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Dear Dr. E,
I have type 2 diabetes and I take Farxiga and metformin. Last week I got really sick and had to go to the hospital. My blood sugar was only 225 mg/dL but they said I was in euglycemic DKA. What’s that?
Dr. Edelman: When most people think of DKA, they think sky-high blood sugars. But there’s another type of DKA called euglycemic DKA (euDKA) that happens when your blood sugars are only slightly elevated. It can happen to people with type 1 or type 2 diabetes, and it’s especially dangerous because people don’t know they’re in DKA since their blood sugar may not be over 250 mg/dL.
What Causes Euglycemic DKA?
One of the biggest triggers for euglycemic DKA is a class of medications called SGLT2 inhibitors (Farxiga, Jardiance, Invokana, and Steglatro). These medications help lower blood sugar by causing the kidneys to flush extra glucose out through the urine.
While SGLT2 inhibitors have major heart and kidney benefits, they can also make DKA harder to recognize because they lower blood sugar so effectively.
Other causes of euglycemia DKA include illness, infection, fasting, extreme keto diets, certain medical issues like gastroparesis, major surgery, and pregnancy. However, SGLT2s are by far the most common cause.
When to Test for Ketones for DKA
The only way to know for sure if you’re in DKA is to test your ketone level – in particular beta-hydroxybutyrate (BHB). BHB is the main type of ketone your body makes when it doesn’t have enough insulin, and starts burning fat for energy instead of glucose. It’s the primary indicator of DKA.
You should test your ketones if your blood sugar has been elevated (over 200 mg/dL) for several hours, but you should also test if you’re symptomatic regardless of your blood glucose value…if you feel sick, if you’re unusually thirsty, tired, or confused, or if you’re nauseous, vomiting, or have stomach pain. These are all warning signs that DKA could be developing.
How to Test for Ketones for DKA
There are a few different ways you can check your ketone levels. Whichever method you choose, just make sure you’re testing for beta-hydroxybutyrate. Urine acetoacetate ketone strips are very popular and you can find them everywhere online, but they measure acetoacetate, which is not an accurate indicator of DKA.
There are two main over-the-counter DKA ketone testing options:
DKA Ketone Meters: The Gold Standard
Ketone meters like the Abbott Precision Xtra use a fingerstick to measure BHB directly in the blood.
Pros
- Measures the main ketone BHB
- Most accurate and reliable
Cons
- Moderately expensive (you have to buy the meter and the test strips)
- Uses a finger stick
- Strips expire relatively quickly (~6 months after opening)
- It’s another meter and supplies to have with you
Urine β-hydroxybutyrate (BHB) Test Strips for DKA: The New Kid on the Block
New test strips called XactBHB measure BHB levels from a urine sample and can provide results either through a free smartphone app with a numeric reading or by comparing the strip to a color chart on the bottle.
Pros
- No meter needed, only a test strip (and your cell phone if you choose to use the app for a quantitative numeric value)
- Non-invasive (no finger stick)
- Lower cost than blood ketone testing and longer shelf life (about 24–36 months after opening)
Cons
- Requires a urine sample
Abbott Continuous Ketone Monitor: Coming Soon
One of the most exciting advances on the horizon is the first dual glucose-ketone monitor from Abbott. It was just approved in Europe and is currently under review with the FDA. It measures blood sugar and ketone levels every minute, which will help people catch rising ketones before they develop into an emergency situation.
Euglycemic DKA Treatment
If you’ve tested your ketones and your level is over 1 mmol/L, you’re getting into a problem area and you need to take action quickly. If you’re able to safely self-treat, contact your healthcare provider immediately for their guidance, or follow the recommended steps to treat DKA at home. If you’re vomiting, having trouble breathing, or cannot treat yourself for any reason, call 911 or high tail it to the ER.
Euglycemic DKA: Key Takeaways
The most important thing to know about euglycemic DKA is that you can be in diabetic ketoacidosis even when your blood sugar is normal or only mildly elevated. That’s what makes it so easy to miss – and so dangerous!
If you feel sick – especially if you’re on an SGLT2 inhibitor – you should check your ketones even if your blood sugar isn’t high.
Euglycemic DKA requires the same urgent treatment as “traditional” DKA…with fluids, insulin, carbs, and continuous monitoring until you’re in the clear. DKA can develop quickly, but it’s often preventable with early detection.
Remember, if something feels off, don’t let a good blood sugar fool you!
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