Editing Diabetic ketoacidosis (section)

==Cause==
DKA most frequently occurs in those who know that they have diabetes, but it may also be the first presentation in someone who has not previously been known to be diabetic. There is often a particular underlying problem that has led to the DKA episode; this may be intercurrent illness ([[pneumonia]], [[influenza]], [[gastroenteritis]], a [[urinary tract infection]]), [[pregnancy]], inadequate insulin administration (e.g. defective insulin pen device), [[myocardial infarction]] (heart attack), [[stroke]] or the use of [[cocaine]]. Young people with recurrent episodes of DKA may have an underlying [[eating disorder]], or may be using insufficient insulin for fear that it will cause [[obesity|weight gain]].<ref name=Powers2005/>

Diabetic ketoacidosis may occur in those previously known to have diabetes mellitus type 2 or in those who on further investigations turn out to have features of type 2 diabetes (e.g. [[obesity]], strong [[family history]]); this is more common in African, African-American and Hispanic people.<ref>{{Cite web |title=Diabetes |url=https://www.who.int/health-topics/diabetes |access-date=2024-04-27 |website=www.who.int |language=en}}</ref> Their condition is then labeled "ketosis-prone type 2 diabetes".<ref name=ADA2009/><ref name=Umpierrez2006>{{cite journal | vauthors = Umpierrez GE, Smiley D, Kitabchi AE | title = Narrative review: ketosis-prone type 2 diabetes mellitus | journal = Annals of Internal Medicine | volume = 144 | issue = 5 | pages = 350–357 | date = March 2006 | pmid = 16520476 | doi = 10.7326/0003-4819-144-5-200603070-00011 | s2cid = 33296818 }}</ref>

Drugs in the [[SGLT2 inhibitor|gliflozin]] class ([[SGLT2]] inhibitors), which are generally used for type 2 diabetes, have been associated with cases of diabetic ketoacidosis where the blood sugars may not be significantly elevated ("euglycemic DKA").<ref name=Goldenberg2016>{{cite journal | vauthors = Goldenberg RM, Berard LD, Cheng AY, Gilbert JD, Verma S, Woo VC, Yale JF | title = SGLT2 Inhibitor-associated Diabetic Ketoacidosis: Clinical Review and Recommendations for Prevention and Diagnosis | journal = Clinical Therapeutics | volume = 38 | issue = 12 | pages = 2654–2664.e1 | date = December 2016 | pmid = 28003053 | doi = 10.1016/j.clinthera.2016.11.002 }}</ref> While this is a relatively uncommon adverse event, it is thought to be more common if someone receiving an SGLT2 inhibitor who is also receiving insulin has reduced or missed insulin doses. Furthermore, it can be triggered by severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive [[alcohol (drug)|alcohol]] intake.<ref name=Goldenberg2016/> Proposed mechanisms for SGLT2-I induced "euglycemic DKA" include increased ketosis due to [[Hypovolemia|volume depletion]] combined with relative insulin deficiency and [[glucagon]] excess.<ref>{{cite journal | vauthors = Perry RJ, Rabin-Court A, Song JD, Cardone RL, Wang Y, Kibbey RG, Shulman GI | title = Dehydration and insulinopenia are necessary and sufficient for euglycemic ketoacidosis in SGLT2 inhibitor-treated rats | journal = Nature Communications | volume = 10 | issue = 1 | pages = 548 | date = February 2019 | pmid = 30710078 | pmc = 6358621 | doi = 10.1038/s41467-019-08466-w | bibcode = 2019NatCo..10..548P }}</ref>  SGLT2 inhibitors should be stopped before surgery and only recommenced when it is safe to do so.<ref>{{cite journal | vauthors = Milder DA, Milder TY, Kam PC | title = Sodium-glucose co-transporter type-2 inhibitors: pharmacology and peri-operative considerations | journal = Anaesthesia | volume = 73 | issue = 8 | pages = 1008–1018 | date = August 2018 | pmid = 29529345 | doi = 10.1111/anae.14251 | doi-access = free }}</ref> SGLT2 inhibitors may be used in people with type 1 diabetes, but the possibility of ketoacidosis requires specific risk management.<ref>{{Cite journal |last1=Horii |first1=Takeshi |last2=Oikawa |first2=Yoichi |last3=Atsuda |first3=Koichiro |last4=Shimada |first4=Akira |date=September 2021 |title=On-label use of sodium–glucose cotransporter 2 inhibitors might increase the risk of diabetic ketoacidosis in patients with type 1 diabetes |journal=Journal of Diabetes Investigation |language=en |volume=12 |issue=9 |pages=1586–1593 |doi=10.1111/jdi.13506 |pmid=33448127 |issn=2040-1116|pmc=8409873 }}</ref> Specifically, they should not be used if someone is also using a [[low carbohydrate diet|low carbohydrate]] or [[ketogenic diet]].<ref name=Dan2019>{{cite journal | vauthors = Danne T, Garg S, Peters AL, Buse JB, Mathieu C, Pettus JH, Alexander CM, Battelino T, Ampudia-Blasco FJ, Bode BW, Cariou B, Close KL, Dandona P, Dutta S, Ferrannini E, Fourlanos S, Grunberger G, Heller SR, Henry RR, Kurian MJ, Kushner JA, Oron T, Parkin CG, Pieber TR, Rodbard HW, Schatz D, Skyler JS, Tamborlane WV, Yokote K, Phillip M | display-authors = 6 | title = International Consensus on Risk Management of Diabetic Ketoacidosis in Patients With Type 1 Diabetes Treated With Sodium-Glucose Cotransporter (SGLT) Inhibitors | journal = Diabetes Care | volume = 42 | issue = 6 | pages = 1147–1154 | date = June 2019 | pmid = 30728224 | pmc = 6973545 | doi = 10.2337/dc18-2316 | quote = As a general guideline, SGLT-inhibitor therapy should not be used in patients using lowcarbohydrate or ketogenic diets as, anecdotally, they seem to be at increased risk of adverse ketosis effects | authorlink24 = Thomas Pieber | doi-access = free }}</ref>