DKA typically occurs with blood glucose above 250 mg/dL, plus elevated ketones, plus metabolic acidosis. Euglycemic DKA is a variant with glucose under 250 mg/dL — seen especially with SGLT2 inhibitors, during pregnancy, and with prolonged fasting. Common triggers include missed insulin doses, illness, and SGLT2 inhibitor use in the setting of sickness. Warning signs are nausea, vomiting, abdominal pain, deep rapid breathing, fruity breath, extreme thirst, and confusion. DKA is a medical emergency — any suspicion warrants urgent ER evaluation.
The Formal DKA Definition
| Criterion | Threshold |
|---|---|
| Blood glucose | Usually over 250 mg/dL (can be under 250 in euglycemic DKA) |
| Blood pH | Under 7.3 (mild DKA) to under 7.1 (severe) |
| Serum bicarbonate | Under 18 mEq/L (mild) to under 10 (severe) |
| Blood beta-hydroxybutyrate | Over 3.0 mmol/L |
| Urine ketones | Moderate to large |
| Anion gap | Elevated (typically > 12) |
DKA Severity Classification
| Severity | pH | Bicarbonate | Mental Status |
|---|---|---|---|
| Mild | 7.25–7.30 | 15–18 | Alert |
| Moderate | 7.00–7.24 | 10–14 | Alert or drowsy |
| Severe | Under 7.00 | Under 10 | Stupor or coma |
Euglycemic DKA — The Special Case
- Blood glucose under 250 mg/dL, sometimes normal (80 to 150)
- Ketones and acidosis still present
- Symptoms the same as classic DKA: nausea, vomiting, rapid breathing, fatigue
- Most often seen with:
- SGLT2 inhibitors during illness (empagliflozin, dapagliflozin, canagliflozin)
- Pregnancy
- Prolonged fasting
- Alcohol excess
- Low-carb or ketogenic diet combined with insulin dose reduction
- Diagnosis requires checking ketones regardless of glucose — blood beta-hydroxybutyrate or urine ketones
- Treatment is the same — IV fluids, insulin, electrolyte replacement; hospital admission typical
Most Common DKA Triggers
| Trigger | Frequency | Notes |
|---|---|---|
| Insulin omission (missed doses) | Most common | Accidental or intentional; pump failure included |
| Infection or illness | Very common | UTI, pneumonia, skin infection, GI viral illness |
| New-onset type 1 diabetes | Common presentation | Especially in children and adolescents |
| Insulin pump failure | Less common but increasing | Tubing kinks, infusion set dislodgement |
| Surgery or major stress | Moderate | Counter-regulatory hormones raise glucose |
| Corticosteroid use | Moderate | Oral or IV steroids raise glucose significantly |
| Acute pancreatitis | Moderate | Especially in type 2 diabetes |
| Myocardial infarction or stroke | Moderate | Stress response |
| SGLT2 inhibitor use during illness | Growing | Euglycemic DKA risk |
| Severe dehydration | Occasional | From any cause |
| Alcohol or substance use | Occasional | Especially binge drinking |
| Unknown | 10–15% | No clear trigger identified |
Warning Signs and Symptoms
- Nausea and vomiting: often the earliest signs
- Abdominal pain: can mimic surgical abdomen
- Deep rapid breathing (Kussmaul respirations): body trying to blow off CO2 to compensate for acidosis
- Fruity or acetone breath: from exhaled ketones
- Extreme thirst and urination (polyuria and polydipsia)
- Fatigue and weakness
- Confusion, drowsiness, or altered mental status (later)
- Signs of dehydration: dry mouth, sunken eyes, poor skin turgor
- Tachycardia and hypotension
- Weight loss (from fluid and ketone loss)
What to Do If You Suspect DKA
- Check blood glucose — if over 240 mg/dL, check ketones
- Check urine ketones or blood beta-hydroxybutyrate
- If moderate or large ketones — call your clinician or go to ER immediately
- If vomiting, unable to keep fluids down — same-day ER
- If confusion, rapid breathing, or fruity breath — call 911
- Do not stop basal insulin — continuing it reduces DKA progression
- Do not take extra rapid-acting insulin without clinician guidance (risks severe hypoglycemia)
- Maintain hydration with sugar-free fluids while awaiting care
Emergency Treatment (In Hospital)
- IV fluids to correct dehydration (often 1 to 2 liters of normal saline initially)
- IV regular insulin infusion to lower glucose and suppress ketogenesis
- Electrolyte replacement, especially potassium (which drops as acidosis corrects)
- Identification and treatment of the trigger (infection, pump failure, etc.)
- Monitoring of pH, bicarbonate, ketones, glucose, and electrolytes every 1 to 4 hours
- Transition to subcutaneous insulin when acidosis resolves and the patient can eat
- Typical admission 24 to 72 hours; severe cases longer
Prevention — Sick Day Rules
- Check blood glucose every 2 to 4 hours during illness
- Check ketones if glucose is above 240 mg/dL (or during any illness if on SGLT2 inhibitor)
- Continue taking long-acting insulin even if not eating (reducing insulin during illness causes DKA)
- Take supplemental rapid-acting insulin for high glucose or moderate/large ketones per your sick-day plan
- Stay hydrated — 8 oz of sugar-free fluid per hour
- Have an anti-nausea plan (ondansetron if prescribed)
- Know when to call your clinician — persistent vomiting, inability to keep fluids down, any ketone elevation
- If on SGLT2 inhibitor and become sick: hold the SGLT2 inhibitor, check ketones, call clinician
Recovery After DKA
- Most patients recover fully within days
- Debrief with the care team about the trigger and how to prevent recurrence
- Review insulin regimen and pump settings
- Address psychosocial factors if insulin omission was intentional
- Refer to diabetes educator or psychologist as needed
- Discuss CGM use — alarms can catch rising glucose before DKA develops
- Develop or update written sick-day rules
Related Reading
See our guides on what ketones in urine mean, prediabetes 101, and complications and related conditions.
The Bottom Line
DKA typically occurs with blood glucose above 250 mg/dL, plus significant ketones, plus metabolic acidosis (pH under 7.3 or bicarbonate under 18). Euglycemic DKA — with glucose under 250 — occurs on SGLT2 inhibitors, during pregnancy, and with fasting. The glucose threshold alone does not diagnose DKA; the full picture does. Warning signs include nausea, vomiting, abdominal pain, deep rapid breathing, and fruity breath. Any patient with diabetes experiencing these symptoms needs same-day medical evaluation. Prevention involves sick-day rules, never stopping basal insulin, frequent ketone checks, and holding SGLT2 inhibitors during significant illness.
