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The DKA demon?

In 1975, a famous endocrinologist published a very elegant experiment. He recruited 7 healthy adults with long standing type 1 diabetes. Using a chemical inhibitor called somatostatin, he blocked all glucagon production from their pancreases. Then he withheld their insulin doses to induce diabetic ketoacidosis (DKA).

It took 18 hours for DKA to begin, compared to the 10 hours it took for the unblocked type 1 patients to develop DKA. His study was the first to affirm that insulin deficiency alone is not enough to trigger DKA. It took glucagon too.

Glucagon is a so-called "stress hormone". In the pre-insulin era, progressive diabetes doctors knew that careful avoidance of stress and a low calorie (high fat) diet could extend life in persons with new onset "juvenile" diabetes (the old term for type 1 diabetes). Any stress could be the final straw which would send insulin deficient people into the fatal abyss of DKA. In the case of newly diagnosed type 1 diabetes patients, they retain some (albeit not a lot) insulin production ability for months to years after a formal diabetes diagnosis is made.

Years later in 2011, building upon on this background of practical knowledge and clinical studies, researchers genetically removed glucagon hormone receptors from mice. They then chemically induced the equivalent of type 1 diabetes in these animals. Unmodified mice soon became overtly diabetic, developed DKA and died. Mice genetically lacking glucagon receptors did not develop diabetes and did not die. Fascinating.

After more than three decades of caring for thousands of persons of all ages with type 1 diabetes, I've heard and seen a lot.

A commonly recurring story I hear goes like this. DKA will descend upon a child or adult with type 1 diabetes seemingly from out of nowhere. The patient or family can often find no explanation for this. They may conclude that DKA simply "happens" and can strike anytime, anywhere. It's almost as if demons are at fault for sending them or their child into a chaotic upward glycemic spiral. And as much as we would like to imagine that DKA was due to an uninvited visit from supernatural beings, it’s simply not true.

After diagnosis, any episode of diabetic ketoacidosis (DKA) is always due to a lack of effective insulin action, period. The "demon" is in the details.

The list of DKA causes are many, starting with insulin omission, an insulin interruption (pump malfunction), or failure to 'step up' insulin dosing amount and frequency in order to compensate for the stress of illness or even some medication effects (such as high dose steroids). But in the end, DKA is a potentially preventable event. It’s not something that simply strikes from nowhere without explanation as some of us may think.

Well meaning friends will soothe the parent or person with diabetes by agreeing with them that DKA came upon them as some kind of mysterious fog that suddenly rolled into their life entirely under its own power.

Fairies and goblins, like any other mythology, were created to explain the seemingly unexplainable. If DKA strikes, there IS an explanation, whether we can easily identify it or not.

But PLEASE UNDERSTAND THIS. The point here is not to assign blame or diminish anyone, but to explain that once the causes are learned in each case, future events can be better avoided or managed. After all, most misfortunes can be transformed into great learning opportunities.

My first and only episode of DKA happened when I omitted an insulin dose. In my unaware state, I blamed the most recent action I had done (the cheeseburger I ate for lunch) as the immediate cause. I was never taught what would happen to my body without minimally sufficient insulin. I learned a valuable lesson, and it only took one time. Today, we teach all families and patients that illness is usually associated with a greater insulin need, not less. Also, that totally withholding a scheduled insulin dose in response to a low BG or reduced appetite is NOT usually the proper action.

As a busy practicing pediatric endocrinologist for over 30 years I have seen thousands of cases (and near cases) of DKA. In many cases the origins of the DKA are shrouded in mystery. This is because omitting insulin is not something that most people like to talk about. Forgetting to check and correct high BG's or check for ketones when BG's are high is another example where a missed opportunity festers into a much more serious outcome. In the insulin pump era, DKA is commonly due to poorly functioning/dislodged infusion sites, improper site insertion with poor follow up, and air bubbles in tubing or backflow of insulin secondary to the process called "tunneling".

Once again, PLEASE don't misread the intent of this post. No reasonable person wants to develop DKA. It's usually an unintended consequence of some kind of omission or failure to act soon enough. But in a small number of circumstances it IS intentional. When that happens, hopefully it's revealed and the reasons can be further explored.

Next time you hear about somebody’s mysterious, inexplicable bout with DKA you can refer them to this post and make sure everyone knows how to prevent DKA using my Fifteen Fast Facts about ketones in the book Sugar Surfing.

Please share some of your unexplained DKA events and what you later learned the actual trigger was. Also, what steps do you take now to prevent DKA before it has a chance to bite you?

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