Can Someone with Type 2 Diabetes Develop DKA?
Yes, people with type 2 diabetes can absolutely develop diabetic ketoacidosis (DKA), though it occurs less commonly than in type 1 diabetes and typically requires specific precipitating factors. 1
When DKA Occurs in Type 2 Diabetes
DKA seldom occurs spontaneously in type 2 diabetes, but when it does develop, it typically arises under the following circumstances: 1
Primary Precipitating Factors:
Severe physiologic stress from acute illness such as infection (particularly COVID-19, pneumonia, or urinary tract infections), myocardial infarction, or stroke 1, 2
Medication-related triggers including:
Insulin deficiency states in patients already on insulin therapy who miss or take inadequate doses 1
Ketosis-prone type 2 diabetes (a specific subtype more common in ethnic minorities) 1
Illicit drug use such as cocaine 1
Social determinants of health that limit access to care or medications 1
Key Clinical Differences from Type 1 DKA
Type 2 diabetes patients who develop DKA present with distinctly different characteristics that require modified treatment: 4
- More profound hyperglycemia (mean glucose 48.4 mmol/L vs. 37.1 mmol/L in type 1) 4
- More severe dehydration requiring larger fluid replacement volumes (4.17L vs. 2.29L) 4
- Higher insulin requirements to resolve DKA (35.9U vs. 20.2U daily) 4
- Greater potassium supplementation needs (23.9 mEq vs. 11.2 mEq) 4
- Higher mortality rates compared to type 1 diabetes patients with DKA 5
Critical Clinical Pitfall
Do not assume DKA cannot occur in type 2 diabetes based on the diagnosis alone. 6 Ethnic minorities may present with DKA despite having type 2 diabetes, and this can lead to diagnostic confusion. 1, 6 The key is recognizing that while type 2 diabetes involves relative (not absolute) insulin deficiency, severe physiologic stress or certain medications can tip patients into an insulinopenic state sufficient to trigger ketoacidosis. 1
Mixed Presentations
Patients with type 2 diabetes can also present with mixed features of both DKA and hyperosmolar hyperglycemic state (HHS), which is more typical of type 2 diabetes. 1 HHS is characterized by severe hyperglycemia, hyperosmolality, and dehydration in the absence of significant ketoacidosis, but overlap syndromes occur. 1
Prevention Strategy
The majority of DKA cases in type 2 diabetes are preventable through early detection of precipitating factors, patient education about sick-day management, and ensuring access to medical care. 2 Patients on SGLT2 inhibitors require specific education about euglycemic DKA risk, as blood glucose may not be markedly elevated despite severe ketoacidosis. 3