Diabetic ketoacidosis

Last reviewed: 24 Feb 2023
Last updated: 18 Nov 2022



History and exam

Key diagnostic factors

  • known diabetes or features of diabetes
  • nausea and/or vomiting
  • abdominal pain
  • dehydration
  • hyperventilation
  • reduced consciousness
  • presence of risk factors
  • hypothermia
Full details

Other diagnostic factors

  • acetone smell on breath
Full details

Risk factors

  • inadequate or inappropriate insulin therapy
  • infection
  • myocardial infarction
  • pancreatitis
  • stroke
  • acromegaly
  • hyperthyroidism
  • drugs (e.g., corticosteroids, thiazides, pentamidine, sympathomimetics, second-generation antipsychotics, cocaine, immune checkpoint inhibitors, or SGLT2 inhibitors)
  • Cushing's syndrome
  • Hispanic or black ancestry
  • bariatric surgery
Full details

Diagnostic investigations

1st investigations to order

  • venous blood gas
  • blood ketones
  • blood glucose
  • urea and electrolytes
  • full blood count
Full details

Investigations to consider

  • urinalysis
  • ECG
  • pregnancy test
  • amylase and lipase
  • cardiac enzymes
  • creatinine kinase
  • chest x-ray
  • liver function tests
  • blood, urine, and sputum cultures
Full details

Treatment algorithm


initial systolic blood pressure <90 mmHg

initial systolic blood pressure ≥90 mmHg


Expert advisers

Gerry Rayman, MD, FRCP

Consultant Physician and Head of Service

Diabetes and Endocrine Centre and the Diabetes Research Unit

Ipswich Hospitals NHS Trust




GR is Lead and Innovator of the National Inpatient Diabetes Audit; and Joint Clinical Lead of the Diabetes, Getting It Right First Time programme.


GR has been paid for advisory board meetings with the following companies: Sanofi Aventis, Abbott Diabetes UK, Lilly Diabetes, and Bayer. GR has received lecture fees from Sanofi Aventis, Abbott Diabetes UK, Lilly Diabetes, Novo Nordisk, and Napp Pharmaceuticals Ltd.


BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:

Aidar R. Gosmanov, MD, PhD, FACE

Associate Professor of Medicine

Division of Endocrinology

Albany Medical College

Chief, Endocrinology Section

Albany VAMC



Laleh Razavi Nematollahi, MD

Assistant Professor of Medicine

Case Western Reserve University




ARG and LRN declare that they have no competing interests.

Peer reviewers

Edward Jude, MD, MRCP

Consultant Diabetologist and Endocrinologist

Tameside and Glossop Integrated Care NHS Foundation Trust

Honorary Professor, University of Manchester

Honorary Professor, Manchester Metropolitan University Manchester



EJ declares that he has no competing interests.

Ketan Dhatariya, MBBS, MSc, MD, MS, FRCP, PhD

Honorary Professor of Medicine

Norwich Medical School, University of East Anglia

Consultant Diabetes & Endocrinology

Norfolk and Norwich University Hospitals NHS Foundation Trust




KD is the chair of the Joint British Diabetes Societies for Inpatient Care. KD has received honoraria from Diabetes Professional Care to speak at its annual meeting about these guidelines. No other reimbursement has been received from commercial organisations with respect to these guidelines. KD has helped to develop educational materials on this subject for the European Association for the Study of Diabetes, but did not receive any reimbursement. For other work as the chair of JBDS, KD has received honoraria from Lilly for developing educational material.


Annabel Sidwell

Section Editor, BMJ Best Practice


AS declares that she has no competing interests.

Luisa Dillner

Head of Research and Development, BMJ


LD declares that she has no competing interests.

Anna Ellis

Head of Editorial, BMJ Best Practice


AE declares that she has no competing interests.

Rachel Wheeler

Lead Section Editor, BMJ Best Practice


RW declares that she has no competing interests.

Julie Costello

Comorbidities Editor, BMJ Best Practice


JC declares that she has no competing interests.

Adam Mitchell

Drug Editor, BMJ Best Practice


AM declares that he has no competing interests.

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