At what blood glucose level can diabetic ketoacidosis (DKA) occur?

Blood Glucose Levels in Diabetic Ketoacidosis (DKA)

DKA can occur at blood glucose levels above 250 mg/dL, but importantly, it can also present as euglycemic DKA with glucose levels below 200 mg/dL. 1

Diagnostic Criteria for DKA

• DKA diagnosis requires the presence of hyperglycemia (blood glucose >250 mg/dL) OR prior history of diabetes with the following parameters 1:

  • Venous pH <7.3
  • Serum bicarbonate <15 mEq/L
  • Moderate ketonuria or ketonemia

• Resolution of DKA requires 2:

  • Glucose <200 mg/dL
  • Serum bicarbonate ≥18 mEq/L
  • Venous pH >7.3
  • Anion gap ≤12 mEq/L

Euglycemic DKA

• Approximately 10% of people experiencing DKA present with euglycemic DKA (plasma glucose <200 mg/dL) 1

• Euglycemic DKA requires insulin deficiency and can be associated with 1, 3:

  • Reduced food intake/starvation
  • Pregnancy
  • Alcohol use
  • Liver failure
  • SGLT2 inhibitor therapy
  • Chronic liver disease
  • Glycogen storage disorders

• The risk of DKA in individuals with type 2 diabetes treated with SGLT2 inhibitors is relatively low (0.6-4.9 events per 1,000 patient-years) but still present 1

Risk Factors for DKA

• Type 1 diabetes/absolute insulin deficiency 1
• Younger age 1
• Prior history of hyperglycemic crises 1
• High A1C level 1
• Very-low-carbohydrate diets (especially with SGLT2 inhibitors) 1, 4
• Prolonged fasting 1
• Dehydration 1
• Excessive alcohol intake 1
• Presence of autoimmunity 1
• Missed insulin doses 1

Monitoring and Prevention

• Individuals at risk for DKA should measure urine or blood ketones in the presence of symptoms and potential precipitating factors, particularly if glucose levels exceed 200 mg/dL 1
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA 2
• The nitroprusside method only measures acetoacetic acid and acetone (not β-hydroxybutyrate) and should not be used as an indicator of treatment response 2

Clinical Presentation

• Common symptoms of DKA include 5:
  • Polyuria with polydipsia (98%)
  • Weight loss (81%)
  • Fatigue (62%)
  • Dyspnea (57%)
  • Vomiting (46%)
  • Preceding febrile illness (40%)
  • Abdominal pain (32%)
  • Polyphagia (23%)

Management Considerations

• When treating DKA, insulin therapy should continue until resolution of ketoacidosis, regardless of glucose levels 6
• When serum glucose reaches 250 mg/dL during treatment, add dextrose to IV fluids while continuing insulin infusion 2, 6
• Ketonemia typically takes longer to clear than hyperglycemia 2, 6
• Individuals treated with intensive insulin therapy should not stop or hold their basal insulin even if not eating 1

Special Considerations

• Pregnant individuals may present with euglycemic DKA (glucose <200 mg/dL) 1
• Up to 2% of pregnancies with pregestational diabetes (most often type 1 diabetes) are complicated by DKA 1
• The incidence of DKA in gestational diabetes is low (<0.1%) 1
• Ketogenic diets can precipitate euglycemic DKA in susceptible individuals 4, 7

Common Pitfalls to Avoid

• Failing to consider DKA in patients with glucose levels <250 mg/dL 3, 7
• Premature termination of insulin therapy before ketoacidosis resolves 6
• Relying solely on glucose levels to guide DKA management 2, 6
• Using nitroprusside method to measure ketones instead of direct β-hydroxybutyrate measurement 2