What Is Diabetic Ketoacidosis (DKA)? | FreeStyle Libre Providers

Image of a doctor wearing a stethoscope around his neck

Contents Morbidity and mortality Identifying DKA Common factors Lack of patient awareness Guidelines FAQs

Reducing DKA burden, building better patient awareness

DKA is a preventable¹ metabolic emergency that continues to be associated with substantial morbidity, mortality, and healthcare costs^4–7,†8.

This resource page reviews the growing clinical burden of DKA, highlights key features and risk factors, and examines real-world challenges that delay early recognition of DKA and prevention. It also summarizes current guidelines and outlines evidence-based strategies clinicians can use to improve patient education and help reduce DKA risk.

DKA remains prevalent and the burden is increasing*^3,†8.

Hospitalizations of patients with DKA have increased over the last decade (2012–2022), according to recent reports^†8. Meanwhile, findings from multiple studies suggest that DKA remains prevalent—even in populations using CGM and AID—and that recurrent episodes are not uncommon^6,9.

As incidence continues to climb*³, earlier recognition and proactive management remain critical for prevention¹⁰. While CGM use supports improved glycemic control¹¹, routine ketone monitoring remains an essential tool for timely detection and prevention of DKA¹⁰.

Patients with T1D and T2D are both at risk²

While DKA is more prevalent in patients with T1D, it can also affect those with T2D².

Common barriers to DKA prevention

Although education and early detection are essential to reducing DKA risk², low awareness and inconsistent ketone-testing behaviors among patients make it challenging^‡¶12.

AID = automated insulin delivery; CGM = continuous glucose monitor(ing); T1D = type 1 diabetes; T2D = type 2 diabetes

DKA is associated with substantial morbidity and mortality^4,6,7,†8.

A 13X higher age-corrected risk of mortality exists within 1 year of a DKA episode compared to the general population¹³.

The leading cause of mortality in children and adolescents with T1D is DKA¹⁴.

DKA remains a major cause of mortality among adults with T1D under the age of 58².

DKA-related mortality was more than 4X higher in patients with T2D than in those with T1D (0.91% vs 0.22%; p<0.001), according to a retrospective analysis among adult patients admitted to acute care with T1D and T2D¹⁵.

A 55% increase in DKA hospitalization rates was reported to occur between 2009 and 2014, particularly among adults under 45 years¹⁶.

Clinical insight:
About 1 in 8 patients with DKA is readmitted to hospital within 30 days, with 40.8% representing recurrent DKA episodes^§17.

DKA is driving up healthcare utilization and related costs*³.

Lengthy hospital stays
The mean length of stay for patients hospitalized with DKA is⁵:

3.0 days (T1D)
3.7 days (T2D)

Substantial hospital charges of $21,215^§17–$36,600⁵
Reported range of typical U.S. hospital charges for a DKA admission

Increased healthcare spend of $6.76 billion*³
Estimated annual DKA-related healthcare spend in the U.S.

What does this mean for your patients?
DKA continues to pose a significant clinical and economic burden⁴ for patients^§17, healthcare systems¹⁸, and payers*^3,18.

Access more DKA information

View additional DKA resources, including clinical articles. Request to talk to a medical science liaison (MSL).

CONTACT MSL

Primary signs, symptoms, and risk factors of DKA

Overview of DKA progression

DKA typically progresses through this pattern²:

Insulin deficiency promotes increased lipolysis and hepatic ketogenesis.
Ketone bodies accumulate in systemic circulation.
When left unchecked, this can result in ketoacidosis.

Who is at risk?

Patients with T1D and T2D, including those with¹¹:

A prior history of hyperglycemic or hypoglycemic crises
Other diabetes complications or chronic health conditions
High A1C
SGLT2 inhibitor use

See the 2026 ADA guidelines for a full list.

Common symptoms

Early symptoms of elevated ketones¹⁹:

Thirst/dry mouth
Frequent urination
High levels of blood glucose and/or urine ketones

Progressive symptoms of DKA¹⁹:

Constant fatigue
Dry or flushed skin
Difficulty breathing
Fruity breath
Confusion

Is it the stomach flu or DKA?
DKA symptoms commonly include nausea, vomiting and abdominal pain (>50%)⁴, which can overlap with acute gastrointestinal presentations²⁰.

What are common precipitating factors for DKA onset?

Illness, injuries, or infections are among the most common causes of DKA¹.

Use of SGLT2 inhibitors in patients with T1D confers a
5–17X greater risk compared to non-users¹¹.

Certain other medications also increase risk, including:

Corticosteroids¹
High-dose thiazides¹
Sympathomimetic agents¹
Atypical antipsychotics¹
Checkpoint inhibitors⁴

Misuse of prescribed medications and substance use¹, such as:

Illicit drugs²¹
Alcohol¹

Missed or insufficient insulin dosing, including dislodgement and/or occlusion of infusion sets in insulin pump users^4,21

Early identification of DKA is essential to improve outcomes²².

SGLT2 = sodium-glucose cotransporter 2

Lack of routine ketone monitoring due to low patient awareness²

DKA risk often goes unrecognized^‡¶12.

While DKA can be a life-threatening condition, gaps in early detection and education among patients persist.

32% of patients were unfamiliar with the term “diabetic ketoacidosis.”

46% could not name a DKA symptom.

45% could not recall potential DKA causes.

Low ketone monitoring delays DKA detection^10,23.

Ketone monitoring can yield substantial results for DKA prevention¹⁰, but inconsistent ketone monitoring practices²³ mean many patients miss the early signs¹⁰.

64% of at-risk patients never test ketones^‡¶12.

Nearly half (45%) of patients reported “never” checking ketones when they detected a fever²³.

1 in 3 patients (32%) lack ketone testing supplies at home²³.

Clinical insight:
Among surveyed patients, 67% explicitly said they would like more information about DKA and how it can be avoided^‡¶12.

What are some challenges that delay early DKA recognition?

Monitoring ketones is often delayed until hyperglycemia is present.

Study findings show that many patients did not test for ketones at all, over half tested less than every 6 months, and about one third only tested if glucose was high or if testing was required^‡¶12.

Barriers to ketone testing limit consistent use.

Low adherence to ketone monitoring can reflect multiple barriers, including education gap but also the need for convenient, reliable, and readily available methods of testing for blood ketones¹⁰.

Limitations of ketone testing

Current ketone monitoring methods detect ketosis only after it is already progressing and may require urgent medical care. While appropriate timing of testing is essential, proactive sick-day guidance is also critical¹⁰.

Clinical insight:
Nearly two thirds (63%) of patients are performing ketone testing less than once a year, or never^‡¶12.

2026 American Diabetes Association (ADA) guidelines¹¹

Clinical guidelines recommend ketone self-monitoring for at-risk patients, to help detect and self-manage hyperketonemia or hyperketonuria early and reduce the risk of DKA.

The 2026 ADA Standards of Care in Diabetes recommend that individuals at risk for DKA should receive:

Counseling on the early signs and symptoms of DKA
Appropriate tools for ketone measurement (urine and/or blood ketone tests)
Education about timely self-management of hyperglycemia and hyperketonemia

Aligning with ADA guidance includes pairing ketone monitoring with patient education to support earlier DKA detection and intervention.

Supporting ketone risk awareness in diabetes management

IDENTIFY
Early warning signs may require prompt evaluation.

Support patients in recognizing early signs and symptoms of DKA and understanding when urgent evaluation may be needed¹¹.

MONITOR
Clinical guidance on when to assess ketones in diabetes management

Key considerations for patients include potential triggers, when to test, and access to urine- or blood-based methods¹¹.

PREPARE
Sick-day planning can support timely action.

To help patients understand when to monitor ketones, sick-day plans can clarify when insulin adjustments may be needed and when to seek medical attention¹¹.

Empowering patients with actionable tools and education can help them feel prepared to prevent and manage DKA¹¹.

Frequently asked questions about DKA and patient care

Ketoacidosis as a complication of SGLT2 inhibitor therapy has been reported in both T1D and T2D²⁴. The use of such therapy can precipitate DKA through three mechanisms. First, increased ketogenesis in the liver (due to increased glucosuria) may be followed by the need for a lower insulin dose. Lower insulin concentrations cause plasma glucagon levels to increase. Second, decreased insulin concentrations lead to increased lipolysis, increased free fatty acid release, and consequently, increased ketone production by the liver. Third, SGLT2 inhibitor therapy decreases sodium reabsorption, followed by decreased renal clearance of ketone bodies²⁴.

DKA can develop over a variable time course, depending on the clinical context and precipitating factors. In many cases, early metabolic changes evolve over hours to days⁴, with initial symptoms such as increasing thirst, frequent urination, and rising blood glucose levels¹⁹. However, once vomiting occurs, progression can accelerate rapidly and DKA may become life threatening within just a few hours¹⁹.

Patients should be instructed to check ketones during any acute illness (“sick days”), typically every four to six hours, or when experiencing any warning signs of DKA²⁵. Ketone testing is also recommended when blood glucose is persistently elevated, generally above 250 mg/dL².

* Data from a retrospective analysis of U.S. hospital admissions for DKA between 2003–2017.

† Data from a retrospective analysis of U.S. emergency department visits for adults with DKA between 2012–2022.

‡ Multinational, multicenter survey of endocrine outpatient clinic patients with average duration of T1D of 22 years (N=333).

§ Data based on a nationwide analysis of 30-day readmissions among adult patients with DKA in the United States (2010–2014).

¶ Participants rated their own knowledge of DKA significantly lower than their healthcare providers did (p<0.0001).

References: 1. Lizzo, Jenna M., Amandeep Goyal, and Jasleen Kaur. “Adult Diabetic Ketoacidosis.” In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing, 2025. Accessed January 22, 2026. https://www.ncbi.nlm.nih.gov/books/NBK560723/. 2. Nguyen, Kevin T., et al. “Continuous Ketone Monitoring Consensus Report 2021.” Journal of Diabetes Science and Technology 16, no. 3 (2022): 689–715. https://doi.org/10.1177/19322968211042656. 3. Ramphul, Kamleshun, and Jyotsnav Joynauth. “An Update on the Incidence and Burden of Diabetic Ketoacidosis in the U.S.” Diabetes Care 43 (2020): e196–e197. https://doi.org/10.2337/dc20-1258. 4. Umpierrez, Guillermo E., et al. “Hyperglycemic Crises in Adults With Diabetes: A Consensus Report.” Diabetes Care 47 (2024): 1257–1275. https://doi.org/10.2337/dci24-0032. 5. Shaka, Hafeez, et al. “Comparing Patient Characteristics and Outcomes in Type 1 versus Type 2 Diabetes With Diabetic Ketoacidosis: A Propensity-Matched Nationwide Analysis.” Journal of Investigative Medicine 69 (2021): 1196–1200. https://doi.org/10.1136/jim-2021-001901. 6. Shaka, Hafeez, et al. “Rate and Predictors of 30-Day Readmission Following Diabetic Ketoacidosis in Type 1 Diabetes Mellitus: A US Analysis.” Journal of Clinical Endocrinology & Metabolism 106, no. 9 (2021): 2592–2599. https://doi.org/10.1210/clinem/dgab372. 7. Gill, Vikram Jeet Singh, Siddhant Govekar, Suha Soni, Ashna Grover, and Skand Shekhar. “Trends and Disparities in DKA-Related Mortality in the United States (1999–2022): Insights from the CDC WONDER Database.” Journal of the Endocrine Society 9, suppl. 1 (2025): A622, https://doi.org/10.1210/jendso/bvaf149.1172. 8. Haas, Nathan L., et al. “National Intensive Care Unit Utilization for Diabetic Ketoacidosis Increased from 2012 to 2022.” Academic Emergency Medicine 32 (2025): 1248–1250. https://doi.org/10.1111/acem.70099. 9. Riveline, J-P, et al. “Prevalence and Characteristics of Diabetic Ketoacidosis in Type 1 Diabetes: Real-World Data from the French SFDT1 Cohort.” Abstract #LBA 27 presented at 61st EASD Annual Meeting of the European Association for the Study of Diabetes, Vienna, Austria, 15–19 September 2025. https://link.springer.com/article/10.1007/s00125-025-06497-1#Sec181. 10. Virdi, Naunihal, Yeesha Poon, Richard Abaniel, and Richard M. Bergenstal. “Prevalence, Cost, and Burden of Diabetic Ketoacidosis.” Diabetes Technology & Therapeutics 25, suppl. 3 (2023): S75–S84. https://doi.org/10.1089/dia.2023.0149. 11. American Diabetes Association Professional Practice Committee for Diabetes. “Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes—2026.” Diabetes Care 49, suppl. 1 (2026): S132–S149. https://doi.org/10.2337/dc26-S006. 12. Hepprich, Matthias. “Awareness and Knowledge of Diabetic Ketoacidosis in People With Type 1 Diabetes: A Cross-Sectional, Multicenter Survey.” BMJ Open Diabetes Research & Care 11 (2023): e003662. https://doi.org/10.1136/bmjdrc-2023-003662. 13. Shand, James A. D., Paul Morrow, and Geoff Braatvedt. “Mortality after Discharge from Hospital Following an Episode of Diabetic Ketoacidosis.” Acta Diabetologica 59 (2022): 1485–1492. https://doi.org/10.1007/s00592-022-01953-5. 14. Garg, Satish K., and Christopher G. Parkin. “Role of Continuous Dual Glucose–Ketone Monitoring in Diabetes Care.” Diabetes Technology & Therapeutics 27, suppl. 4 (2025): S1–S5. https://doi.org/10.1177/15209156251369529. 15. Portillo-Canales, Shellsea, John Peters, Garry Francis-Morel, and Sandeep Dhindsa. “Disparities in Outcomes and Health Care Utilization for Diabetic Ketoacidosis Among Patients With Type 1 and Type 2 Diabetes Mellitus: A 6-Year National Retrospective Cohort Study.” Endocrine Practice 31, no. 6 (2025): 784–789. https://doi.org/10.1016/j.eprac.2025.04.002. 16. Benoit, Stephen R., Yan Zhang, Linda S. Geiss, Edward W. Gregg, and Ann Albright. “Trends in Diabetic Ketoacidosis Hospitalizations and In-Hospital Mortality — United States, 2000–2014.” Morbidity and Mortality Weekly Report 67, no. 12 (2018): 362–365. https://doi.org/10.15585/mmwr.mm6712a3. 17. Hurtado, Carolina R., et al. “Causes and Predictors for 30-Day Re-Admissions in Adult Patients with Diabetic Ketoacidosis in the United States: A Nationwide Analysis, 2010–2014.” Endocrine Practice 25, no. 3 (2019): 242–253. https://doi.org/10.4158/EP-2018-0457. 18. Desai, Dimpi, et al. “Health Care Utilization and Burden of Diabetic Ketoacidosis in the U.S. Over the Past Decade: A Nationwide Analysis.” Diabetes Care 41, no. 8 (2018): 1631–1638. https://doi.org/10.2337/dc17-1379. 19. American Diabetes Association. “Diabetes & DKA (Ketoacidosis).” Accessed January 22, 2026. https://diabetes.org/about-diabetes/complications/ketoacidosis-dka/dka-ketoacidosis-ketones. 20. Dhatariya, Ketan, Omar Mustafa, and Dimitra Stathi. “Hyperglycemic Crises.” In Endotext, ed. Kenneth R. Feingold et al. (South Dartmouth, MA: MDText.com, Inc., 2000–), last updated June 10, 2025, https://www.ncbi.nlm.nih.gov/books/NBK279052/. 21. Mohan, Viswanathan, and Kenneth Lee. “Global Burden of Diabetic Ketoacidosis.” Diabetes Technology & Therapeutics 27, suppl. 4 (2025): S6–S13. https://doi.org/10.1177/15209156251390828. 22. Miller, Eden, Kevin Miller, and Richard M. Bergenstal. “Integrating Continuous Dual Glucose–Ketone Monitoring into Clinical Practice.” Diabetes Technology & Therapeutics 27, suppl. 4 (2025): S32–S35. https://doi.org/10.1177/15209156251392900. 23. Albanese-O’Neill, Anastasia, et al. “Poor Adherence to Ketone Testing in Patients With Type 1 Diabetes.” Diabetes Care 40 (2017): e38–e39. https://doi.org/10.2337/dc16-2620. 24. Huang, Jingtong, et al. “Update on Measuring Ketones.” Journal of Diabetes Science and Technology 18, no. 3 (2024): 714–726. https://doi.org/10.1177/19322968231152236. 25. American Diabetes Association. “Planning for Sick Days.” Accessed January 22, 2026. https://diabetes.org/getting-sick-with-diabetes/sick-days.

ADC-2687362 v1.0

Important Safety Information

Failure to use FreeStyle Libre systems as instructed in labeling may result in missing a severe low or high glucose event and/or making a treatment decision, resulting in injury. If glucose reading and alarms (if enabled) do not match symptoms or expectations, use a fingerstick value from a blood glucose meter for treatment decisions. Get medical attention when appropriate. Abbott Customer Service at 855-632-8658 or visit FreeStyleLibre.us for safety info.

The product images are for illustrative purposes only.

No use of any Abbott trademark, trade name, or trade dress in this site may be made without prior written authorization of Abbott Laboratories, except to identify the product or services of the company.

This website and the information contained herein is intended for use by residents of the United States.

ADC-45115 v24.0

Diabetic ketoacidosis (DKA): A metabolic emergency^1,2 and growing clinical concern*³

Reducing DKA burden, building better patient awareness