What are the precipitating factors of Diabetic Ketoacidosis (DKA)?

Precipitating Factors of Diabetic Ketoacidosis

Infection is the most common precipitating factor for DKA, followed by insulin non-compliance or inadequate dosing, which together account for the majority of cases. 1

Primary Precipitating Factors

Infection (Most Common)

• Infection represents the leading precipitating cause of DKA, occurring in approximately 52-69% of cases 1, 2, 3
• Common infectious sources include:
  • Pneumonia (most frequent respiratory infection) 3
  • Urinary tract infections 3
  • Gastroenteritis 4
  • Other bacterial infections 5
• Patients may be normothermic or even hypothermic despite active infection due to peripheral vasodilation; hypothermia is a poor prognostic sign 1

Insulin-Related Issues

• Discontinuation or inadequate insulin therapy is the second most common precipitating factor, occurring in 21-53.5% of cases 1, 2, 3
• This includes:
  • Complete omission of insulin doses 6
  • Taking less insulin than prescribed 6
  • Failure to increase insulin during illness 5
  • Discontinuation of basal insulin during menstruation, even when food intake is reduced 7

New-Onset Diabetes

• Newly diagnosed type 1 diabetes commonly presents with DKA as the initial manifestation 1, 7
• Approximately 26.7% of DKA cases occur in patients with type 1 diabetes, while 73.3% occur in type 2 diabetes 3

Secondary Precipitating Factors

Cardiovascular Events

• Myocardial infarction can precipitate DKA through stress hormone elevation 1
• Cerebrovascular accident (stroke) 1

Other Medical Conditions

• Pancreatitis 1
• Trauma 1
• Alcohol abuse 1

Medications That Affect Carbohydrate Metabolism

• Corticosteroids 1, 7
• Thiazide diuretics 1, 7
• Sympathomimetic agents (e.g., dobutamine, terbutaline) 1, 7
• Sodium-glucose co-transporter 2 (SGLT2) inhibitors should be monitored carefully as they can precipitate DKA 5

Psychological and Behavioral Factors

• Psychological stress is a recognized precipitating factor 7
• Non-compliance to antidiabetic treatment beyond just insulin (21% of cases) 2

Physiological Stressors

• Fever and significant stressful situations can trigger DKA by increasing counterregulatory hormones 6
• Eating significantly more than prescribed meal plan 6
• Dehydration leading to stress hormone excess 8

Common Clinical Pitfall

A critical error is failing to recognize that elderly patients in chronic care facilities or those unable to communicate thirst are at particularly high risk for hyperglycemic crises, especially when they become hyperglycemic and cannot access fluids 1. Additionally, clinicians must remember that patients on SGLT2 inhibitors can develop DKA even with relatively normal glucose levels (euglycemic DKA), requiring heightened vigilance 5.