What Causes Ketoacidosis?

Diabetic ketoacidosis (DKA) is a serious complication of diabetes that happens when the body produces too many ketones and turn a person’s blood acidic. It is caused by a lack of insulin in the body.

Insulin allows glucose to pass from the bloodstream into body cells, where it is used for energy. When your cells don’t get the glucose they need, your liver begins to burn fat for energy instead. This process produces ketones, and when ketones are produced too quickly and build up, they can be toxic.

This condition is most commonly seen in type 1 diabetes, but can also occur in type 2 diabetes. DKA is dangerous and possibly fatal.

Complications of DKA include low levels of potassium (hypokalemia), swelling inside the brain (cerebral edema), fluid in the lungs (pulmonary edema), and damage to the kidneys and other organs. There are many reasons why DKA can happen, and knowing them allows people to recognize if they have DKA.

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Missed Insulin Treatment

DKA occurs when there is not enough insulin in the body. This commonly happens in people who have diabetes but haven’t been diagnosed yet and aren’t getting the treatment they need. For those who are diagnosed, skipping a treatment or having insulin pump problems can result in a lack of insulin and contribute to DKA.

When the signal from insulin in the body is so low that glucose can’t go into cells to be used as a fuel source, the liver makes a huge amount of emergency fuel in ketones, and fat is broken down too rapidly for the body to process. Ketones are normally used by the muscles and the heart. When they are produced too quickly and build up in the blood, the blood becomes acidic, which causes vomiting and abdominal pain.


Another common trigger of DKA is infection. Viral or bacterial infections such as pneumonia, urinary tract infection, and sepsis can trigger DKA. This is because your body needs more insulin than usual during an infection.

Also, an infection can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol, that counter the effect of insulin. If your body is unable to meet the demand, it may set off the liver’s ketone production to compensate for this need.

Heart Disease

Cardiovascular disease, particularly myocardial infarction (heart attack), can rarely put people with diabetes at risk for DKA. However, DKA can worsen heart conditions and cause cardiopulmonary complications, including pulmonary edema and respiratory failure.

Missed Meals

Eating and blood sugar levels are directly related to DKA. For blood sugar management, people with diabetes shouldn’t go more than five or six hours without food. Missing meals can put someone at risk for DKA because it can result in dangerously high or low blood sugar levels.

Skipping a meal throws off the balance of food intake and insulin production. When someone is dependent on insulin or other medications to maintain optimal blood sugar levels, missing a meal can lead to extremely low blood sugar.

Additionally, missing meals will create a roller-coaster effect on your blood sugar levels. This will cause the person with diabetes to jump between low and high blood sugar levels, which can be difficult to control.

Reaction to Medication

Some medications can cause a reaction that triggers DKA. Unfortunately, this can include medications for treating diabetes. In 2015, the Food and Drug Administration warned that three particular diabetes medications called SGLT2s multiply the risk of DKA by three times. Speak to your healthcare provider about medications that may increase your risk.

The three SGLT2s that may increase your risk of DKA include:

  • Farxiga (dapagliflozin)
  • Jardiance (empagliflozen)
  • Invokana (canagliflozin)

Also, some prescription medications can raise your glucose and therefore lead to DKA. These include:

Medications that increase certain hormones or glucose levels have the potential to lead to DKA. Therefore, discussing these risks with your healthcare professional and keeping them up to date on your medication and symptoms can help you avoid DKA.

Alcohol Abuse

Alcohol abuse can cause DKA for a few reasons. Excessive amounts of alcohol can lead to alcohol changing to acid in the body. This is called alcoholic ketoacidosis. Alcohol consumption doesn’t have to be excessive to trigger DKA.

Drinking alcohol can lead to:

  • Impairment and inability to detect onset of hypoglycemia
  • Hypoglycemia, which may be mistaken for intoxication by self or others
  • Impairment to hormone responses

Additionally, for some people with type 2 diabetes, excess alcohol can worsen dehydrating conditions and contribute to DKA. Occasional excess drinking should be coupled with wearing identification that indicates diabetes diagnosis, keeping a blood glucose monitor nearby, and eating carbohydrates.

Injury or Surgery

Injury and surgery can lead to stress, which has been shown to trigger hyperglycemia. This is an undesirable consequence in people with diabetes, where hyperglycemia can be brought on quickly and should be treated as soon as possible.

Similar to illness, the body reacts to injury by releasing elevated levels of hormones, which lead to high blood sugar. Therefore, people with diabetes who have had an injury or recent surgery should look out for DKA symptoms and check their blood sugar levels often.


Hyperthyroidism occurs when your thyroid gland produces too much of the hormone thyroxine. Hyperthyroidism can destabilize blood sugar metabolism, which can lead to hyperglycemia and result in DKA. Hyperthyroidism is also associated with a reduction of insulin’s half-life.

Additionally, hyperthyroidism causes metabolism to be quicker; therefore, medications like insulin will be  eliminated faster. This means those with hyperthyroidism and diabetes should be aware of possible high blood sugar due to insulin dose not staying in the body long enough.


Finally, pregnancy is another common cause of DKA. The body changes extensively during pregnancy, and one way is increased insulin resistance. This, along with vomiting often associated with pregnancy, causes dehydration, stress, and more that can lead to DKA. DKA is most likely to present during the second or third trimester when insulin resistance is at its highest.

When to See a Healthcare Provider

DKA usually develops slowly, but when vomiting occurs, this life-threatening condition can develop in a few hours. Watch out for early signs of DKA, including thirst or a very dry mouth, frequent urination, high blood glucose levels, and high levels of ketones in the urine. Seek emergency medical attention or call 911 immediately if you have these symptoms and suspect DKA.

A Word From Verywell

Diabetes is a chronic condition that requires ongoing care and management. DKA is a serious complication that can occur in people with diabetes and can be triggered by many different causes.

You can lower your chances of getting DKA by adhering to your treatment and checking your blood sugar and ketone levels regularly. Even though some causes of DKA are not avoidable, you can still prevent it by learning and recognizing the warning signs of DKA early so you can get help as soon as possible when it happens.

6 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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By Kimberly Charleson
Kimberly is a health and wellness content writer crafting well-researched content that answers your health questions.