Susan B. Sloane, BS, RPh, CDE, has been a registered pharmacist for more than 20 years and a Certified Diabetes Educator for more than 15 years. Her two sons were diagnosed with diabetes, and since then, she has been dedicated to promoting wellness and optimal outcomes as a patient advocate, information expert, educator, and corporate partner.

Diabetic ketoacidosis, or DKA, is a term most people with diabetes hear at some point in their journey with the disease. Sometimes it happens when you are diagnosed, and other times it happens when you start to lose control of your blood sugars.

If you heed some good practices and keep track of blood sugars, you can potentially avoid DKA, but sometimes even with the best efforts to keep it at bay, it happens.

What causes DKA?

DKA occurs when blood glucose starts to get very high and STAYS high for an extended period of time; this can happen over several hours or several days depending on many factors. The body’s response to prolonged periods of high blood sugars is to frantically try to get back to normal by secreting what are known as counter-regulatory hormones like glucagon, epinephrine, and cortical, just to name a few.

These hormones cause more glucose in the blood and enhance the breakdown of fat for fuel because the cells can’t absorb the glucose due to lack of insulin. Insulin serves as the key to get energy into the cells.

What happens next

With the release of fat stores for energy and no ability to store fat, weight loss occurs rapidly. Fats are also broken down in the body to free fatty acids that create an acidic environment in the blood. This imbalance signals the kidneys to excrete the ketones that result from fat breakdown and the excess glucose. The kidneys work frantically to correct this, taking precious water with them. This results in dehydration, which is dangerous by itself. The resulting acidosis causes rapid shallow breathing as the lungs try to keep balance in the body. As DKA gets more severe, deep, gasping breathing may occur. 

At diagnosis, a person with diabetes may present with DKA. It may be an elderly person who may not have realized that something was wrong until symptoms got very bad. Type 2 diabetes can happen over a long period of time, and if a person has not seen a doctor in a long time, they may find the initial weight loss desirable and even get lulled into thinking they are healthier, especially if they had been overweight. I have even had some patients who initially bought entire new wardrobes because they felt like they looked so much better. Sudden weight loss without having changed eating habits is a big red flag, not only for diabetes but for other potential illnesses as well. Other symptoms of DKA can be excessive thirst, excessive urination, nausea, confusion, and fruity smelling breath.

DKA can develop due to bad infections, new onset of diabetes, extreme stress, and serious disruption in diabetes care. Sometimes insulin pumps don’t work correctly or are not used properly and can cause blood sugars to rise abruptly. If you keep good track of you blood sugars and listen to your body, DKA can be avoided. I have never had an incident with either of my boys, except at diagnosis, where this was even a remote threat. If you have ketones in your urine and you cannot get your blood sugars down despite your best efforts, call your doctor immediately. Early intervention can keep you safe.


The treatment for DKA consists of insulin, IV fluids, and electrolytes to restore balance from dehydration. This treatment protocol will be coupled with constant monitoring of the blood to make sure balance is restored. Treatment is very individualized and takes place in the hospital as a rule.

This may sound scary, but it is meant to keep you well. In the words of the great Elliot Joslin, “The patient that knows the most lives the longest.”