Who Is Most at Risk for DKA (and Who Thinks They Aren’t?)

Who Thinks They’re Not at Risk for DKA?

The majority of people who don’t think they’re at risk for DKA are the ones who’ve never had it!

It’s a natural assumption to think, “It hasn’t happened to me, so I must be doing something right”. But DKA can develop quickly (sometimes within hours) from an unexpected loss of insulin, an illness, or even certain medications.

Those who tend not to feel at risk generally fall into three categories:

People with Type 2 Diabetes

DKA is less common in type 2 diabetes, but it happens more often than you’d think. If someone with type 2 diabetes is on insulin and they miss a dose, their blood sugar may shoot up, but they aren’t likely to go into DKA. However, as their body produces less of its own insulin and beta cell function declines over time, their risk of DKA increases. DKA can also happen in T2D due to certain medications…see below.

People with Type 1 or Type 2 Diabetes on SGLT-2 Inhibitors

SGLT2 medications like Invokana, Farxiga, and Jardiance can increase the risk of a type of DKA called euglycemic DKA. This form of DKA is easy to miss because blood sugar levels may not be that high. Many people aren’t even aware that DKA is a possibility when starting these medications, because their doctors don’t tell them!

People on Insulin Who Are Sick (and don’t know their sick day rules!)

Many people don’t realize that insulin needs typically go up (not down) when you’re sick, even if you’re not eating or drinking as much as you normally do. When you’re sick, the illness (and the stress from the illness) causes your body to release hormones that raise blood sugar and counteract the effects of insulin, so you will likely need more insulin to keep your blood sugar in your target range.

Who Is Most at Risk for DKA?

DKA can happen to anyone with diabetes anytime insulin levels drop too low, but some situations can make it more likely to occur. DKA rates go up as A1c goes above 9%, which indicates under-insulinization.

Your risk is higher if:

You’re In Early Stage Type 1 Diabetes

There are actually three stages to type 1 diabetes. Stage 2 is when your immune system is attacking the insulin-producing cells in your pancreas and blood sugar is starting to rise, but there usually aren’t symptoms. As your body makes less insulin and moves into the clinical diagnosis stage, ketones can start to build up. Every type 1 goes into this stage before they go into DKA, but now that we have screening tools like autoantibody testing, people can be prepared if they know they are at risk.

You Use an Insulin Pump

Insulin pumps and AID systems are incredible technology, but they only use rapid-acting insulin, so there’s no long-acting “backup” in the body. If insulin delivery is interrupted from a kinked tube or a site failure, ketones can rise quickly. Pump issues are one of the most common causes of DKA. 

You Take SGLT-2 Inhibitors

As mentioned above, SGLT2s can increase the risk of euglycemic DKA, when blood sugar levels may be only slightly elevated. Since high blood sugar is a primary warning sign of DKA, this makes it easy to overlook.

You’re Sick

Sickness raises stress hormones, which can increase blood sugar and insulin needs (even if you’re not eating). Many people think they need less insulin when they’re sick, but the opposite is usually true. 

You Have a High A1c (above 10%) from Missed Insulin Doses

People who miss insulin doses often and are not in good control can go into DKA more easily than others. When insulin levels are consistently too low, the body is closer to producing ketones, which lowers the threshold for developing DKA.

DKA Triggers You Might Not Expect

Some causes of DKA are easier to figure out (like a kinked infusion line), but other DKA triggers can catch you off guard because they may not seem serious at first:

• Mild illness: Even a mild cold or stomach bug can raise stress hormones and increase insulin needs.
• Dehydration: Not drinking enough fluids, especially during illness or hot weather, can cause ketones to build up more quickly in the blood.
• Very low-carb or ketogenic diets: In some cases, these diets can increase ketone production beyond safe levels, particularly for people on insulin.
• Certain medications like steroids: Steroids and some psychiatric medications can affect blood sugar and ketone balance.

None of these situations means DKA is inevitable, but they can create the conditions for it to develop.

What Are the Symptoms of DKA?

DKA can develop gradually over several hours, or it can become serious very quickly.

Early signs of DKA include:

• Excessive thirst
• Dry mouth
• Frequent urination
• High blood sugar (usually well over 200 mg/dL), except for euglycemic DKA when blood sugar is not significantly elevated
• High ketones

As DKA progresses, more severe symptoms include:

• Nausea and vomiting
• Abdominal pain 
• Rapid breathing or shortness of breath
• Headache
• Muscle stiffness
• Fatigue
• Confusion
• Fruity-smelling breath

DKA Testing and Treatment 

The only way to know if you’re in DKA is to check your ketone levels. Make sure you use a ketone test that checks for beta-hydroxybutyrate (BHB) in the blood. You can get ketone meters and test strips at local pharmacies or on Amazon (sometimes meters and strips are sold separately). 

Blood ketone meters are preferred because urine tests that measure acetoacetate aren’t nearly as predictive of DKA. 

How to interpret your BHB 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 and need to take action quickly. 

If you can eat and drink and administer insulin yourself, contact your healthcare provider for guidance or take the recommended steps to self-treat at home. If you’re vomiting, can’t hold anything down, or cannot self-treat for any reason, call 911 or go straight to the ER. 

How to Reduce Your Risk of DKA When You’re Sick

Sick days are one of the most common times for DKA to develop, but also one of the most preventable.

Here’s how to protect yourself:

1. Never stop insulin completely. Even if you’re not eating, your body still needs insulin to prevent ketone buildup.
2. Check your blood sugar more often. Monitor blood glucose every 2–4 hours (or as advised), and check ketones if blood sugar is elevated (typically >250 mg/dL), or you feel sick, even if glucose isn’t very high.
3. Stay hydrated. Fluids help flush out excess glucose and ketones. Try small sips of water, electrolyte drinks, or broth.
4. Have a sick day plan. Work with your healthcare provider to create a step-by-step plan so you know what to do before you get sick.
5. Know when to get help. Call your doctor or go to the hospital if ketones are moderate or high, you can’t keep fluids down, blood sugars stay high despite taking insulin, or symptoms of DKA are worsening.
6. Keep supplies on hand. A ketone monitor, backup insulin, and electrolyte drinks (with and without carbs) can help you treat problems early.