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July 26, 2006

Hyperglycemia and DKA

Question from Florida, USA:

I was hoping you could clear up how ketones affect the three different types of diabetics. Do all diabetics get DKA or just people with type 1? I was under the impression DKA was unique to type 1s, but I've been told from gestational diabetics that they get it, too, and it's the same as DKA in a type 1. They've also advised me that I'm treating episodes of DKA all wrong. They told me that if I'm in DKA I need to drink milk, or have a snack without insulin before going to bed. That that is what their doctors had them do. This confused me. My diabetes education was decades ago. But, I was taught that I should treat any episode of DKA with extra insulin, push clear non-calorie fluids, and avoid high carbohydrate meals until my blood sugar and the ketones got under control. Sure enough, I read a pamphlet on gestational diabetes in the doctor's office and it referred to DKA and said if they have ketones they may need to eat more. Why would you eat more if you have DKA? I'm confused.

Answer:

ANYONE, diabetic or not, can (and does) produce ketones. Ketones are natural compounds, primarily resulting, from the metabolism of fat. The brain can actually use ketones for fuel, in some measure.

The large accumulation of ketones, along with acid production, is what is dangerous and potentially to a person with diabetes.

Individuals with type 1 diabetes are more prone to develop ketones and the acids and the conglomeration called diabetic ketoacidosis (DKA). Type 2 diabetes can, on occasion, lead to this as well. One presumes that gestational diabetes can lead to this also.

The treatment of DKA is insulin. Some substrate (glucose, for example) may also be required. If you have DKA and your glucose is elevated, then you need insulin but you are supplying your own glucose. If your glucose is relatively low but you have ketones, you might need a bit of glucose added.

So, I think that you were NOT treating DKA “all wrong” at all! If you have increasing ketones, you need more insulin! You MAY need extra food, especially to avoid HYPOglycemia, following the administration of extra insulin.

DS

[Editor’s comment: It sounds like you are referring to “starvation” ketones (ketosis) in those with gestational diabetes, not DKA. These “starvation” ketones can occur in a person with type 1 when they are ill and unable to eat. You can have low or normal blood sugars, but ketones from not eating enough carbohydrates. Under these circumstances, you would need to increase your food intake.

Furthermore, it appears that you may be a bit confused about ketones and actual DKA. According to the Diabetes Dictionary, “Ketoacidosis starts slowly and builds up. The signs include nausea and vomiting, which can lead to loss of water from the body, stomach pain, and deep and rapid breathing. Other signs are a flushed face, dry skin and mouth, a fruity breath odor, a rapid and weak pulse, and low blood pressure. If the person is not given fluids and insulin right away, ketoacidosis can lead to coma and even death.” Usually, someone in DKA is unable to treat his/herself without medical intervention. The treatment of ketones is usually insulin and extra fluids. It seems more likely that you are referring to your treatment of ketones, not DKA.

BH]