DKA without high blood sugar: What it is, why it happens, and what to do

When you think of diabetic ketoacidosis, a life-threatening condition caused by severe insulin shortage that leads to dangerous acid buildup in the blood. Also known as DKA, it’s typically linked to very high blood sugar — often over 250 mg/dL. But what if your sugar levels are normal or only slightly elevated? That’s when you’re dealing with euglycemic DKA, a form of diabetic ketoacidosis that occurs without the usual spike in blood glucose. It’s rare, but it’s real — and it’s often missed because doctors and patients expect high numbers.

This isn’t just a quirk of diabetes. It happens in people with type 1 diabetes, but also in type 2 users on newer drugs like SGLT2 inhibitors — medications that push sugar out through urine. These drugs lower blood sugar so well that they can hide the warning signs of DKA. Even if your glucose reads 120 or 150, your body can still be burning fat like crazy, flooding your blood with ketones. Without insulin, your cells can’t use glucose, so they turn to fat for fuel — and that’s where the acid builds up. It’s like your body is starving, even if you just ate. People on insulin pumps, those with infections, or who’ve skipped meals or insulin doses are especially at risk. And because their sugar isn’t sky-high, they might not even think to check ketones.

What makes euglycemic DKA so dangerous is how quietly it sneaks up. You might feel nauseous, tired, or breathless — symptoms you’d blame on the flu. But if you’re diabetic and on an SGLT2 inhibitor, or if you’ve recently cut back on insulin, those symptoms could be your body screaming for help. Unlike classic DKA, where high sugar is the red flag, here the red flag is ketones in your urine or blood — not your glucometer. That’s why checking for ketones matters, even when your sugar looks fine. Hospitals now have protocols to test for ketones in anyone with diabetes who’s sick, even if their glucose is normal. Ignoring it can lead to coma or death.

The posts below cover real cases, medications that can trigger this, how to test for ketones at home, and what to do if you suspect you’re in danger. You’ll find advice on insulin adjustments, warning signs to watch for, and how SGLT2 inhibitors like Farxiga or Jardiance can play a role — even when your sugar seems under control. This isn’t theoretical. It’s something that’s happened to people who thought they were doing everything right. If you’re on diabetes meds, especially newer ones, you need to know this. The information here could save your life — or someone else’s.