What are the most common precipitating factors for diabetic ketoacidosis (DKA)?

Common Precipitating Factors for Diabetic Ketoacidosis

Infection is the single most common precipitating factor for DKA, occurring in 52-69% of cases, followed by discontinuation or inadequate insulin therapy in 21-53.5% of cases. 1, 2

Primary Precipitating Factors (In Order of Frequency)

1. Infection (Most Common)

• Infection accounts for approximately 52-69% of all DKA cases and should be your first consideration when evaluating precipitating causes 1, 2, 3
• Specific infections to investigate:
  • Pneumonia (most common infection type, 38.7% of infection-related DKA) 3
  • Urinary tract infections (30.6% of infection-related DKA) 3, 4
  • Skin and soft tissue infections (25% of proven infections) 5

Critical pitfall: Temperature is unreliable in DKA—patients can be normothermic or even hypothermic despite serious infection, and hypothermia is actually a poor prognostic sign 1. Use procalcitonin rather than WBC count or temperature to identify bacterial infection, and obtain cultures (blood, urine, throat) with empiric antibiotics if clinical suspicion exists 1.

2. Insulin Omission or Non-Compliance

• Discontinuation or inadequate insulin therapy occurs in 21-53.5% of DKA cases 1, 2
• This is particularly common in:
  • Urban African-Americans stopping insulin for economic reasons 6
  • Patients with psychiatric illness 1
  • Those from single-parent homes 1
  • Underinsured patients 1
  • Children and adolescents with eating disorders 1

Key point: Psychological problems and lack of financial resources are the most common causes of DKA in patients with established diabetes 1.

3. New-Onset Type 1 Diabetes

• First presentation of type 1 diabetes commonly manifests as DKA, particularly in children and adolescents 1, 2

Secondary Precipitating Factors

Medications That Precipitate DKA

• SGLT2 inhibitors are now a leading cause of DKA, including euglycemic DKA (glucose 177-180 mg/dL or lower), particularly dangerous as their use expands to heart failure and chronic kidney disease in non-diabetic patients 1
• Corticosteroids (affect carbohydrate metabolism) 7, 1, 2
• Thiazide diuretics 7, 1, 2
• Sympathomimetic agents (dobutamine, terbutaline) 7, 1

Acute Medical Events

• Myocardial infarction (through stress hormone elevation) 1, 2
• Acute febrile illness (increases insulin requirements) 1
• Trauma or surgery 4
• Pancreatitis 4

High-Risk Clinical Scenarios

• Pregnancy in type 1 diabetes (up to 2% of pregnancies complicated by DKA) 1
• Reduced caloric intake in patients on SGLT2 inhibitors 1
• Elderly individuals in chronic care facilities who become hyperglycemic and cannot access fluids—this is a critical error to avoid 1, 2
• Menstruation (through psychological stress and potential insulin reduction) 7

Underlying Pathophysiology

The mechanism involves absolute or relative insulin deficiency combined with elevated counterregulatory hormones (glucagon, catecholamines, cortisol, growth hormone), triggering uncontrolled lipolysis and ketogenesis 7, 1, 4.

Prevention Algorithm

To prevent DKA in your patients:

1. Never allow patients to discontinue basal insulin, even during illness, reduced food intake, or menstruation 7
2. Educate on sick-day management: contact provider when blood glucose >300 mg/dL, use supplemental short-acting insulin, suppress fever, treat infection, and maintain liquid diet with carbohydrates and salt 6
3. Address economic barriers to insulin access, particularly in urban African-American populations 6
4. Screen for psychiatric illness and eating disorders in patients with recurrent DKA 1
5. Ensure elderly patients in chronic care facilities have adequate supervision and fluid access 6, 2
6. If prescribing SGLT2 inhibitors, counsel patients about euglycemic DKA risk and need to discontinue during acute illness or reduced caloric intake 1