Most people think diabetic ketoacidosis (DKA) only happens when blood sugar is really high. But there’s a lesser-known type that can happen even when blood sugar looks “normal”—and it’s easy to miss.
What is DKA?
DKA is a serious condition that develops when the body does not have enough insulin. Without enough insulin, the body begins breaking down fat for fuel, leading to a buildup of acids called ketones in the blood. When our blood becomes really acidic, this leads to vomiting, extreme dehydration, confusion, and even a coma.
This more typical form of DKA usually presents with high blood sugar levels and more obvious warning signs. It most commonly occurs in individuals with type 1 diabetes, but it can also happen in those with type 2 diabetes.
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What is Euglycemia DKA?
Euglycemic DKA is a less recognized form of diabetic ketoacidosis in which blood sugar levels remain near normal (typically below 250 mg/dL), but dangerous ketone buildup is still occurring.
Because blood sugar may not be elevated, this condition can be more difficult to recognize and may delay treatment.
Euglycemic DKA is more likely to occur in individuals taking SGLT-2 inhibitors such as Jardiance, Invokana, or Farxiga. These medications work by helping the body remove excess glucose through urine, which can mask high blood sugar levels while ketones are still rising. It is important to note that these medications do not directly cause DKA, but they can increase the risk when combined with certain factors.
Common Factors:
- Prolonged fasting
- Very low-carbohydrate or ketogenic diets
- Pregnancy
- Illness (viral or bacterial)
- Surgery
- Missed insulin or pump issues
- Alcohol use
What Are the Warning Signs?
Thankfully, euglycemia DKA is very preventable. If you can identify the warning signs early, you can take action and prevent it from escalating to the ER.
Here are some warning signs to pay attention to:
- Nausea/vomiting
- Headache
- Fatigue
- Fruity breath
- Shortness of breath
Unlike typical DKA, you might not feel very thirsty or urinate as frequently, so be sure to pay close attention to the symptoms listed above.
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How to Prevent DKA
- Eat consistent carbohydrates throughout the day
Including a small amount of complex carbohydrates at each meal helps maintain a steady supply of glucose and reduces risk of ketone buildup. We recommend aiming for around 30gm (or 1/4 of your plate) of carbohydrates per meal, but make sure to ask your Dietitian or Health Coach what is best for you.
**If you are pregnant, sick, or taking an SGLT-2 inhibitor or insulin, it is especially important not to skip or severely restrict carbohydrates.
- Stay well hydrated
Aim for at least half your body weight in ounces of fluid daily. If you are sick or exercising for long periods, consider adding electrolytes to your fluids.
- Check ketones and be prepared
If something feels off, check your ketone levels—even if your blood sugar looks normal. If they are moderate or high, notify your doctor right away.
Tip: Keep ketone test strips on hand, especially for sick days, after alcohol intake, or anytime you are feeling unwell.
- Continue taking insulin as prescribed
Even if you are eating less, feeling sick, or your blood sugar appears normal, your body still needs insulin. Skipping insulin can increase the risk of ketone buildup and DKA.
When to Seek Help
Seek medical attention right away if you begin vomiting or are unable to keep fluids down. At that point, you may need treatment with IV fluids, insulin, and dextrose to help lower ketone levels and prevent complications.
Final Thoughts
Though rare, euglycemia DKA is very serious. By knowing when you might be more vulnerable and recognizing symptoms early, you can reduce your risk.
