Diabetic Ketoacidosis (DKA) Without High Blood Sugar? Yikes!

If you live with diabetes, it was probably drummed into you that dangerous diabetic ketoacidosis (DKA) is a direct result of very high blood sugar.

But guess what: The potentially life threatening condition of DKA can also happen when your blood sugar is in the normal range. A number of people with type 1 diabetes (T1D) have learned this the hard way.

What’s a person with diabetes to do, to avoid this stealthy threat?

Know the main causes and risks, and stay alert for certain tell-tale signs from your body. Read on to learn all about it.

What is euglycemic DKA?

DKA is caused when your cells cannot access the glucose they need for energy. Lacking that glucose, the cells turn to burning the fat in your body instead. This process of rapidly burning fat for use as energy produces what are known as ketones, alternative fuels produced by your liver from the breakdown of fats when glucose is in short supply.

Ketones are acidic, and our kidneys can only process a bit at a time. But when your kidneys turn to fat for energy due to a lack of glucose, they produce more ketones than our kidneys can keep up with, explains Dr. Ping H. Wang, diabetes researcher with the City of Hope in Southern California.

As ketones build up in the blood, they become more and more acidic, which can eventually lead to DKA — a state normally accompanied by super-high blood sugar that can lead to a diabetic coma. Symptoms of DKA include extreme thirst, dry mouth, feeling dizzy or flushed, nausea, vomiting, or abdominal pain.

If you feel any combination of these symptoms, you should get medical attention immediately, Wang points out, because DKA cannot be diagnosed at home. That’s because a pH value (acidity test) and other necessary lab tests are needed to confirm — or rule out — DKA.

Euglycemic Diabetic Ketoacidosis (EDKA) is different from regular DKA in just one critical way: It happens without elevated blood sugars, which are generally considered the hallmark of DKA and the fastest way to recognize it.

Pinpointing the cause

Experts say the most common reason for EDKA is one that is easily identified: the use of SGLT2 inhibitor drugs by people with T1D. These drugs prevent the reabsorption of glucose from blood that’s filtered through your kidneys, therefore facilitating glucose excretion in the urine. This helps to lower your blood sugar levels, but it can also trigger DKA.

“That’s the cause almost exclusively setting this off,” Dr. Samar Hafida, a staff physician at Joslin Diabetes Center in Boston, told DiabetesMine. “Clinically, that’s the only time we are seeing it.”

SGLT2 inhibitors are not approved by the Food and Drug Administration for use in people with T1D, but are sometimes prescribed anyway to cut down on post-meal blood sugar spikes or help people fight insulin resistance.

Those people, Wang said, can experience DKA without elevated blood sugars as a result of how this drug works in the body. SGLT2 inhibitors transport glucose into the kidney quickly. That means that while a person may dose what seems like the correct amount of insulin, they can still have cells searching for fuel. The cells in search of fuel begin to burn fat, causing DKA.

Wang believes SGLT2 inhibitors should not be prescribed to people with T1D. He said that while glucose values may not reflect it, any DKA caused by use of these drugs is actually resulting from a lack of needed insulin.

The rare times this may happen to a person with T1D outside of SGLT2 drug use can be related to experiencing an infection of any kind, recovering from surgery, or fighting another major disease, Wang said.

How to avoid it

Hafida said for those people taking SGLT2 inhibitors, diligently checking glucose levels and also using a blood ketone meter is key.

So is knowing when to stop taking them.

She said those times include:

  • Before, during, and after a major procedure such as surgery, particularly if it includes fasting. She suggests people with T1D should stop the drugs a week prior to their procedure and stay off them at least until they are able to take food by mouth again.
  • When experiencing any kind of illness that impacts the ability to stomach food or drink.
  • If you are on a low carb diet of any kind.

Wang feels the main step to avoiding EDKA with T1D is to not take SGLT2 inhibitors at all.

“The FDA did not approve this medication for T1D and that’s the reason,” he said. “I would not recommend using them.”

If you do, though, and happen to experience an unexplained headache, muscle weakness, or other feelings of sickness, always check ketones no matter what your blood sugar reading may be, Hafida said. It’s also critical to do diligent ketone testing.

If you still have concerns, talk to your medical provider about your symptoms, she said. They may ask for more testing, such as looking for a pH drop.

“There are no testing kits for that at home,” she added, reminding us that the only way to confirm or rule out DKA is via medical laboratory testing.

A patient’s experience

Brandon Arbiter has lived with T1D for a decade and currently serves as vice president of product and business development at diabetes data platform company Tidepool. Despite having access to all the latest diabetes technology including a Looping system that helps automate his insulin dosing, he had a scary experience with EDKA a few years ago.

“One night, I had an insulin pump infusion site failure after a tiny dinner (and small bolus insulin dose) going into a long night’s sleep. It was the perfect storm,” he told DiabetesMine. “My glucose stayed at 130 mg/dL because of the SGLT2, so I got no CGM alarms, but my ketones skyrocketed. At first, I thought it was a stomach bug.”

He woke up the next morning feeling horrible and unable to keep food down, and within 4 hours he realized that despite his in-range blood glucose numbers, he was going into DKA.

“When the paramedics arrived, they were not familiar with euglycemic DKA,” he said. “They told me they’d give me fluids and take me to the hospital.”

He ended up having a friend drive him to the hospital, and then spending a full day and night in the ICU unit.

“My conclusion: If a person with T1D is going to be on an SGLT2 inhibitor, they should be checking their ketones with a digital ketone meter every morning when they wake up,” he said.

“On my doctor’s advice, I am no longer on an SGLT2 inhibitor.”

This content is created for Diabetes Mine, a leading consumer health blog focused on the diabetes community that joined ishonest Media in 2015. The Diabetes Mine team is made up of informed patient advocates who are also trained journalists. We focus on providing content that informs and inspires people affected by diabetes.

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