Diabetes Forecast

How to Avoid DKA

A lack of insulin plus dehydration can add up to diabetic ketoacidosis

It used to be that type 1 diabetes wasn't usually diagnosed until a person landed in the hospital with diabetic ketoacidosis, or DKA. Today, type 1 often gets diagnosed without DKA, but this medical emergency hasn't disappeared. In fact, a 2009 study found there was a 35 percent increase in DKA hospitalizations between 1996 and 2006. DKA is preventable, though, if you know what to look for and what to do.

Getting to Know You

DKA develops when two conditions are present in the body, says Devin Steenkamp, MD, an endocrine fellow at Boston Medical Center. First, there must be "either an absolute or relative deficiency of insulin," he says. People with type 1 can end up in a situation where they literally have no insulin in their bodies—an absolute deficiency—while people with type 2 who develop DKA don't have enough insulin relative to their tissues' needs. Second, says Steenkamp, a person develops an excess of anti-insulin hormones, such as glucagon, that raise blood glucose levels.

The result of this hormone misalignment is that the glucose absorbed into the body from food can't enter the cells, so glucose gets stuck in the circulatory system. The high blood glucose levels then block the kidneys' ability to reabsorb water from the blood. Glucose exits the body via urine, but it takes water and critical electrolytes along with it. The person with DKA is thirsty, urinating frequently, and at risk for severe complications related to electrolyte imbalances.

Sick-Day Rules

When ill, follow these guidelines:
1. Check blood glucose and urine ketones every two to four hours.

2. Continue taking insulin, even if you're too ill to eat. A sick body needs extra insulin.

3. Stay hydrated by drinking 8 ounces of caffeine-free fluids every hour.

4. Take in calories even if you're vomiting or your blood glucose levels are high by alternating 8 ounces of sugar-free fluid per hour with 8 ounces of sugar-sweetened fluid. Vomiting with moderate to high ketones? Go to an emergency room.

5. Contact your provider if blood glucose is over 250 mg/dl for six or more hours or you have urine ketones that long. Record glucose and ketone readings, and symptoms, for your provider.

At the same time, the lack of insulin causes cells to go into starvation mode because they aren't getting any glucose from the blood. The body has some tricks up its sleeve to ensure that, even without glucose, the cells can get energy from somewhere: namely, protein and fat. But tapping into these alternative fuel sources has consequences. The breakdown of fats for energy leaves a byproduct called ketone bodies, a small acidic molecule.

Ketone bodies are what give DKA its name. It may take only a few hours without an adequate supply of insulin for ketones to build up and acidify the body. "We are supposed to have a very narrow pH range," says Georgeanna Klingensmith, MD, professor of pediatrics at the Barbara Davis Center for Childhood Diabetes at the University of Colorado. "If the pH gets too acidic, then the cells don't work the way they're supposed to." Ketone bodies, like glucose, can also spill over into the urine, which is why ketone strips are used to help people detect DKA. Better yet, you can use blood ketone strips for an earlier warning that DKA is developing.

It's the combination of ketoacidosis and dehydration that can be fatal. Death from DKA is rare, but it is more common in children with type 1, most often from cerebral edema. "It's a swelling of the brain," says Klingensmith, that can occur during treatment when fluid surges into the brain. The swelling can damage the brain and stop the person from breathing.

Risk and Prevention

People with type 1 diabetes and children are at greater risk for DKA than those with type 2 and adults, respectively. Also, "certain ethnic groups get ketosis-prone diabetes," says Steenkamp, such as those of West African descent. He also says that low-income people have more DKA episodes than others. "People just stop taking insulin," he says. "A lot of them are patients who don't have access to their medications because of cost." Another contributing factor is drug abuse. "When you are busy using substances, your insulin becomes less of a need," he says. Plus, some illicit substances, such as cocaine, can drive up levels of anti-insulin hormones, pushing the body toward DKA.

One reason that kids are prone to DKA is illness, which can trigger DKA. "They are sick more often," says Klingensmith, largely because they spend a lot of time in close association with other children. However, when sick, adults with diabetes, especially type 1, may also develop DKA. Illness increases the levels of stress hormones in the body, the same hormones that counteract insulin and raise blood glucose levels. Nausea and vomiting can also cause dehydration (especially dangerous in infants and toddlers), which can increase the risk for DKA. Plus, if people don't feel like eating, they may not think to take at least some of their mealtime insulin, which is a mistake, says Klingensmith.

The good news is DKA can be prevented by following some simple rules. "The reason that DKA can occur is that people forget diabetes can make you sick," says Klingensmith. To help them remember, diabetes experts developed sick-day rules (shown at left), a list of guidelines intended to prevent DKA. The keys to staying out of the hospital when ill are to keep eating, drinking water, checking blood glucose, and taking your medication. It's also important to know when to seek help. "Someone who is vomiting can't hydrate themselves. That's when you need to go to the hospital for intravenous fluids," including insulin, says Klingensmith. "If you're dehydrated, insulin won't absorb through the skin."

The methods of treating DKA in a hospital have become very advanced. Only about 1 percent of adults with DKA who get the proper care end up dying from it. Plus, there are no long-term complications from DKA, according to Steenkamp: "If you get insulin, you get better."



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