Description

• A life-threatening medical emergency which most commonly occurs in patients with type 1 diabetes
• Characterized by a biochemical triad of hyperglycemia, ketosis, and high anion gap metabolic acidosis
• Rarely, it can occur in the absence of hyperglycemia (i.e., euglycemic diabetic ketoacidosis [DKA]) during pregnancy and in individuals taking sodium-glucose cotransporter-2 (SGLT2) inhibitors (1).
• System(s) affected: endocrine/metabolic, neurologic

Epidemiology

Incidence
Incidence by age group: 1 to 17 years (10.1%), 18 to 44 years (53.3%), 45 to 64 years (27.1%), 65 to 84 years (8.7%), and ≥85 years (0.8%)

Etiology and Pathophysiology

• Impaired glucose utilization secondary to insulin deficiency, leading to the activation of counter regulatory mechanisms (gluconeogenesis, glycogenolysis, proteolysis) which further increase blood glucose level and trigger ketone bodies production; resulting ketonemia and hyperglycemia lead to osmotic diuresis, dehydration, electrolytes disturbances and acidosis.
• Leading causes include medication noncompliance and infection. Other precipitating factors are:
  • First presentation of DM
  • Myocardial infarction (MI); cerebrovascular accident (CVA)
  • Medications (corticosteroids, sympathomimetics [e.g., dobutamine, terbutaline], atypical antipsychotics, SGLT2 inhibitors)
  • Alcohol and illicit drugs (cocaine)
  • Trauma; surgery
  • Emotional stress and psychiatric comorbidities
  • Pregnancy

Risk Factors

• Type 1 DM
• Ketosis-prone type 2 DM (Hispanic and African American ethnicity, G6PD deficiency)
• Euglycemic ketoacidosis specially with SGLT2 inhibitor drug use
• COVID-19 infection

General Prevention

• Close monitoring of glucose during periods of stress, illness, and trauma with “sick day” management instructions
• Careful insulin control and regular monitoring of blood glucose levels along with education on symptom recognition

Commonly Associated Conditions

>30% of patients have features of both DKA and hyperosmolar hyperglycemic syndrome (HHS).