How To Spot the Signs of Diabetic Ketoacidosis

Here's what you need to know about the life-threatening diabetes complication.

Diabetic ketoacidosis is one of the most serious complications of diabetes. Symptoms can take you by surprise, coming on in just 24 hours or less. It can be fatal without treatment, so it's important to know how to recognize it so you can respond in time.

"Every minute that the person is not treated is [another] minute closer to death," said Joel Zonszein, MD, professor of medicine at Albert Einstein College of Medicine in New York City.

Causes of Diabetic Ketoacidosis

Diabetic ketoacidosis occurs when your body doesn't produce enough insulin. Diabetic ketoacidosis most often affects people with type 1 diabetes, but can also occur with type 2 diabetes. Without insulin, sugar can't be stored in your cells to be used as energy and builds up in your blood instead. Your body has to go to a backup energy system: fat. In the process of breaking down fat for energy, your body releases fatty acids and acids called ketones.

Ketones are an alternative form of energy for the body, and just having them in your blood (ketosis) isn't necessarily harmful. Ketosis can happen when you go on a low-carb diet or even after fasting overnight.

"When I put people on a restricted diet, I can get an estimate of how vigorously they're pursuing it by the presence of ketones in the urine," said Gerald Bernstein, MD, an endocrinologist and coordinator of the Friedman Diabetes Program at Lenox Hill Hospital in New York City.

But too many ketones are a problem. "In individuals with diabetes who have no or low insulin production, there is an overproduction of ketones, and the kidneys can't get rid of them fast enough," said Dr. Zonszein. "Diabetic ketoacidosis occurs when so many ketones build up in the blood that it becomes acidic."

In people with type 1 diabetes, diabetic ketoacidosis can be caused by skipping insulin either on purpose (say, because you felt you didn't eat enough) or accidentally (like if your insulin pump breaks). Diabetic ketoacidosis can also be caused by illnesses, namely pneumonia, and urinary tract infections.

"If someone has a modest amount of insulin, but they are put under medical stress from an illness, then the body's stress mechanisms are going to push the glucose levels higher," said Dr. Bernstein, who is also past president of the American Diabetes Association.

Rarely certain drugs can cause diabetic ketoacidosis in people with either type 1 or type 2 diabetes.


Initial diabetic ketoacidosis signs include:

  • excessive thirst
  • frequent urination
  • dry mouth

In some cases, diabetic ketoacidosis might be the first sign you even have diabetes.

Later diabetic ketoacidosis symptoms include:

  • nausea and vomiting
  • diarrhea
  • abdominal pain
  • trouble breathing
  • confusion or difficulty concentrating
  • loss of appetite
  • weakness
  • fruity smell on your breath

"Someone who gets diabetic ketoacidosis starts to feel weak, they start to vomit, they urinate a lot, and start to breathe very, very fast," said Dr. Zonszein. These are the body's attempts to compensate for the extra acid in the blood, Dr. Zonszein explained. "When they're vomiting, they're vomiting a lot of acid. They come in with acetone [a type of ketone] on their breath, which may give off the smell of a rotten apple."

Blood tests can reveal that people with diabetic ketoacidosis also have high blood sugar levels and high levels of ketones in their blood.

Treatment and Prevention

Diabetic ketoacidosis treatment consists of giving insulin and IV fluids and monitoring electrolyte levels. "The moment we make a diagnosis, we can start treatment," said Dr. Zonszein. Some people may need to be hospitalized; doctors will test your ketones, blood sugar, and electrolytes every few hours.

If you don't know you have diabetes, there's no way to prevent diabetic ketoacidosis. If you do know, you can take steps to stay healthy. Diabetes management is key. Make sure you stick to a healthy diet—lots of fruit, vegetables, whole grains, and legumes without a lot of refined carbs or sugar. Equally important is taking your insulin on schedule and monitoring your blood sugar carefully if you get sick.

See a healthcare provider right away if you have any of these symptoms and suspect you might have diabetic ketoacidosis.

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