The Many Faces of Diabetic Ketoacidosis
Upon perusal of the www.healthcentral.diabeteens.com web site, there appears to be pervasive discussions of Diabetic Ketoacidosis (DKA) and its various permutations.
I wanted to define and discuss the multiple situations leading up to DKA and talk about the mythical condition of “brittle” diabetes.
What is diabetic ketoacidosis? DKA results when there is insufficient insulin to enable carbohydrates to enter into the body’s cells. As a result, the body must metabolize fat and muscle to manufacture energy. This process is extraordinarily inefficient and leads to the development of ketones, a by product of fat breakdown. The blood ketones accumulate and can lead to increased acid in the blood resulting in serious consequences such as vomiting, loss of consciousness, potential coma or death. Because glucose cannot get into the cells, the concentration increases in the blood and thereby causes increased drinking, increased thirst and increased urination resulting in dehydration. Dehydration, in association with acidosis (increased levels of acid in the blood), leads to a condition known as Diabetic Ketoacidosis. The treatment of DKA involves IV fluids to allow for rehydration, an IV insulin drip to enable blood glucose to go into cells, and very close monitoring of vital signs and laboratory values. Generally, DKA requires an admission to the Intensive Care Unit. It is important to understand the different paths leading to this dangerous condition so you may take early action to prevent the situation.
There is essentially 1 path to DKA: insufficient insulin to transport blood glucose into cells. Therefore, it is important to remember that the final common pathway to DKA is lack of insulin to metabolize glucose.
Frequent hospitalizations for Diabetic Ketoacidosis raise red flags for your diabetes team. It is important to understand why teens and adults may intentionally and unintentionally make insulin errors. Intentional insulin omission may be due to diabulemia, family dysfunction or economic concerns. In a recent blog, we discussed diabulemia, a condition by which the manipulation of insulin allows for weight loss. In this situation, insulin is intentionally omitted to allow for fat breakdown. Obviously, this can become uncontrolled resulting in full-blown DKA and a hospitalization. Diabulemia is an eating disorder and can lead to severe metabolic complications and death. It must be treated by an experienced professional team.
In some cases, people with diabetes may omit insulin in an unconscious effort to ask for help in dealing with diabetes. After these multiple hospitalizations, the family and healthcare team realize that the underlying root cause must be unearthed before DKA prevention may occur. The problem may be due to lack of diabetes education; however, it is more likely related to issues with family, school, or underlying psychological problems. The diabetes team often includes a psychosocial expert who can unravel the issues that might provoke repeated episodes of DKA. Other reasons for intentional omission of insulin include the desire to hide the need for diabetes care, a lack of financial support, or denial of a diabetes diagnosis in an effort to be like everyone else. In each situation, your diabetes team can help counsel and find supplies and financial support. Do not wait until the problems become insurmountable.
Unintentional lack of insulin usually results from the need for more insulin in certain situations including illness, puberty, and other unique circumstances. During illness, it is important to keep well hydrated and test blood sugars frequently even if you are not eating. Blood sugar levels may increase despite a lack of exogenous carbohydrate, leading to DKA. Other typical reasons for an increase in blood sugar may be due to lack of bolusing of insulin for carbohydrates and malfunctioning insulin pumps. It is important to vigilantly monitor blood sugars while on an insulin pump due to the possibility of a kink in the tubing, a bad site, disconnection, or technical glitch in the pump itself. Unfortunately, if you monitor blood glucose infrequently, you may not realize that insulin has not been delivered for a significant amount of time leading to DKA. Another pump issue that often leads to DKA is changing the site before bedtime. It is a good idea to change the site earlier in the day to ensure that insulin is flowing and that blood sugars are controlled. Children’s diabetes team strongly discourages site changes at night to prevent this problem.
Frequent episodes of DKA may lead the healthcare team to consider the diagnosis of “brittle diabetes.” Brittle diabetes is actually very rare and it is often difficult to manage despite adequate education and medical treatment. It is difficult to understand the root cause of the problem and often requires extensive discussions with the patient and family to uncover deep-seated issues, thus leading to unstable diabetes. People rarely have true unstable diabetes that requires intensive medical intervention to determine the reason for blood sugar variability and rapidity of the development of DKA. There is usually a reason for the frequent DKA episodes if the diabetes team takes the time and appropriate steps to uncover the underlying, often interplaying, factors.
I hope this discussion leads to a better understanding of DKA and its origins, as well as the means to hopefully prevent this serious and possibly fatal consequence of uncontrolled diabetes. Feel free to ask questions; I am happy to respond.
Fran Cogen, M.D., C.D.E., is the director of the Childhood and Adolescent Diabetes Program at Children’s National Health System. She wrote about diabetes for HealthCentral.