doctor might also do tests to diagnose DKA or check how it’s affecting you. These include:

  • Basic metabolic panel. Blood tests check how well your kidneys, liver, and pancreas are working. These look at the levels of different chemicals in your blood such as salt, electrolytes, and potassium.
  • Blood pH. PH is a measure of how acidic things are. Because ketones can make your blood too acidic, doctors will take blood to check its pH level. Blood pH levels under 7.3 are too acidic.
  • Blood glucose test (A1C). This blood test looks at how your blood sugar has been over the last few months and how controlled your diabetes has been overall. You can also check your sugar levels at home with a urine test strip.
  • Testing your pee (urinalysis). Looking at a sample of pee helps your doctor measure your ketones, sugar, and other nutrients. They might also measure how much pee you make (to make sure that you aren’t getting dehydrated) and test for infections.

Other diagnostic testing for DKA includes:

Your doctor might give you a chest X-ray, CAT scan, or MRI to rule out other problems or get more information about how DKA is impacting you. They may also recommend tests for your heart (electrocardiogram, or ECG) to check how it's working.

Testing for ketones

You can check yourself for ketones at home with a urine sample. You can buy kits for testing your pee over the counter. Some glucose meters can also test for ketones in the blood sample when you do a finger prick. Ask your doctor to show you how to do an at-home ketone test if you have any questions.

If you have diabetes, it’s important to follow advice from your doctor about when to test for ketones. In general, you should test for ketones in these situations:

  • If your blood sugar is 240 mg/dL or more. You should test your blood sugar and ketones again 30 minutes after your first high reading
  • If you are sick, check your ketones every 4-6 hours
  • If you have any symptoms of DKA

If you have any symptoms of DKA, you should call your doctor or go to the emergency room right away. This is especially important if you have certain risk factors.

If diabetic ketoacidosis is untreated, you could pass out, go into a coma, and possibly die. You should go to the hospital to treat diabetic ketoacidosis. There, you will receive emergency treatments, such as:

  • Insulin through an IV to bring your ketones down
  • Fluids to get you hydrated and bring your blood chemistry back into balance
  • Electrolyte replacement through an IV to replace key minerals such as sodium, potassium, and chloride to keep your heart, muscles, and nerves working properly
  • Antibiotics, if you have any infection
  • A further heart evaluation, if your doctor suspects you’re at risk for a heart attack

DKA complications are possible if you don’t have emergency treatments such as electrolyte replacement and insulin. They include:

  • Low blood sugar or hypoglycemia
  • Low potassium or hypokalemia
  • Brain swelling (cerebral edema) if your blood sugar levels are adjusted too quickly
  • Loss of consciousness
  • Death

Your doctor may change your insulin dose, or the kind you use, to prevent DKA from happening again.

Good blood sugar control will help you avoid ketoacidosis in the future. Make sure you manage your diabetes through your diet, exercise, medications, and self-care.

Follow these steps to help prevent DKA:

  • Drink lots of water or sugar-free, nonalcoholic beverages.
  • Take your medicines as directed.
  • Follow your meal plan closely.
  • Keep up with your exercise program.
  • Test your blood sugar regularly.
  • Check for expired insulin.
  • Don't use your insulin dose if it has clumps. Insulin should either be clear or evenly cloudy with small flecks.
  • If you're on an insulin pump, look closely for insulin leaks, and check your tube connections for air bubbles.
  • Talk to your doctor if your blood sugar levels are often out of your target range.
  • Manage your insulin dose with help from your doctor or diabetes coach. Make adjustments based on your blood sugar levels, diet, activity levels, or during any illness.
  • Create a DKA emergency plan. If your blood sugar levels are too high or your urine has too many ketones, make a plan to go to the hospital.

 

Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. With DKA, your body doesn’t have enough insulin to process sugar, so it starts burning fats instead. This creates ketones that can build up and begin to poison your system if you don’t get medical help in time. You can prevent DKA by keeping your blood sugar in your target range. Make sure to go to the doctor or emergency room right away if you have any DKA symptoms such as being very thirsty, having to pee a lot, fruity-smelling breath, or feeling confused or weak.

  • How long does it take to recover from diabetic ketoacidosis? The goal of diabetic ketoacidosis treatment is to get your blood back into balance and lower your blood sugar. That way, your body won’t make ketones anymore. This usually takes about 24 hours, but it might take longer if your DKA was severe or didn’t get treated soon enough. You can usually leave the hospital about a day after your blood sugar gets down to 200 mg/dL or less and your blood pH is over 7.3.
  • What happens when a diabetic goes into ketoacidosis? When a person with diabetes goes into ketoacidosis, it means that too many ketones have built up in their blood. Ketones are made when your body starts burning fat because it thinks that your cells need fuel. This happens when your blood sugar is high but you don’t have enough insulin to help the sugar get into your cells to “feed” them.

 Diabetic ketoacidosis can be treated and you can get better from it, especially if you get medical help right away.

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