Keeping blood sugars within range is one of the greatest challenges for most people with diabetes. And unfortunately, since there are so many factors involved in this tricky balancing act, it’s not always possible.
As someone with diabetes, you probably make more than 50 therapy-related decisions every day. To hit the bullseye and get it right requires a good amount of diabetes know-how and oftentimes a fair bit of luck!
You know that things don’t always go as planned. Things happen. Sometimes they are easier to fix than others, and some problems are cause for more concern than others. One major diabetes-related metabolic malfunction you need to know about is diabetic ketoacidosis or DKA for short. It is an emergency situation and needs prompt medical attention.
It’s important to point out here that everyone with diabetes can experience high blood sugars, but that doesn’t mean DKA will happen. Diabetic ketoacidosis only happens with an absolute deficiency of insulin.
In the traditional sense, this affects people with type 1 diabetes or people who, for other reasons, no longer produce their own insulin. In the case of type 2 diabetes, there is usually some insulin production that prevents ketoacidosis.
Ketoacidosis is critical because our bodies like to keep a very strict pH balance. When ketones build up in the blood, the pH balance becomes dangerously acidic.
Fat loss triggered by a lack of insulin
Without enough insulin, your body cannot deliver glucose from your blood to your cells. If this lasts long enough, your body turns to its energy reserves for fuel – fat. So the body breaks down more and more fat. This sounds great, right? But this method of getting energy is messy. It’s a dirty burn and leaves behind ketones that build up in your blood. Too much ketone buildup poses a risk and can become life-threatening!
Ketones from fasting or exercise
By the way, ketones can also happen to anyone from fasting, intensive exercise, or a very low-carbohydrate diet. As mentioned above, the body usually fuels its cells with glucose, but when this becomes scarce, the body cleverly switches to fats as an energy supplier. With some people, ketones can be found after fasting overnight.
However, this is not a sign of the onset of ketoacidosis, but only a sign that more fats have been metabolized, which is not in itself a cause for concern.
The point is, however, that this fat loss and presence of ketones must not be triggered by a lack of insulin. Typically, when there’s a problem with your insulin to the point where you have ketones, you will notice unusually high blood sugars .
When it reaches a point of concern, your fat burning takes place so uncontrollably that far too many ketones are formed which acidifies the pH balance of the blood. Then all of the important enzymes no longer work properly and things quickly become life-threatening.
Having ketones in the blood is only of concern if there is an absolute insulin deficiency at the same time.
Dangers of diabetic ketoacidosis
These ketone bodies are made up of acids such as acetone acetate, beta-hydroxyl-butyrate, and acetone, which over acidify our blood when present in more than normal amounts. Remember that ketones are typically accompanied by high blood sugar.
When the blood sugar is higher than about 180 mg/dL (10 mmol/L), your body gets rid of some excess sugar by peeing it out, and ketones go along for the ride. In fact, this is the only way to get rid of ketones – you need to pee them out.
The increased loss of fluid from high blood sugars can lead to severe dehydration without countermeasures. So hydration is critical, and that along with correcting the source of insulin deficiency is the only way to clear your body of the ketone buildup. However, when far enough along, you may not even be able to keep water down without vomiting. If you haven’t already, at that point you need emergency assistance.
Acidification of the blood can lead to loss of consciousness and even a coma. Severe DKA can usually only be treated in the intensive care unit, and without appropriate countermeasures, DKA can be fatal.
So it’s important to know the early signs of DKA so you can act quickly if it occurs. More on that below.
Possible causes of ketoacidosis
DKA is caused by an absolute insulin deficiency. There are a number of reasons your supply of insulin might be interrupted.
● Wrong or insufficient dosage of insulin, no corrections for high glucose values.
● Omission of insulin
● Increased insulin requirements, for example, due to illness or infection
● Hormonal fluctuations that require more insulin
● More insulin needs caused by stress, anger, or worry
● Clogged pen needle
● Ineffective / spoiled / expired insulin
For insulin pump users:
● Clogged or leaking infusion set
● Cannula inserted into hardened tissue (scar tissue usually)
● empty infusion set (forget to fill)
● Air bubbles in the infusion set
● Kinked Teflon cannulas or cannula slipped out of the skin.
● Inflammation or infection at the infusion set injection site
How do you recognize diabetic ketoacidosis?
Persistently high glucose values of over 250 mg/dL (14 mmol/L) paired with increased ketone values ( source: S3 guideline of the DDG ) along with one or more of the following symptoms. Note - the symptoms of ketoacidosis are diverse and do not necessarily occur together.
Typical symptoms of diabetic ketoacidosis
● Heavy/deep breathing
● Fruity smelling breath / acetone odor
● Extreme thirst
● Frequent urination / increased urination at night
● Visual disturbances
● Tiredness, sleepiness
● Feeling lethargic
● Nausea with vomiting
● Abdominal ache or pain
● Muscle pain or aches
When and how do I measure ketones?
If your blood sugars spike up after a meal (postprandial) that’s no need for worry about ketones. Correct the high as discussed with your medical team and move on. You can find more about postprandial glucose, i.e. increased blood sugar levels after eating, in this article:
However, if blood sugars are inexplicably high (above 250 mg/dL (14 mmol/L)) for a longer time or the above-mentioned symptoms appear, a ketone measurement is highly recommended.
If you’re sick or fighting an infection, it’s better to measure ketones too often than not often enough.
For the ketone measurement itself, you either use special urine test strips or a blood ketone measuring device much like a blood sugar meter. Some blood glucose meters nowadays also offer the possibility of ketone measurements using different test strips.
Measuring ketones in urine
Depending on the ketone concentration of the urine, the test strip changes color. The concentration can then be read using a color scale on the test strip container.
This method does not give absolutely exact measurements, but rather a statement about whether there are many (+++), few (++), or no (neg.) ketones in the urine. This is better than nothing. But keep in mind that it is not an exact measurement and there is a significant delay measuring your urine when compared to measuring your blood.
Measure ketones in blood
Here you get an exact value of the ketone concentration in the blood using a special meter and strip combination, much like the blood sugar strips and meters you are familiar with.
Ketones in the blood are measured in mmol/L. High levels of ketones in the blood is one of the most reliable signs of upcoming or already existing ketoacidosis.
How is diabetic ketoacidosis treated?
Treatment for DKA can vary depending what country you’re in.
In Germany, people with diabetes are taught to recognize ketoacidosis at an early stage and take immediate countermeasures. In the United States, however, the recommendation is to go to the emergency room at the first sign of DKA and hand the treatment over to medical experts.
In principle, the main treatment is to figure out and fix the trouble with your insulin delivery and to prevent dehydration by drinking lots of fluids. There are, of course, many different approaches and strategies for this.
Your “Keto Game Plan”
It’s smart to have discussed a strategy for ketoacidosis with your doctor. If you haven’t already, now is a good time to ask about it!
As already mentioned, people in the German-speaking area feel well prepared to take the necessary countermeasures themselves. Their diabetes care teams provide a so-called “keto scheme” for this. Such a ketoacidosis plan can look a little different depending on the care center, but it is generally something like this:
From a positive test result, the following applies (ketones in urine: ++, ketones in blood: 1.5 mmol / l):
drink a lot, at least half a liter per hour (ideally water).
And above all: inject additional insulin.
Ketones make you much more resistant to insulin so significantly more insulin is typically required. Check your blood sugar and correct with more insulin as prescribed by your doctor, until you no longer have ketones in your blood or urine. Exercise and falling asleep must be avoided.
Be sure to let someone know if you are fighting ketones! Ask them to check on you periodically. If you still test positive for ketones after the third insulin correction and your general condition deteriorates, contact your doctor or the emergency room right away.
If you have ketones and are vomiting, you should go straight to the emergency room.
For pump wearers: Take correction doses with a pen or syringe to ensure there isn’t a problem with your insulin pump infusion set.
Ketoacidosis is always an emergency and you have to react quickly and consistently.
How can I prevent diabetic ketoacidosis?
Easier said than done – but good blood sugar management significantly reduces the risk of diabetic ketoacidosis. See our other blog articles for more information.
As is often the case, the better you manage your diabetes, the less it manages you.
The following points can help:
● Measure blood sugar at least 4 times a day.
● Have ketone test strips on hand so you can check when needed
● Check ketones in case of illness, nausea, abdominal pain and infections.
● Know and recognize the signs of ketoacidosis.
● For insulin pump wearers: Change the infusion set every 2-3 days. Do not change your infusion set before bed and check blood sugars regularly.
You can find more information for great diabetes management here:
By the way, in the mySugr app, you can log your ketone values easily, track them, and add tags like “Hyper Feeling” like you already do with your blood sugar values. So you can simply pull out your cell phone at the next doctor's appointment and discuss any adjustments to your insulin therapy with the doctor.
Last but not least, you should always check and maintain your diabetic kit and ensure that you have all of the supplies you need and that they all work properly.
 It is possible to experience diabetic ketoacidosis with normal blood sugar levels if using an SGLT2 inhibitor.