From the Guidelines
Yes, individuals with type 2 diabetes mellitus can develop diabetic ketoacidosis (DKA), although it is less common than in type 1 diabetes. According to the most recent evidence from 2025 1, DKA in type 2 diabetes typically occurs in individuals who are insulinopenic, already treated with insulin, or have ketosis-prone type 2 diabetes, and is often associated with severe physiologic stress, such as infection, myocardial infarction, or the use of certain medications like SGLT2 inhibitors.
Key Points to Consider
- DKA in type 2 diabetes can be triggered by various factors, including severe infections, myocardial infarction, or the use of certain medications like glucocorticoids, second-generation antipsychotics, or SGLT2 inhibitors 1.
- Certain populations, such as those of African American, Hispanic, or Asian descent, are at higher risk of developing ketosis-prone type 2 diabetes, which can increase the likelihood of DKA 1.
- The underlying mechanism of DKA in type 2 diabetes involves insulin deficiency combined with increased counter-regulatory hormones, leading to increased lipolysis, ketone production, and metabolic acidosis.
- Treatment principles for DKA in type 2 diabetes are the same as for type 1 DKA: intravenous fluids, insulin therapy, electrolyte replacement, and addressing the underlying trigger.
Recommendations for Patients with Type 2 Diabetes
- Patients with type 2 diabetes should be educated about the risk of DKA, especially when starting SGLT2 inhibitors, and advised to seek immediate medical attention if experiencing symptoms like nausea, vomiting, abdominal pain, excessive thirst, frequent urination, or fruity-smelling breath.
- Regular monitoring of blood glucose levels and ketone production can help identify individuals at risk of DKA and allow for early intervention.
- Healthcare providers should be aware of the risk factors and triggers for DKA in type 2 diabetes and take a proactive approach to preventing and managing this complication.
From the Research
Diabetic Ketoacidosis in Type 2 Diabetes Mellitus
- Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus (DM) that can occur in both type 1 and type 2 DM patients 2, 3, 4.
- While DKA is more common in type 1 DM, it can also occur in type 2 DM, especially under stressful conditions such as trauma, surgery, or infections 3, 4.
- The use of sodium-glucose cotransporter 2 (SGLT-2) inhibitors, a class of antihyperglycemic medications, has been associated with an increased risk of euglycemic DKA (euDKA) in both type 1 and type 2 DM patients 2, 5, 6.
Risk Factors and Precipitating Causes
- Infections, such as urinary tract infections and pneumonia, are common precipitating causes of DKA in both type 1 and type 2 DM patients 3, 4.
- Other precipitating causes of DKA include intercurrent illnesses, psychological stress, and non-compliance with insulin therapy 4.
- The use of SGLT-2 inhibitors can increase the risk of euDKA, especially in patients with type 2 DM 5, 6.
Clinical Characteristics and Management
- DKA is characterized by the triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketone concentration 4.
- EuDKA, on the other hand, is characterized by the presence of metabolic acidosis and ketosis in the absence of significant hyperglycemia 2, 5, 6.
- Successful treatment of DKA and euDKA requires frequent monitoring of patients, correction of hypovolemia and hyperglycemia, replacement of electrolyte losses, and careful search for the precipitating cause 4.