Diabetic ketoacidosis (high blood ketones)

Diabetic ketoacidosis is a condition that can affect people with diabetes, usually those with type 1 diabetes. People with type 2 diabetes or diabetes in pregnancy can also have diabetic ketoacidosis but this is much rarer.

Diabetic ketoacidosis happens when your body does not have enough insulin to help it use sugar for energy. Instead, your body starts burning fat for energy, which releases harmful ketones. A build-up of ketones in your body causes your blood to become acidic. This is why it is called ketoacidosis.

Because diabetic ketoacidosis upsets the chemical balance in your body, it can quickly become dangerous. It needs immediate medical attention. It is isn't treated, diabetic ketoacidosis can lead to coma and even death. If picked up early, it can be treated with extra insulin, glucose and fluid. 

Diabetic ketoacidosis usually happens to people with type 1 diabetes. It is triggered by low insulin levels, most often caused by one of the following:

• Missed doses of insulin.
• Insulin not being given correctly. This may be because of problems with your insulin pen, insulin cartridge or insulin pump.
• An illness or hormonal change. Insulin in your body may not work well if you have an infection such as gastroenteritis (tummy bug), urinary tract infection, a chest infection or skin infection, or if you have stress or are pregnant. This is due to your body producing higher levels of other hormones, such as adrenaline or cortisol, which reduce the effect of insulin. 
• An injury or surgery.

People with type 2 diabetes are at risk if they are taking empagliflozin.  

Other causes include:

• a heart attack
• alcohol or drug abuse, in particular, cocaine
• certain medicines, such as corticosteroids and some diuretics.

Sometimes there is no obvious cause.

Ketones are easy to test for. The best way is to use a blood ketone meter. If you have type 1 diabetes you can get a blood ketone meter and 2 boxes of ketone testing strips on prescription from your doctor. You can also test for ketones in your urine (pee), but this is not as accurate because it reflects your ketone levels a few hours ago rather than right now. 

Monitoring blood ketones at home allows you to find out early if you are developing ketoacidosis, so that you can give yourself insulin and potentially prevent a trip to hospital. 

You should test for ketones in the following situations:

• your blood glucose is more than 15mmol/L and you have any symptoms of ketoacidosis
• your blood glucose is over 15mmol/L twice in a row (3 hours apart) and you don’t have any symptoms
• you feel unwell and and your blood glucose is increasing
• you are injured and your blood glucose is increasing.

Monitoring blood glucose and ketone levels when you are sick is especially important. During minor illness or injury, blood glucose levels might increase but ketones may stay normal. However, during serious illness, such as a fever (high temperature) or infections, blood glucose AND ketone levels can both become high. Monitoring blood glucose and ketones during sickness will help you decide whether you need extra insulin.

Read more about blood glucose testing for type 1 diabetes and sick day plan and type 1 diabetes. 

Whatever your ketone levels, it's important to never stop taking your background insulin.

If your ketones are raised, adjust your insulin dose as outlined in your diabetes sick day plan. If you are unsure about how to adjust your insulin dose, contact your diabetes care provider or emergency service.

Measure your blood glucose levels and ketone levels at frequent intervals, as outlined in your diabetes sick day plan. If they remain high, contact your GP, diabetes nurse, diabetes care provider or emergency health service.

Diabetic ketoacidosis can quickly become life threatening, so it's important to get medical help as soon as possible. 

Diabetic ketoacidosis is a medical emergency and needs to be treated in hospital. Treatment of diabetic ketoacidosis includes:

• insulin given through your vein
• fluids given through a drip into your vein
• salt and nutrients such as potassium given through your vein to replace any loss of these.

Your healthcare team will monitor you closely in the hospital to prevent complications of diabetic ketoacidosis such as:

• too low or too high potassium levels in your blood
• hypoglycaemia (low blood glucose) – this can be caused by insulin being given to treat diabetic ketoacidosis 
• brain oedema (fluids in your brain)
• pulmonary oedema (fluids in your lungs).

Your doctor or diabetes nurse specialist will find out the cause of your diabetic ketoacidosis and talk to you about your sick day management plan again.

If you have diabetes, there are lots you can do to prevent diabetic ketoacidosis.

• Take control of your diabetes. Take your medicines, including insulin, as directed. Don't skip insulin doses. If you think your insulin pen or pump may not be working properly, get it checked out.
• Be aware of how food and exercise affect your blood glucose levels.
• Be prepared — work with your diabetes care provider to make a sick-day plan. Know how to manage your diabetes when you are unwell, such as what your target blood glucose level should be during an illness, how often to check your blood glucose and your ketone levels, how to adjust your insulin dose or timing and when to contact your doctor for help. Read more about having a diabetes sick day plan.
• Be careful when you start new medicines – check with your doctor or pharmacist to find out if the medicines are safe for you to take.

Apps reviewed by Healthify

You may find it useful to look at some Diabetes apps.