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Understanding Diabetic ketoacidosis (DKA): symptoms, prevention and management
The content in this article should not be taken as medical advice. Please consult your healthcare provider regarding your individual health needs.
“An ounce of prevention is worth a pound of cure.”
-Benjamin Franklin
When it comes to Diabetic Ketoacididosis (DKA), prevention plus speedy detection and intervention can be worth a ton.
If you live with Type 1 or Type 2 diabetes, being proactive with your health is imperative. A crucial aspect of living with diabetes is monitoring glucose levels. Continuous glucose monitors (CGMs), such as the Dexcom G7, allow people with diabetes to monitor in real-time where their glucose is, where it has been, and where it is going. Dexcom G7 also offers customizable alerts that can be used to help manage glucose and increase time in range.1-5 All of this glucose information can help the person impacted by diabetes know when action or intervention may be needed. For instance, if someone is experiencing higher glucose levels over the course of a few hours, particularly if during illness or for unknown reason or cause, this is an important time to act to hopefully prevent diabetic ketoacidosis (DKA).
What is DKA, its causes and symptoms?6
DKA is a serious, life-threatening condition that occurs when the body has a lack of insulin and elevated glucose. While people with Type 1 and Type 2 diabetes can experience DKA it's more prevalent for those with Type 1 diabetes whose bodies produce little to no insulin. When the body's cells cannot get the glucose they need for energy due to the lack of insulin, the liver will break down fat too quickly and produce acid molecules called "ketones."
As those ketones build up in your body, they create a dangerous situation. High ketone levels can cause blood to become acidic, causing hypokalemia (low potassium/electrolyte shifts), cerebral edema (brain swelling), pulmonary edema (fluid in the lungs), damage to kidneys and other organs, dehydration, and/or confusion. Put simply, high ketone levels poison the body.
Diabetic ketoacidosis (DKA)
signs and symptoms
DKA is caused by not getting enough insulin (forgetting to take insulin, pump site malfunction, expired insulin, etc.) Additionally, times of acute stress, such as illness, particularly with dehydration, can increase risk of DKA.
Per the American Diabetes Association, common symptoms of DKA include but are not limited to7:
- Thirst/dry mouth
- Frequent urination
- High glucose levels/high glucose levels for an extended period
- High ketone levels
- Dry/flushed skin
- Abdominal pain, nausea, vomiting
- Difficulty breathing
- Fruity-smelling breath
- Confusion
How to prevent diabetic ketoacidosis (DKA)
When living with diabetes, it's important to not simplify "brush off" when you feel off, unwell or unlike yourself. If your glucose has been elevated for a few hours or if you feel "off", unwell or unlike yourself, particularly with any abdominal symptoms, such as nausea (feeling like you might vomit), an abdominal cramp or abdominal pain, listen to your body and check your ketone levels. And if you are not wearing a CGM, in addition to ketones, check your blood glucose levels with glucometer.
The earlier the detection, the better. Early detection gives you an opportunity to take action to get your glucose and ketone levels back on track as fast as possible, hopefully avoiding DKA and any associated acute complications.
If you're concerned about your ketone levels, check your urine ketones or blood ketones every two hours. Ignoring high ketone levels or other DKA symptoms can be fatal. If you are concerned about ketone levels or DKA and you are unsure of how to monitor ketones or what to do, you should seek medical care immediately.
How to manage diabetic ketoacidosis (DKA) with Dexcom
Dexcom G6 and G7 both offer customizable, unique monitoring advantages that, in addition to helping daily diabetes management, can also help you avoid DKA. Dexcom G6 allows users to customize high alerts, including setting the glucose level one wishes to be alerted to and the ability to turn the "repeat" alert on. For example, if someone sets a high alert to 250 mg/dl and turns on "repeat" 60 minutes. The person would be alerted when their glucose is 250mg/dl and would be alerted again if their glucose remained at 250 mg/dl or above for 60 minutes. This can alert the person with diabetes that it might be time to take action.
Dexcom G7 has a "delay 1st alert" (High Alert only) that enables users to delay their first alert until their sensor reading is at, or past, the designated alert setting for a specific amount of time. For instance, if you have your high alert set to 200 mg/dl and activate "delay 1st" for 2 hours, you will not receive an alert the moment your glucose reaches 200 mg/dl. You will only receive an alert when your glucose has been consistently 200 mg/dl or above for 2 hours. This allows the person with diabetes to know their glucose has been high for a long period of time and they should consider taking action.
Smart device sold separately.*
In addition to alerts, Dexcom CGM allows users to share glucose data with up to 10 followers.* Even if you are using an automated insulin delivery system, you can still share your data with your loved ones. This is helpful, particularly during times when you might need it most, such as during sleep or during illness. This can allow your followers to be in the know, alerting them to times when they might want to check in on your diabetes health.
The Follow App* also comes in handy for glucose monitoring while sleeping or engaged in sports or social activities where you may not pay as close attention to your Dexcom CGM as you normally would. Or if you use an insulin pump with Dexcom CGM, those who use the Follow App* will know if your device's cannula gets kinked or the device detaches during sleep or physical activities, because the Dexcom CGM alerts in real time to subsequent changes in glucose levels.
Smart device sold separately.*
Treatment of diabetic ketoacidosis
If you feel sick, "off" or unlike yourself and your normal/usual efforts to get your glucose into range do not work or if your ketones levels are moderate or high, contact your healthcare provider for recommendations and/or treatment. Do not delay seeking emergency medical care for high ketones.
Contact your healthcare provider immediately if you are vomiting and can't keep down food or liquids, if your glucose is higher than your target range and doesn't respond to home treatment, or if your ketone level is moderate or high. When in doubt, always call your doctor or specialist.
Seek emergency care when your glucose is higher than 300 (mg/dL) for more than one test, you have ketones in your urine and you can’t get in touch with your healthcare provider, or you have DKA symptoms, including excessive thirst, frequent urination, nausea and vomiting, abdominal pain, fatigue, difficulty breathing, fruity-smelling breath, and/or confusion.
If you go to the emergency room, you can expect treatment for DKA to include IV hydration/electrolytes and/or IV insulin for an extended period. Once your glucose, ketone and electrolyte levels have stabilized, the medical team will help you transition back to your insulin injections or insulin pump.
After a DKA incident, reach out to your diabetes healthcare provider or endocrinologist to let them know about it. That information is vital because it can help them to help you, particularly if you need to adjust or update your diabetes regimen or routine to help you avoid DKA in the future.
Your diabetes healthcare provider or endocrinologist should also give you a detailed "Sick Day Management" or "Ketone Management" plan that tells you what to do in case of illness or during times when ketones are present. Make sure to have multiple copies of that plan readily available in case of emergency. Please also share with anyone who might be a support for you during times when you are ill or having challenges with diabetes management.
Likewise, another good preventative measure is to always have back-up diabetes supplies such as insulin, syringes, and/or insulin pump supplies. But don't forget to ensure the insulin is not expired, because injecting expired insulin can lead to complications, including DKA. A good rule of thumb is to write the date on the insulin pen or vial when you first open it, that way you know your insulin is good for a set period.
Remember, DKA is a serious, life-threatening condition with symptoms you should not ignore. Delaying action to address high ketone levels puts your life in jeopardy. Any time you feel sick or "off" or unlike yourself, particularly if glucose is elevated, check your ketone levels, follow your sick day management or ketone management plan, and seek medical attention if necessary.
Prevention, fast detection, aggressive intervention and proper diabetes management are all keys to avoiding DKA and its complications. Dexcom CGM can play an important and meaningful role in helping you to manage diabetes during everyday life and during the times when we need it most!
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*Seprate Dexcom Follow app and internet connection required.
1 Beck, RW et al. JAMA. 2017;317-378. 2 Beck RW, et al. Ann Intern Med. 2017;167(60: 365-374. 3 Martens T, et al. JAMA. 2021;325(22):2262-2272. 4 Laffel LM, et al. JAMA. 2020;323(23):2388-2396. 5 Welsh JB, et al. J Diabetes Sci Technol. 2024;18(1):143-7. 6 Centers for Disease Control and Prevention. (n.d). About diabetic ketoacidosis. Centers for Desease Control and Prevention. https://www.cdc.gov/diabetes/about/diabetic-ketoacidosis.html 7 Diabetes & DKA (ketoacidosis). Diabetic Ketoacidosis - Signs & Symptoms | ADA. (n.d.). https://diabetes.org/about-diabetes/complications/ketoacidosis-dka/dka-ketoacidosis-ketones
BRIEF SAFETY STATEMENT: Failure to use the Dexcom Continuous Glucose Monitoring System and its components according to the instructions for use provided with your device and available at https://www.dexcom.com/safety-information and to properly consider all indications, contraindications, warnings, precautions, and cautions in those instructions for use may result in you missing a severe hypoglycemia (low blood glucose) or hyperglycemia (high blood glucose) occurrence and/or making a treatment decision that may result in injury. If your glucose alerts and readings from the Dexcom CGM do not match symptoms, use a blood glucose meter to make diabetes treatment decisions. Seek medical advice and attention when appropriate, including for any medical emergency.