Are we over-confident about avoiding DKA?

Living with insulin-treated diabetes requires us to navigate between severe hypoglycemia on one end of the spectrum and hyperglycemia and diabetic ketoacidosis (DKA) on the other end. The penalty for poor or untimely insulin decisions can lead to either extreme, both of which can be fatal.

This steering between two evils that diabetes presents us, however, is a concept well known by people without diabetes. It is, in fact, a classic part of the human condition. In Greek mythology, Homer writes about this topic in metaphoric fashion using the passage of a sailing ship between the twin dangers of two monsters, Scylla and Charibdis.

From Wikipedia:

Scylla and Charybdis were mythical sea monsters noted by Homer; Greek mythology sited them on opposite sides of the Strait of Messina between Sicily and the Italian mainland. Scylla was rationalized as a rock shoal (described as a six-headed sea monster) on the Italian side of the strait and Charybdis was a whirlpool off the coast of Sicily. They were regarded as maritime hazards located close enough to each other that they posed an inescapable threat to passing sailors; avoiding Charybdis meant passing too close to Scylla and vice versa. According to Homer, Odysseus was forced to choose which monster to confront while passing through the strait; he opted to pass by Scylla and lose only a few sailors, rather than risk the loss of his entire ship in the whirlpool.

This fundamental human challenge has embedded itself in our language. Have you ever used the expressions, “between a rock and hard place,” or finding yourself stuck on the “horns of a dilemma,” or even, “damned if you do, damned if you don’t”?

Does this sound familiar? We must choose which monster to challenge. Do we want to sail closer to severe hypoglycemia or closer to DKA? I choose steering closer to severe hypoglycemia because it’s much closer to the sweet spot of diabetes management, normoglycemia.

Wil Dubois over at DiabetesMine, himself a long-term type 1 diabetic, wrote about his recent, first, and unexpected experience with DKA. Will had never experienced DKA before this and when he presented with the symptoms, he was in complete denial about it and refused to play the “DKA card” when he showed up in the emergency room for help. This lead to him being triaged as a less important medical issue and he waited hours for medical attention.

Wil’s account certainly got my attention. I’ve lived with T1D for 35 years now and I’ve never experienced DKA. In fact, this long term success with avoiding DKA has lulled me into unjustified sense that “it just won’t happen to me.” I now see my overly confident attitude about avoiding DKA as adding to my vulnerability.

Back in 2012, when I established my low carb way of eating, I was fascinated by the concept of nutritional ketosis – not to be confused with DKA, by the way. I convinced my doctor to prescribe to me blood ketone test strips. I would only get 10 or so in a prescription and while I can’t remember the exact price, I do remember that they were expensive, not something I could afford to pay full price out-of-pocket.

Reading Wil’s account caused me to assess what I could do to better my chances of avoiding DKA. I conclude that having blood ketone test strips handy and using them at the appropriate time would be a good practice for me.

Since 2012, I have failed to pursue securing a steady supply of ketone test strips due to the hassle of the whole prescription process. I considered contacting my doctor about getting a new prescription and the thought occurred to me that I should check and see if these strips were available over-the-counter.

I checked and they are. Not only that but the price has dropped a lot. Amazon sells 30 Precision Xtra blood ketone test strips, individually foil wrapped, for $28.54 USD. I went ahead and ordered them; I already have the needed meter.

I see this tactic as a pragmatic one that will help me steer my preferred course between the two diabetes monsters. Living with insulin treated diabetes means we must navigate the mythical Strait of Messina each and every day.

Anyone else employ blood ketone testing?


I have been diabetic since before 1978 and I have never been in dka despite making none of my own insulin sometime after 1979. I don’t know when I actually became diabetic because doctors did not diagnose my symptoms correctly back then. I had a brief respite known as the honeymoon phase which is why I say I stopped making insulin sometime after 1979. There were a number of times that I had trouble with infusion sets or when I just couldn’t manage my diabetes well on MDI through my own ignorance such as not counting carbs. I know I reached over four to five hundred a number of times.I’ve never been hospitalized for dka and I used to have ketone strips which I would use once in a blue moon but they never showed ketones. Color me lucky

Yeah, sometimes we think our skill is what helps in this situation but I do think luck plays an important role.

For me it isn’t skill, it’s just that I am not susceptible to dka

Are you confident that your luck will continue to hold as you age and face other medical situations? Aren’t you worried about tempting Fate? Did you read Wil’s story?

I am 71 years old and pretty much have the pumping thing down to the point where I shouldn’t ever get anywhere near dka given my background with far higher glucose levels prior to my first pump in 1996 . My A1C is in the fives and never strays out of the sixes. Because of the type of sets that I use I am not likely to lose basal insulin due to an occlusion. Many years ago I use cannula sets which would frequently occlude and that would cause my blood sugar to go up quite high at night. I nearly quit pumping because of those problems until I found out about SureTs

This is the paragraph from Wil’s account that shook my confidence.

What happened? I still don’t know. A lot of it is a blur. Something made me sick. I did throw up, but my sugar was at a normal level when it happened. But then things went south. My blood sugar level started rising and wouldn’t stop. I threw insulin at it, but it all happened so fast. So frickin’ fast. It only took a few hours, coasting just below 300 mg/dL, to send me into a full-blown metabolic crisis that left me in the hospital for three days, two of them in the ICU.

That’s horrible and unfortunate

I’m a T1 prone to DKA, even at fairly low blood glucose levels. For me the issue is gastroparesis, repeated vomiting and dehydration. Over the years I’ve been in the ICU eight times due to DKA. Even with bG as low as 200. My blood just turns into a toxic mess.

I’ve learned to forstall this by managing the gastroparesis through diet and going to the ED for fluids if I start vomiting. The usual anti-emetics like zofran don’t work on me, so it’s hit or miss.

I guess I’m just saying that some people are prone, some are not and most probably fall in the middle.

Thanks for adding your experience, @anon31175731. That seems daunting to manage but we all must play the hand we’re dealt. Good for you for developing your survival tactics.

I’m not prone to DKA, but do have urine and blood ketone strips. I don’t rely on the government to buy any of it (most they don’t cover) - my life and health are worth the small pocket change it cost to have at least minimal coverage.

I believe 55 or 56 years ago I was in DKA when admitted as a little kid into hospital with T1D diagnosis, but I’ve never had it or worried much about it since. Even now I don’t worry nor would I test for high ketones unless I was ill and severely dehydrated (the main cause of DKA)

Everyone who’s T1D should have strips to test with, and try them at least once so they’re familiar with how they work. One of the main side effects of DKA is altered mental status (read: Confusion) when you’re febrile.

Read more about DKA Myths and Truths

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I have never been in DKA, except possibly at diagnosis (I was too young to know whether I was actually in DKA, but I definitely had high ketones and was hospitalized for four days). I have had several times where I’ve felt I’ve been close, though, and I do develop ketones very quickly if I”m without insulin.

I am terrified of vomiting and dehydration. My endocrinologist has warned me about it more than once. I have not vomited in well over ten years, and if I ever did vomit repeatedly, I would not hesitate to go to the hospital sooner rather than later.

I do carry ketone blood test strips with me at all times. They plus the Precision Neo meter are super thin, so easy to include in my daily medical kit. The strips have never been covered for me. I go through about a pack of ten each year, so they are not that expensive in the grand scheme of things.

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From the article:
“Any time I’m over 275 mg/dL for more than two hours, I’m breaking that puppy out. If that meter clocks anything above 1.5 mmol/L, I’m getting my ■■■ to the ER.”

This was the protocol we were given at dx, & at every workshop & webinar we’ve attended. At every ped endo appt for 7 years we were given the dosage for ketones, based on current weight. While we wouldn’t necessarily head to the ER with 1.5 ketones, we would definitely be more vigilant. I’ve often been shocked by the (what appears to me) the lack of concern over ketones by many posters here. Quite possibly it’s a matter of point of view. As a parent, my job has been to protect my daughter, & teach her good self-care habits. We were taught that DKA can happen very quickly in kids. It has always been one of biggest worries, particularly since my daughter has seemed to catch any & every bug going around since her T1 dx.

Very interesting. Dx in 1959 almost in a coma. I have never had a problem with DKA, and my bloodsugars were all over the place in the first 22 yrs with urine testing.

I have never in my 60 yrs tested for ketones. In the last 20 yrs I haven’t had an A1c over 5.5. I have been on strict eating plans for the last 14 yrs. I am not going to worry about it, because except in a national emergency, or a severe illness I can’t see it happening to me.

Also whenever I have gone into the hospital, which for diabetes I haven’t done since I was dx. the first thing I tell hospital
staff is that I am a type 1 diabetic. It isn’t playing the diabetic card, it is a necessity!!

I didn’t get to 60 yrs with this disease by letting anyone including myself forget that I have an extremely serious illness.

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I have the same issue. My sugar will be pretty normal, but getting sick, dehydration, anything like that, can send me into DKA. I’ve been in the hospital/ER several times. I’m averaging twice a year right now. :confused:

I’ve run ketones, but have never gone into DKA. So I’m curious about the definition of DKA.

Maybe once a year I’ll do something stupid, get a high glucose reading for a day or so, causing mild ketones. I just test and correct until it all calms down.

My non-medical understanding is that DKA involves:

  1. High blood sugar (but does not need to be extraordinarily high)
  2. High ketones (my understanding is anything >3.0 blood ketones is an immediate hospital visit)
  3. Change in blood pH level (this can only be measured at the hospital)

I hear a lot of people on forums talk about having DKA and recovering at home. DKA is not the same as ketones. You can have ketones and not have DKA, in which case you can turn the situation around at home. If you have DKA, there is no way to reverse that without a hospital.

Dehydration is also a big risk in speeding up the process of getting to DKA…that’s why vomiting is so dangerous for people with diabetes.


Thank you.

I just received my blood ketone test strips and I ran a ketone check. My number came up at 2.7 mmol/L. My blood glucose is 73 mg/dL (4.1 mmol/L). I otherwise feel well, am sufficiently hydrated, and feel cognitively alert. My breathing is normal. I’ve lost nine pounds since last October and I’m still losing weight although it is coming off slowly.

I eat a low-carb diet, high fat (LCHF) diet. People who use nutritional ketosis say the sweet spot for weight loss is a ketone level of 1.5-3.0 mmol/L. I eat fewer than 30 net grams of carbs per day. In the absence of carbs that readily turn into glucose, my body produces ketones for energy needs.

If I ate more carbohydrates, my ketone level would likely be < 0.6 mmol/L. I think this ambiguity between healthy nutritional ketosis levels and T1Ds who are headed toward DKA muddies the distinction between these two different situations.