DKA or the Flu? The Life-Saving Difference You Need To Know

What Is DKA?

DKA is a serious complication of diabetes that occurs when your body doesn’t have enough insulin to move sugar into your cells for energy. This can happen if you lose access to insulin for any reason, like if your insulin pump infusion set (or site) is not working and insulin delivery is not happening.

Without insulin, your body starts breaking down fat for fuel, which leads to ketone production. A small amount of ketones is generally not a problem, but if the ketone levels get too high, they make your blood way too acidic. Rising ketones are your body’s way of waving the red flag when insulin is too low and you’re on your way to DKA. Left untreated, DKA can be life-threatening.

Many people are first diagnosed with type 1 diabetes while in DKA, and hopefully they never experience it again. But about 5–8% of adults with T1D still end up in DKA every year. And while it’s much more common in type 1 diabetes, people with type 2 diabetes don’t get a free pass. DKA can happen there too if you’re on insulin and/or taking certain medications like SGLT2 inhibitors.

What Causes DKA?

The top culprits are illness and insulin delivery issues, but here’s a detailed breakdown of the primary DKA causes:

• Not enough insulin, or no insulin at all: Missing insulin doses, taking less insulin than your body needs, using expired insulin, insulin pump failure, or any type of infusion set or infusion site problem
• Illness or infection: Illnesses like the flu, pneumonia, urinary tract infections, stomach bugs, etc. can raise your body’s stress hormones, making insulin less effective (when you’re under stress, you need more insulin)
• Certain medications: SGLT2 inhibitors (Jardiance, Faxiga, Invokana, Brenzavvy, Inpefa) and certain steroids
• Other medical events: Heart attack, stroke, pancreatitis, surgery

DKA Symptoms (and How They Can Feel Like the Flu)

In a recent study, 46% of people with type 1 diabetes couldn’t name a single DKA symptom. Without cheating and looking at the list below, can you?? It’s important to know the warning signs because DKA can escalate quickly. 

Early DKA Symptoms Include:

• High blood sugar levels (usually above 200 mg/dL)
• Muscle aches, muscle stiffness, body aches, cramps
• Fatigue or weakness
• Extreme thirst or very dry mouth
• Frequent urination
• Brain fog
• High levels of ketones

Severe DKA Symptoms Include:

• Rapid breathing, deep breathing, or difficulty breathing
• Flushed face
• Fruity-smelling breath
• Headache
• Confusion
• GI symptoms like stomach pain, nausea, vomiting

As you can see, DKA can look a lot like the flu. Knowing the key differences can help you catch DKA early before it becomes an emergency situation.

Comparison of DKA and Flu Symptoms

So How Do You Know If You Have the Flu, DKA, or Both?

One of the more telling signs that you are in DKA and not the flu is fruity smelling breath, but if you’re experiencing other symptoms (and no one is there to tell you your breath smells like a kumquat) what do you do?

You need to test your ketones.

Everyone with type 1 diabetes – and people with type 2 diabetes on insulin or SGLT2 medications –  should have a ketone meter and unexpired test strips. You can find ketone meters and test strips at the pharmacy or on Amazon (keep in mind, sometimes you have to buy the meter and strips separately).

Blood ketone meters are preferred because urine ketone tests aren’t as accurate. Urine ketone tests only detect acetoacetate and do not measure beta-hydroxybutyrate, which is the predominant ketone present in DKA. This is what limits their accuracy.

If you’ve never used a ketone meter, check your ketones a couple of times when you’re feeling fine just to get an idea of what your typical baseline value is, and to get familiar with how to use a ketone meter.

DKA and Ketones: When Should You Test?

Most people don’t check for ketones nearly as often as they should. In fact, about 64% of people with type 1 diabetes either rarely test, or have never tested at all. Healthcare professionals may not always prescribe ketone tests or suggest them. Skipping these checks can be risky.

Here’s when to pull out the meter and test strips:

• When you’re sick, especially if you’re vomiting, have stomach pain, or a fever (and yes, test even if your blood sugar isn’t high)
• When you have prolonged blood glucose elevation (over 200 mg/dL for several hours) and are resistant to the glucose-lowering effects of insulin
• When insulin delivery is in question: clogged pump tubing, a dislodged infusion site, or a dislodged patch pump 

How to interpret blood ketone level results:

• Normal: less than 0.6 mmol/L
• Elevated: levels between 0.6 and 1.5 mmol/L (test again in 2 hours)
• High: levels between 1.6 and 2.9 mmol/L
• Urgent High: levels above 3.0 mmol/L

If your level is over 1 mmol/L, that’s when you’re getting into a problem area. If you can self-treat, follow the procedures below, but if you are vomiting, have difficulty breathing, or cannot self-treat for any reason, follow your HCP’s guidance, call 911, or go to the ER.

How Do You Treat DKA?

If you’re able to hold down food and liquids, here’s how to treat DKA in order to avoid a visit to the ER and/or hospitalization:

• Stop taking an SGLT2 inhibitor if you’re on one.
• Give yourself insulin. The recommendation is to give yourself a correction dose of insulin that’s 1.5 times your usual dose (or increase insulin dose per your healthcare provider’s guidance). Everyone’s needs will be different. Insulin should be taken at the same time as the carbs and fluids mentioned below. It’s important to know that when you’re in DKA, your body is resistant to insulin. If you wear an insulin pump and there’s a chance you have an infusion set or infusion site problem, use fast-acting insulin from a pen or syringe. Then change the infusion site location for your pump so you’re still getting basal insulin. 
• Consume carbs. If glucose is less than 250 mg/dL (or otherwise directed by your HCP), eat or drink about 30 grams of fast-acting carbs (juice, gummy bears, regular soda, regular Gatorade, glucose tabs, etc). It might feel counterintuitive, but carbs help shift your brain’s fuel source from ketones back to glucose, which stops your body from making more ketones.
• Hydrate. Drink no/low calories liquids like water or sugar-free, caffeine free sports drinks with electrolytes to help flush the ketones out.

When it comes to treating DKA, the faster you intervene, the faster you will get better, though it may take several hours. And you cannot forget to take carbs and insulin because that turns off the brain’s drive to produce ketones. 

Continue to check your glucose and your ketone levels at least every hour. Keep bolusing every one to two hours until your glucose starts to come down and you feel better.

Understanding Euglycemia DKA: You Can Be in DKA Even If Your Glucose Is Normal

There is a fairly common variant of DKA called euglycemic DKA when glucose levels aren’t super high. They could even be below 200 mg/dL! In the recent past, the commonly accepted criteria for DKA was above 250 mg/dL, but because of euglycemic DKA they lowered it to 200 mg/dL. Certain medications like SGLT2 inhibitors can cause euglycemic DKA to occur. Euglycemia DKA follows the same treatment protocol mentioned above. 

When to Seek Medical Treatment

When it comes to treating DKA, if you’re vomiting and you can’t hold anything down, you’re not going to be able to self-treat or get better on your own. You need to go to the ER because they can give you fluids and insulin through an IV line.

How to Prevent DKA

Preparation and education are the best ways to keep DKA at bay. If you have type 1 diabetes – or type 2 diabetes and you take insulin or an SGLT2 inhibitor – here’s how to prevent DKA and lower your risk:

• Know the warning signs. Learn the symptoms of rising ketones or early DKA so you can address them before things get serious.
• Check your ketones when needed and know what the numbers mean. A quick ketone test can help you decide your next move.
• Create a ketone management game plan with your healthcare team. General guidelines are listed below.
• Keep a backup stash of diabetes supplies. If you use an insulin pump, have insulin pens or syringes on hand in case of a pump failure.

How to Manage Diabetes When You’re Sick

Everyone with diabetes should have a game plan on how to manage diabetes when they’re sick.

Here are a few general guidelines:

1. Don’t stop taking your insulin, even if you’re not eating anything. In fact, taking small-to-medium amounts of extra insulin throughout the day may be in order to keep your glucose levels in check. The stress of illness causes the body to release hormones that raise glucose which can increase the risk of DKA, especially if insulin doses are missed or not adjusted upward. 
2. Test your glucose and ketones every 2-3 hours.
3. Rest and drink plenty of fluids. If you’re having trouble keeping fluids down, take small sips every 15 minutes or so to avoid dehydration. If your glucose is low, drink things like regular 7-UP or Gatorade, and if your glucose is high, drink fluids like water and sugar-free Gatorade.
4. Take Tylenol for a fever and other over-the-counter medicines as necessary. Many OTC cold and flu meds contain sugar, so check labels or ask your pharmacist for sugar-free options.

In general, take all of your regular medications if you aren’t vomiting.

If your symptoms worsen, your breathing becomes difficult, you have extremely high fevers or you cannot hold anything down, you need to seek medical attention.