What causes recurrent Diabetic Ketoacidosis (DKA) in a patient?

Causes of Recurrent Diabetic Ketoacidosis (DKA)

The most common cause of recurrent DKA is insulin omission, which is frequently associated with psychological problems, financial constraints, and inadequate access to healthcare. 1

Primary Causes of Recurrent DKA

Insulin-Related Factors

• Insulin omission or non-adherence to insulin therapy is the most common precipitating factor for recurrent DKA 1
• Economic reasons for stopping insulin, particularly observed in urban African-Americans, are a significant cause of recurrent DKA 1
• Lack of financial resources or being underinsured contributes significantly to insulin omission 1, 2

Psychosocial Factors

• Higher incidence of psychiatric illness, especially depression, is observed in patients with recurrent DKA 1, 2
• Patients with recurrent DKA are more likely to come from single-parent homes 1
• Eating disorders are more common in adolescents with recurrent episodes of DKA 1
• Psychological stress can precipitate DKA episodes 3

Medical Factors

• Intercurrent illnesses, particularly infections (urinary tract infections and pneumonia being most common), account for 30-50% of DKA cases 3
• Inadequate sick-day management during intercurrent illness 1
• Surgical procedures, trauma, myocardial ischemia, and pancreatitis can trigger DKA 3
• Use of sodium-glucose cotransporter-2 (SGLT2) inhibitors can increase the risk of DKA 4, 2

Knowledge and Education Gaps

• Insufficient patient education about diabetes management 1
• Lack of knowledge about ketone monitoring during illness 2
• Inadequate understanding of sick-day management protocols 1
• Poor communication with healthcare providers during intercurrent illness 1

Clinical Implications and Outcomes

• Recurrent DKA is associated with significantly greater diabetes morbidity and mortality compared to patients without DKA episodes 1
• Each DKA episode requires substantial healthcare resources, with an average cost of $13,000 per hospitalization 1
• Repeated admissions for DKA are estimated to drain approximately one of every two healthcare dollars spent on adult patients with type 1 diabetes 1

Prevention Strategies

• Regular review of sick-day management with all patients, including when to contact healthcare providers, blood glucose goals, supplemental insulin use during illness, and dietary recommendations 1
• Emphasize that patients should never discontinue insulin and should seek professional advice early during illness 1
• Implement 24-hour telephone availability for patients to contact the healthcare team when blood glucose levels are high or ketones are present 2
• Improve access to medical care and insulin for economically disadvantaged patients 1
• Provide psychological counseling for all patients with recurrent DKA and their families 1
• Educate caregivers and family members about signs and symptoms of worsening diabetes control 1
• Implement public awareness campaigns about signs and symptoms of untreated diabetes 2

Monitoring Recommendations

• Patients/family members should be able to accurately measure and record blood glucose, urine or blood ketones when blood glucose is >300 mg/dl, insulin administered, vital signs, and body weight 1
• Ensure adequate supervision and help from staff or family members, particularly for elderly individuals who may be unable to recognize or treat evolving hyperglycemic conditions 1

By addressing these causes systematically through improved access to care, patient education, and psychological support, many recurrent DKA episodes can be prevented, reducing the associated morbidity, mortality, and healthcare costs.