DKA in type 2 diabetes

Although DKA is less common in type 2 diabetes, it still happens. Over the last 15 years, I have treated hundreds of type 2 diabetics hospitalized with DKA. People with type 2 diabetes are less familiar with DKA, and many fail to recognize it. I have written this article to help people with type 2 diabetes better understand DKA. It is based on my personal experience as a doctor as well as a thorough review of relevant medical journals.

In this article, you will learn:

  1. Why DKA is not common in type 2 diabetes
  2. What causes DKA in type 2 diabetes
  3. Who is at risk of DKA in type 2 diabetes
  4. How to recognize the symptoms of DKA in type 2 diabetes
  5. What to expect when hospitalized for DKA with type 2 diabetes

Why DKA is not common in type 2 diabetes

The main problem in type 2 diabetics is insulin resistance. It means that you need too much insulin to lower your blood sugar with type 2 diabetes compared to people without diabetes or those with type 1 diabetes. Ketones are formed when there is not enough insulin in the body. Usually, type 2 diabetics have enough insulin to prevent the formation of ketones, but not enough to prevent blood sugars form going up. That is the main reason why DKA is not very common in type 2 diabetes.

Although DKA is less common with them, the number of people with type 2 diabetes is significantly higher than that of type 1 diabetes. Even when a smaller fraction of people with diabetes get DKA, the total number of people hospitalized with DKA from type 2 diabetes is significant. Based on a recent estimate, about 34% of all hospitalized patients with DKA have type 2 diabetes. This number highlights why it is important to learn about DKA in type 2 diabetes.

What causes DKA in type 2 diabetes?

There are two main reasons why DKA sometimes occurs in type 2 diabetics:

  1. Relative lack of insulin: Type 2 diabetics usually, but not always, have enough insulin to prevent the formation of ketones from glucose. When they lack enough insulin, they can produce ketones and go into DKA.
  2. Too many stress hormones: Hormones that are released during severe bodily stress can counteract the effects of insulin. This may also apply to insulin’s ability to stop ketone formation, and lead to DKA.
A diagram showing how both a lack of insulin and stress hormones acting as anti-insulin lead to DKA.
A diagram showing how a lack of insulin and stress leads to DKA

Who is at risk of DKA in type 2 diabetes?

There are several different groups of people with type 2 diabetes that are at a higher risk of DKA:

  1. African Americans: In the United States, several studies have identified that African Americans with type 2 diabetes are more likely to be hospitalized for DKA than any other ethnic groups. 
  2. People with previously undiagnosed diabetes: Many adults with type 2 diabetes don’t know they have diabetes unless they get very sick and hospitalized with DKA. DKA is more likely to happen in undiagnosed type 2 diabetics than people that are already diagnosed and getting treatment for their diabetes.
  3. People with a long history of type 2 diabetes: Type 2 diabetics initially increase their insulin production to meet the high insulin requirement created by insulin resistance. After many years of overproduction, their insulin output fails to meet the high demand. It comes to a point where they need to give themselves insulin shots to keep their blood sugar under control, similar to type 1 diabetics. People with type 2 diabetes who are taking insulin are at a higher risk of getting DKA when they miss their insulin injections.
  4. People that are very sick with a major illness: Type 2 diabetics can go into DKA when they are very sick from another life-threatening illness, such as sepsis, a major heart attack, a stroke, or a drug or alcohol overdose. In these people, the DKA is believed to be caused by high levels of stress hormones.

How to recognize the symptoms of DKA in type 2 diabetes

It is important to understand that the symptoms of DKA in type 2 diabetes are somewhat different than the typical symptoms seen in type 1 diabetes. Type 2 diabetics are more dehydrated and less acidotic from DKA. 

Here are the signs and symptoms of DKA in type 2 diabetes:

  1. Generalized weakness: People with DKA feel very weak, tired, and lethargic. This symptom is more prominent in type 2 diabetics because they are usually more dehydrated than type 1 diabetics. In some type 2 diabetics, weakness and lethargy may be the only symptoms of DKA.
  2. Abdominal pain: DKA causes abdominal pain in both type 1 and type 2 diabetics, but the pain is usually milder in type 2 diabetics.
  3. Fast breathing: The acidosis in DKA makes you breathe fast. The more severe the acidosis, the faster you breathe. Because type 2 diabetics are usually only mildly acidotic, their fast breathing may not be very noticeable.
  4. Nausea and vomiting: Many patients with DKA have nausea and vomiting. Vomiting can worsen dehydration and make DKA worse.
  5. Dizziness and lightheadedness: Dizziness and lightheadedness in DKA is worsened by dehydration. Type 2 diabetics are more likely to be dizzy and lightheaded when they have DKA.
  6. Fruity breath: The ketones that are formed from DKA have a fruity oder, and sometimes you can recognize fruity breaths in patients with DKA. As the amount of ketones made in type 2 diabetes with DKA is relatively low, the fruity breath may be very mild or even unnoticeable.
  7. Increased thirst and urination: These types of symptoms are usually seen in people that have undiagnosed type 2 diabetes. They get diagnosed with diabetes after being hospitalized with DKA for the first time.
  8. Confusion and disorientation: Confusion and disorientation are more frequently seen in type 2 diabetics with DKA.
  9. Very high blood sugars: Blood sugars in DKA are significantly higher in type 2 diabetics than type 1 diabetics. Type two diabetics may also go into a diabetic coma from high blood sugars. You can read about diabetic comas from high blood sugar in this article.
  10. Fast heart rates and low blood pressure: These are warning signs of a pending shock. Type 2 diabetics are at a higher risk of crashing down and going into shock.

What to expect when hospitalized with DKA in type 2 diabetes

DKA is a potentially life-threatening condition and usually needs hospitalization for proper treatment. In the United States, people rarely die from DKA these days due to advanced treatment protocols that have been developed over the last 2 decades. If people with type 2 diabetes die in the hospital, it is usually from the illness that precipitated the DKA in the first place.

Here are the important aspects of treating DKA in type 2 diabetes:

  1. IV fluids: This is the most important treatment of DKA in type 2 diabetes. Most people need several liters of fluid to correct the dehydration associated with DKA. Frequent blood pressure checks are done to make sure blood pressures don’t drop. If the blood pressures are running low, more IV fluids are given.
  2. IV insulin: IV insulin is also important to stop formation of more ketones. Type 2 diabetics may require more insulin to lower their blood sugars because of the insulin resistance.
  3. Close monitoring and management of electrolytes: Electrolytes are the charged ions in our body that are essential for most of the electrical activity. With dehydration and DKA, electrolytes may get severely imbalanced. Electrolyte imbalances may cause abnormal heart rhythms and can be dangerous. Frequent blood tests are done to check your electrolytes and replace ones that are running low.
  4. Monitoring breathing: Acidosis can make you breathe faster. When your breathing gets too fast, it may become less effective, as your breaths aren’t deep enough. When the acidosis from DKA improves, breathing slows down. Sometimes very fast and shallow breathing may tire your breathing muscles, and you may need temporary ventilator support. This is usually less of a problem in type 2 diabetes because the acidosis is typically not very severe.

In conclusion, DKA does happen in type 2 diabetes. It is important to recognize the symptoms and risk factors to seek help for DKA as soon as you think about it.