Ketoacidosis (DKA)

Diabetic ketoacidosis (DKA) is an acute, life-threatening diabetes complication. Elevated ketones are only one part of it. DKA also requires metabolic acidosis and either a history of diabetes or qualifying hyperglycemia.¹

Medical disclaimer. This article is for general educational purposes only and is not medical advice. It is not a substitute for professional diagnosis or treatment. Always consult a qualified healthcare provider before starting the ketogenic diet or making changes to your diet, exercise, or medication — especially if you are pregnant or breastfeeding, take medication, or have a medical condition such as diabetes, or kidney, liver, or heart disease. See our editorial & medical-review policy.

Seek emergency care now for persistent vomiting, severe abdominal pain, deep or difficult breathing, confusion, fainting, or marked drowsiness. These signs are especially concerning for DKA with known or possible diabetes, pregnancy, or SGLT2-inhibitor use; do not wait for very high glucose.

The current diagnostic criteria

The 2024 international consensus requires all three components below for DKA:¹

1. Diabetes or hyperglycemia: a prior history of diabetes, regardless of the current glucose, or glucose at least 200 mg/dL (11.1 mmol/L).
2. Elevated ketones: blood beta-hydroxybutyrate (BHB) at least 3.0 mmol/L or urine ketones at least 2+.
3. Metabolic acidosis: venous pH below 7.3 and/or bicarbonate below 18 mmol/L.

A blood ketone meter can measure BHB but cannot measure pH or bicarbonate. A home result therefore cannot diagnose or rule out DKA by itself.

DKA can occur with normal-looking glucose

Euglycemic DKA meets the ketone and acidosis criteria while glucose is below 200 mg/dL. The consensus associates it with SGLT2 inhibitors, pregnancy, reduced food intake, insulin already taken before testing, alcohol-related impaired gluconeogenesis, and liver failure.¹

The FDA warns that SGLT2 inhibitors can cause ketoacidosis even when glucose is below the level usually expected in DKA. If nausea, vomiting, abdominal pain, unusual fatigue, or shortness of breath occurs during SGLT2-inhibitor use, the FDA directs patients to stop the medicine and seek medical attention immediately.²

Do not start a ketogenic or very-low-carbohydrate diet while taking an SGLT2 inhibitor without a plan from the prescriber. Never reduce or omit insulin on your own after changing carbohydrate intake.

DKA is different from nutritional ketosis

Nutritional ketosis is a regulated response to low carbohydrate or energy availability and does not ordinarily include metabolic acidosis. No single ketone cutoff makes a person safe, however. Symptoms, diabetes status, pregnancy, illness, medication use, and acid-base testing determine the clinical meaning of a reading.

Urine tests detect acetoacetate rather than BHB. They may underestimate ketonemia early in DKA and overestimate it during recovery, so the consensus prefers direct blood BHB measurement when available.¹ See ketone urine strips for those limitations and the full ketosis-versus-DKA guide for a detailed comparison.

Frequently Asked Questions

Can DKA happen below 200 mg/dL glucose?

Yes. Euglycemic DKA includes elevated ketones and metabolic acidosis despite glucose below 200 mg/dL. SGLT2 inhibitors, pregnancy, reduced food intake, alcohol-related impaired gluconeogenesis, liver failure, and insulin already taken before testing are recognized contexts.

Does a BHB reading of 3.0 mmol/L diagnose DKA?

No. It meets the ketone component of the consensus criteria, but DKA also requires metabolic acidosis and diabetes or qualifying hyperglycemia. Symptoms or a concerning result in an at-risk person need urgent clinical assessment.

Can breath odor distinguish DKA from dietary ketosis?

No. Fruity or acetone-like breath is not reliable enough to diagnose or exclude DKA.

Can DKA be treated at home?

No. Suspected DKA requires emergency assessment and clinical treatment. Do not try to correct it with water, food, exercise, supplements, or self-directed insulin changes.

Works cited

1. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report — Umpierrez GE, Davis GM, ElSayed NA, et al., Diabetes Care. 2024;47(8):1257–1275, doi:10.2337/dci24-0032 — August 23, 2026 https://pmc.ncbi.nlm.nih.gov/articles/PMC11272983/
2. FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections — U.S. Food and Drug Administration, revised March 15, 2022 — August 23, 2026 https://www.fda.gov/files/drugs/published/FDA-revises-labels-of-SGLT2-inhibitors-for-diabetes-to-include-warnings-about-too-much-acid-in-the-blood-and-serious-urinary-tract-infections.pdf

See also: Ketosis · BHB · Blood ketone meter · Urine ketone strips · Detailed ketosis vs DKA guide · Full glossary

Article history

1. August 23, 2026Updated
2. August 18, 2026First published