Summary
Definition
Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes that is potentially fatal and requires prompt medical attention for successful treatment. It is characterised by absolute (total absence of) or relative (levels insufficient to suppress gluconeogenesis and ketone production) insulin deficiency and elevation of counter-regulatory hormones (glucagon, adrenaline, noradrenaline, cortisol, and growth hormone).[1] It is the most common acute hyperglycaemic complication of type 1 diabetes mellitus.[2] While most cases occur in patients with type 1 diabetes, DKA can also affect patients with type 2 diabetes.
[Figure caption and citation for the preceding image starts]: Triad of DKAAdapted with permission from Kitabchi AE, Wall BM. Diabetic ketoacidosis. Med Clin North Am. 1995;79:9-37. [Citation ends].
This topic covers DKA in adults. Bear in mind that people aged 16 to 18 years may be managed by either a paediatric team or an adult medical team according to local arrangements. The Joint British Diabetes Societies for Inpatient Care guideline recommends following paediatric guidelines if the patient is being managed by a paediatric team, and following adult guidance if they are being managed by an adult team.[2]
In the UK, the British Society for Paediatric Endocrinology and Diabetes publishes guidance for the management of DKA in children.[3]
History and exam
Key diagnostic factors
- known diabetes or features of diabetes
- nausea and/or vomiting
- abdominal pain
- dehydration
- hyperventilation (Kussmaul respiration)
- reduced consciousness
- presence of risk factors
- hypothermia
Risk factors
- type 1 diabetes
- inadequate or inappropriate insulin therapy
- infection
- myocardial infarction
- previous episode of hyperglycaemic or hypoglycaemic crisis
- high HbA1c
- adverse social determinants of health
- age <45 years
- presence of other diabetes-related complications
- presence of other chronic health conditions
- pancreatitis
- stroke
- acromegaly
- hyperthyroidism
- use of certain drugs
- Cushing's syndrome
- Hispanic, Asian, or black ancestry
- bariatric surgery
- prolonged fasting or carbohydrate restriction
- pregnancy
- alcohol and/or substance use
- dementia
- mental health disorders
Diagnostic investigations
1st investigations to order
- venous blood gas
- blood ketones
- blood glucose
- urea and electrolytes
- full blood count
Investigations to consider
- urinalysis
- ECG
- pregnancy test
- amylase and lipase
- cardiac enzymes
- creatinine kinase
- chest x-ray
- liver function tests
- blood, urine, and sputum cultures
Treatment algorithm
Contributors
Expert advisers
Edward Jude, MD, MRCP
Consultant Diabetologist and Endocrinologist
Tameside and Glossop Integrated Care NHS Foundation Trust
Honorary Professor, University of Manchester
Honorary Professor, Manchester Metropolitan University Manchester
Manchester
UK
Disclosures
EJ has received honoraria and travel grants from Novo Nordisk, Sanofi, Lilly, Astra Zeneca, Biocomposites, and Menarini.
Acknowledgements
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:
Aidar R. Gosmanov, MD, PhD, FACE
Associate Professor of Medicine
Division of Endocrinology
Albany Medical College
Chief, Endocrinology Section
Albany VAMC
Albany
NY
Laleh Razavi Nematollahi, MD
Assistant Professor of Medicine
Case Western Reserve University
Cleveland
OH
Disclosures
ARG and LRN declare that they have no competing interests.
Peer reviewers
Gerry Rayman, MD, FRCP
Consultant Physician and Head of Service
Diabetes and Endocrine Centre and the Diabetes Research Unit
Ipswich Hospitals NHS Trust
Ipswich
UK
Disclosures
GR has been paid for advisory board meetings with the following companies: Sanofi Aventis, Abbott Diabetes UK, Lilly Diabetes, and Bayer. GR has received lecture fees from Sanofi Aventis, Abbott Diabetes UK, Lilly Diabetes, Novo Nordisk, and Napp Pharmaceuticals Ltd.
Ketan Dhatariya, MBBS, MSc, MD, MS, FRCP, PhD
Honorary Professor of Medicine
Norwich Medical School, University of East Anglia
Consultant Diabetes & Endocrinology
Norfolk and Norwich University Hospitals NHS Foundation Trust
Norwich
UK
Disclosures
KD is the chair of the Joint British Diabetes Societies for Inpatient Care. KD has received honoraria from Diabetes Professional Care to speak at its annual meeting about these guidelines. No other reimbursement has been received from commercial organisations with respect to these guidelines. KD has helped to develop educational materials on this subject for the European Association for the Study of Diabetes, but did not receive any reimbursement. For other work as the chair of JBDS, KD has received honoraria from Lilly for developing educational material.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia. 2024 Aug;67(8):1455-79.Full text Abstract
Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].Full text
American Diabetes Association. Standards of care in diabetes -2025. Diabetes Care. 2025 Jan 1;48(Suppl 1): S1-343.Full text
Dhatariya KK, Glaser NS, Codner E, et al. Diabetic ketoacidosis. Nat Rev Dis Primers. 2020 May 14;6(1):40. Abstract
National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available here.
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