Can type 2 (Type II) diabetics present with Diabetic Ketoacidosis (DKA)?

Can Type 2 Diabetics Present with DKA?

Yes, patients with type 2 diabetes can present with diabetic ketoacidosis (DKA), though it seldom occurs spontaneously and is usually triggered by specific precipitating factors. 1

Occurrence of DKA in Type 2 Diabetes

While DKA is classically associated with type 1 diabetes, it can occur in type 2 diabetes under certain circumstances:

Common Precipitating Factors for DKA in Type 2 Diabetes:

• Stress of another illness such as infection (particularly COVID-19, urinary tract infections, pneumonia) 1
• Myocardial infarction 1
• Medication-related:
  • SGLT2 inhibitors 1, 2, 3
  • Corticosteroids 1
  • Atypical antipsychotics 1
• Illicit drug use (e.g., cocaine) 1
• Missed or inadequate insulin doses in insulin-treated patients 1
• Certain social determinants of health 1

Special Populations at Higher Risk:

• Patients with ketosis-prone type 2 diabetes 1
• Ethnic minorities (particularly African American, Latino American) 1, 4
• Insulinopenic patients already on insulin therapy 1

Clinical Differences Between DKA in Type 1 vs. Type 2 Diabetes

DKA presents differently in type 2 diabetes compared to type 1:

• Glucose levels: Type 2 patients typically present with higher blood glucose levels (48.4±21.6 vs. 37.1±16.4 mmol/L) 5
• Ketoacidosis severity: Type 2 patients often have milder ketoacidosis but may require longer treatment periods to achieve ketone-free urine (36.0±11.6 vs. 28.9±8.9 hours) 5, 4
• Treatment requirements: Type 2 patients often need:
  • Higher daily insulin doses (35.9±37.0U vs. 20.2±23.3U) 5
  • Larger fluid replacement volumes (4.17±2.69L vs. 2.29±1.57L) 5
  • Greater potassium supplementation (23.9±36.5mEq vs. 11.2±17.9mEq) 5

Special Consideration: Euglycemic DKA

A variant form called euglycemic DKA can occur in type 2 diabetes patients taking SGLT2 inhibitors:

• Characterized by ketoacidosis with relatively normal blood glucose levels 2, 3
• SGLT2 inhibitors cause glycosuria while maintaining a low level of ambient ketones 2
• Any additional ketone formation can trigger ketoacidosis while the glycosuric effect limits hyperglycemia 2
• Treatment requires immediate use of glucose-containing IV fluids to induce endogenous insulin secretion 2
• May have more prolonged duration due to the half-life of SGLT2 inhibitors 2

Clinical Implications

1. Always consider DKA in type 2 diabetic patients presenting with:

   • Acute illness, especially infections
   • Recent medication changes (particularly starting SGLT2 inhibitors)
   • Symptoms of dehydration, nausea, vomiting, or abdominal pain

2. Be vigilant for euglycemic DKA in patients on SGLT2 inhibitors, as normal glucose levels may mask this life-threatening condition 2, 3

3. Type 2 diabetic patients with DKA may require more aggressive fluid resuscitation and higher insulin doses than type 1 patients 5

The 2025 Standards of Care in Diabetes clearly states that while DKA seldom occurs spontaneously in type 2 diabetes, clinicians should remain vigilant for this potentially life-threatening complication, especially in the presence of known precipitating factors 1.