Is it possible that a life-threatening condition—in this case diabetic ketoacidosis (DKA)—can show up with opposite symptoms? I didn’t think so until I recently had to take my Type 1 son Casey to the emergency room.
Sick-day rules for people with Type 1 advised me to take him to the ER, as did his diabetes team, because his ketones were high even though his blood glucose (BG) was normal. He was sick with a nasty stomach bug, unable to keep food or fluids down. Extremely high BG is an unmistakable sign of DKA. It’s what sent us in a panic to the hospital a year earlier, where he was diagnosed with Type 1. But Casey did not have high BG, so he couldn’t be going into DKA, right? Wrong. While I knew to monitor him for ketones, I learned that there is another type of DKA, and that he was on the path to it: euglycemic DKA (EDKA, where “eu” is Greek for good).
Ketones are dangerously high in both DKA and EDKA. In DKA, BG is also high; in EDKA, BG remains normal. So, while off-the-chart BG is a clear sign of (and can worsen) DKA, it is not its cause. The cause for all types of DKA is the body going into starvation mode because its cells can’t take in enough glucose to sustain bodily functions. The body starts burning its own fat for energy, which dumps ketones into the blood stream, making it increasingly acidic, and eventually precipitating ketoacidosis.
The difference between regular DKA and EDKA is what pushes the body into starvation mode. In DKA, blood glucose goes unused for lack of insulin to get it into the cells. In EDKA, it’s insulin that goes unused, because it has no glucose to feed to the cells. Put another way, DKA results from the body not being able to use the carbohydrate the individual has eaten (insulin insufficiency), and EDKA from their not eating enough carbohydrate (carbohydrate insufficiency).
People being treated for Type 1 can still develop regular DKA if their insulin goes bad (not stored properly) or if they intentionally or unintentionally fail to use enough. But why would someone like Casey, who is taking insulin as directed and has normal blood sugar, start producing dangerously high ketones? The short answer: he couldn’t eat or drink because he kept throwing up. This starved his cells of glucose, so his body started burning fat, which produced ketones. Vomiting also dehydrated him, making it hard for his kidneys to expel the ketones. Casey did not proceed to EDKA, but was on the path to it. While DKA often masquerades as a common illness, as Casey’s had the year before, here we see how some illnesses can cause EDKA.
EDKA is also a side-effect among 20 percent of people with Type 2 who take certain glucose-lowering medications (SGLT2 inhibitors). Others with Type 2 can develop DKA when their cells become more insulin resistant. This creates a relative insulin deficit because, when cells more strongly resist the action of insulin, the body needs more insulin to get the same amount of glucose into the cells. Non-diabetics can also develop ketoacidosis, referred to as “starvation ketoacidosis” (SKA). Risk factors for SKA include extended periods of fasting, ketogenic diets, frequent vomiting, eating disorders, gastric banding and pregnancy, which shunts glucose preferentially to the fetus.
All types of DKA are easily missed or misdiagnosed. First, DKA is relatively rare in the general population so healthcare providers may not be familiar with it. Second, DKA produces symptoms typical of garden-variety ailments such as the flu that arouse no particular alarm: stomachache, nausea, vomiting, lethargy, weight loss, headache and muscle pain. People with diabetes can miss the signs of EDKA for another reason. The top priority in diabetes education and self-management is to keep BG within the normal range, which can lead people to wrongly assume that a normal BG means no DKA.
DKAs are rare in the general population, but not in groups at heightened risk. So you need to know if you or a loved one is at risk, the signs and symptoms leading up to DKA and, very importantly, realize that their symptoms are neither obvious nor distinctive unless you know what to look for. Seek medical assistance when in doubt. Don’t delay because quick action matters.
My advice for fellow Type 1 families: When the Type 1 member develops an infection, test for ketones every few hours. Monitor and correct elevated BG with insulin. Have them try to eat something periodically with insulin coverage, and to drink every hour a glass of water or something with electrolytes (such as Pedialyte). They need to stay hydrated, which also helps flush out any ketones. Monitor ketone levels with urine ketone test strips or a blood ketone meter. Go to the hospital if ketone levels are high and you can’t effectively treat this dangerous condition at home. The hospital will do lab tests and, when indicated, give them an IV drip for hydration, anti-nausea medication, glucose and additional insulin.
By evening’s end, Casey was once again his exuberant self. The ER had reduced his ketones from high to moderate and made sure he could hold down food and water before discharging him. With additional hydration, food with insulin coverage, and monitoring at home during the next 24 hours, Casey’s ketones disappeared and he returned to good health.
Lisa Seitles and her husband Sam are the owners of READ Preschool and Camp Tuscaloosa. They have four children and are active members of the community.