Ketoacidosis is a severe, life-threatening metabolic derailment that occurs primarily in people with diabetes mellitus (diabetic ketoacidosis). Ketoacidosis can manifest itself through a variety of symptoms, ranging from so-called “kissing mouth breathing” to coma. Learn here exactly what ketoacidosis is, how it develops, and what treatment options are available.
What does ketoacidosis mean?
The word ketoacidosis is made up of the terms acidosis and ketosis. Acidosis refers to an acid metabolic state of the body, the pH of the blood is in the acidic range (<7.35). This is caused by the predominance of acidic substances in the blood, such as carbon dioxide (CO
2
) and hydrogen ions (H
+
). Ketosis is an excess of so-called ketone bodies in the blood. These are sugar substitutes that the body can make itself and that have acidic properties. Taken together, ketoacidosis thus states that there are so many acidic ketone bodies in the blood that the pH of the blood has dropped into the acidic range. Ketoacidosis is one of the metabolic acidoses (metabolic acidoses), unlike respiratory acidoses, which are caused by breathing problems.
Why does ketoacidosis develop?
The body forms ketone bodies in the liver as substitutes for sugar particles (carbohydrates), which the body needs as an energy source for all its functions. Normally, ketone bodies are formed as an intermediate product of fat metabolism and are always found in small amounts in the blood. However, if not enough sugar is available, more fatty acids are broken down into ketone bodies and released into the blood. Actually, the production of a sugar alternative is a sensible measure by the body to provide us with the energy we need despite a lack of sugar. However, the acidic properties of ketone bodies cause problems. For example, a sugar deficiency that can trigger ketoacidosis typically exists in diabetes mellitus, starvation states, and alcoholism.
Ketoacidosis in type 1 diabetes and type 2 diabetes.
The occurrence of diabetic ketoacidosis is associated primarily with poor glycemic control. The derailment of metabolism occurs in both type 1 diabetes and type 2 diabetes, but more frequently in type 1. In type 1 diabetes, regular cannabis use also appears to increase the risk of developing ketoacidosis.
Diabetic ketoacidosis caused by administration of SGLT-2 inhibitors.
In rare cases, therapy with SGLT-2 inhibitors can also cause atypical diabetic ketoacidosis in terms of a life-threatening adverse drug reaction. This was the result of an evaluation of various specialist publications. Physicians see above all a combination of carbohydrate reduction, reduction of the insulin dose as well as an unchanged further administration of SGLT-2 inhibitors as a “probable trigger” of diabetic ketoacidosis. Increasingly, diabetic ketoacidosis has also been observed as a result of dehydration, illness, intense exercise, and excessive alcohol consumption. To prevent SGLT-2-associated diabetic ketoacidosis, it is recommended that insulin administration not be reduced inappropriately. When diabetic ketoacidosis occurs, SGLT-2 inhibitor administration should be stopped. Physicians from Switzerland also recommend, based on an observed case, that patients with type 1 diabetes should at least not be treated with SGLT-2 inhibitors such as emplaglifozin outside of study scenarios.
Symptoms of ketoacidosis
Symptoms due to ketoacidosis usually develop slowly and over a period of days. Symptoms may include abdominal pain, vomiting, and fever. In the case of diabetic ketoacidosis, a febrile infection often precedes the condition. Affected individuals experience severe thirst accompanied by frequent urination. A typical feature of ketoacidosis is deep breathing, so-called “kissing-mouth breathing”, as the body tries to breathe off the acidic substances during an acidic metabolic state. In addition, the breath may be acetonic and thus smell sweet and a bit like rotten fruit. Furthermore, there are balancing currents of blood salts (electrolytes). If the electrolyte ratios get out of balance, cardiac arrhythmias may occur, as well as kidney dysfunction and water retention, which is particularly dangerous for the brain (brain edema).In the final stages of ketoacidosis, shock and coma are imminent.
Coma in ketoacidosis
Diabetic ketoacidosis is considered the most common cause of death in children and adolescents with type 1 diabetes. The hormone insulin transports sugar molecules into cells, where they are needed to provide energy. If insulin is not available, the sugar molecules remain in the blood (hyperglycemia) and are absent from the cells. Ketone bodies are formed as a compensatory measure. The subsequent hyperacidity of the blood can lead to disorders of consciousness ranging from fainting to coma. Coma in the context of ketoacidosis is called “ketoacidotic coma” and typically occurs in people with type 1 diabetes mellitus (“coma diabeticum”). In the case of type 1, there is a complete lack of insulin, unlike type 2 diabetes mellitus, which can still produce some insulin.
Therapy of ketoacidosis
Treatment of ketoacidosis depends on how far the disease has progressed. If the affected person is in a coma, there is an emergency and intensive medical measures must be taken immediately in the hospital. Breathing and circulation must be secured and the internal organs must be protected from failure. In general, treatment of diabetic ketoacidosis consists of rehydration measures, balancing of the electrolyte balance and administration of insulin. It is always important to provide sufficient fluid intake, which is done via intravenous access. If there is pronounced acidosis and a very low blood pH, balancing agents can be given to buffer the acid metabolic state in the blood. Sodium or potassium substitution is often necessary to rebalance the electrolyte balance. In the case of diabetic ketoacidosis, insulin is given to transport the sugar molecules into the cells. Diabetics should be educated by their physician about the risk of ketoacidosis and given recommendations for proper behavior at the first signs of metabolic derailment.
Prevention of diabetic ketoacidosis.
The most important measure to prevent diabetic ketoacidosis is early treatment of high blood glucose levels. Diabetic patients should also be educated by health care professionals on how to properly act in the event of elevated levels. To prevent the complication of diabetic ketoacidosis in type 1 diabetics in childhood and adolescence, the following options are available:
- Education: studies have shown that the incidence of diabetic ketoacidosis decreases when affected individuals and their parents are aware of typical symptoms of their diabetes.
- Autoantibody screening: the risk of developing type 1 diabetes increases with the number of antibodies present. Those who know they are at risk can take countermeasures before symptoms manifest. Early knowledge of an increased risk of disease and appropriate education can simultaneously reduce the likelihood of diabetic ketoacidosis.
- Vaccinations: Vaccinations against coxsackie B and rotavirus may also be considered.
