Description

• A life-threatening medical emergency which most commonly occurs in patients with type 1 diabetes; however, it may occur in any type of diabetes mellitus and at any age.
• 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
• System(s) affected: endocrine/metabolic, neurology

Epidemiology

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 infection, particularly UTI and pneumonia, and medication noncompliance. Other precipitating factors are:
  • First presentation of DM
  • Myocardial infarction (MI); cerebrovascular accident (CVA), pulmonary embolism (PE), pancreatitis
  • Medications (corticosteroids, sympathomimetics (e.g., dobutamine and terbutaline), atypical antipsychotics, SGLT2 inhibitors)
  • Alcohol and Illicit drugs (cocaine)
  • Trauma; surgery
  • Emotional stress, psychiatric comorbidities and social determinants of health
  • 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
• Younger age at the time of DKA hospitalization, higher HbA1c, lower physical activity, lower socioeconomic status, and psychiatric symptoms have been associated with increased rates of DKA.

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

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