What is euglycemic DKA? Euglycemic diabetic ketoacidosis (DKA) is DKA that happens when blood sugar is below 200 mg/dL. The body still has too little insulin, ketones still build up, and the blood still becomes acidic. Because blood sugar does not look very high, it can be missed. It is a medical emergency.
Key takeaways
- The American Diabetes Association (ADA) says about 10% of people with DKA have euglycemic DKA, with blood sugar below 200 mg/dL. It develops when insulin levels are low.
- A 2024 consensus report says SGLT2 inhibitors, a class of diabetes medicines, now account for most cases. Eating much less than usual, pregnancy, alcohol use, and liver failure are also linked to it.
- Watch for the DKA warning signs the Centers for Disease Control and Prevention (CDC) lists, such as nausea, vomiting, stomach pain, fast, deep breathing, and being very tired. A normal-looking meter reading does not rule out DKA.
- Doctors confirm it with blood tests for ketones and acid. The consensus report says hospital care follows typical DKA treatment, with dextrose (sugar) added to IV fluids from the start.
- Call 911 for high ketones, trouble breathing, confusion, or vomiting that keeps you from keeping food or drinks down, even if your blood sugar looks normal.
How Is Euglycemic DKA Different From Typical DKA?
In typical DKA, too little insulin lets fat break down too fast. The liver turns it into ketones, which make the blood acidic, and the liver also makes a large amount of glucose, according to MedlinePlus. So blood sugar usually climbs.
In euglycemic DKA, ketones and acid build up the same way, but blood sugar stays below 200 mg/dL. ADA's 2026 Standards of Care say it develops when insulin levels are low. For this reason, ADA's criteria for DKA accept a known history of diabetes in place of high blood sugar.
| What doctors look at | Typical DKA | Euglycemic DKA |
|---|---|---|
| Blood sugar | Usually 200 mg/dL or higher | Below 200 mg/dL |
| Ketones | High, meeting ADA's DKA criteria | High, meeting the same criteria |
| Acid in the blood | pH below 7.3 and/or bicarbonate below 18 mmol/L | The same criteria |
| Most common links | Illness and insulin problems, per the CDC | SGLT2 inhibitors, per the consensus report |
| IV dextrose (sugar) in the hospital | Added once blood sugar falls below 250 mg/dL, per the consensus report | Added from the start, per the consensus report |
These are hospital measurements, not numbers to check at home. Our main guide explains what diabetic ketoacidosis is in more detail.
What Causes Euglycemic DKA?
ADA 2026 says euglycemic DKA can be linked to:
- SGLT2 inhibitors, which the consensus report says have accounted for most cases in recent years
- Eating much less than usual, such as during illness or a fast
- Pregnancy
- Alcohol use
- Liver failure
The consensus report explains that alcohol use, liver failure, and SGLT2 inhibitors can reduce the liver's ability to make new glucose. The ADA also lists fasting and very low-carb eating among the risk factors for ketones in people with diabetes. Our guides to whether intermittent fasting is safe for diabetics and whether alcohol lowers blood sugar explain what to ask your care team.
How Are SGLT2 Inhibitors Linked to Euglycemic DKA?
SGLT2 inhibitors are a class of diabetes medicines that help the kidneys pass sugar into the urine. Their generic names end in "-gliflozin." If you are not sure whether you take one, ask your pharmacist.
The consensus report says DKA linked to these medicines may happen on its own or after a lower insulin dose or a missed insulin dose, a long fast, or a sudden illness. It may also come with near-normal blood sugar. In one series, 35% of people taking SGLT2 inhibitors who came in with DKA had blood sugar below 200 mg/dL. In another, 71% had 250 mg/dL or lower.
The report lists these added risk factors for people with type 2 diabetes who take an SGLT2 inhibitor:
- Very low-carb diets and prolonged fasting
- Dehydration
- Drinking too much alcohol
- Autoimmunity, when the immune system attacks the body's own cells
It also says DKA is uncommon in people with type 2 diabetes who take these medicines, with an estimated 0.6 to 4.9 cases per 1,000 patient-years. One patient-year means one person taking the medicine for one year. In type 1 diabetes, ADA 2026 says the risk of DKA with SGLT2 inhibitors can be 5 to 17 times higher than in people who do not take them. Our guide to whether type 2 diabetics can get DKA covers other risks.
Surgery. ADA 2026 says SGLT2 inhibitors should be held for 3 to 4 days before planned surgery. Your surgical team sets the timing, so tell them about every medicine you take. ADA also says people taking these medicines who have emergency surgery should be watched closely for DKA afterward, including euglycemic DKA.
The consensus report says DKA linked to SGLT2 inhibitors may be prevented with specific sick-day rules. Never stop an SGLT2 inhibitor or any other medicine on your own. Ask your care team what to do on sick days, before surgery, and before any fast.
Can Euglycemic DKA Happen During Pregnancy?
Yes. ADA 2026 says up to 2% of pregnancies in people with diabetes that started before pregnancy are complicated by DKA, most often in type 1 diabetes. DKA is rare in gestational diabetes, at less than 0.1%.
ADA says pregnant people may develop euglycemic DKA, and that severe vomiting during pregnancy (hyperemesis) can make DKA harder to diagnose. Because of the serious risk to the pregnant person and the baby, ADA advises pregnant people at risk to learn the signs of DKA and to seek medical care right away if DKA is a concern. The consensus report says DKA in pregnancy needs immediate care from senior medical and obstetric experts.
If you are pregnant or planning a pregnancy and have diabetes, ask your care team for a DKA plan. See our guide to gestational diabetes symptoms for more on diabetes in pregnancy.
What Are the Symptoms of Euglycemic DKA?
Euglycemic DKA is a form of DKA, so the warning signs to know are the DKA signs. The CDC lists:
- Fast, deep breathing
- Dry skin and mouth
- Flushed face
- Fruity-smelling breath
- Headache
- Muscle stiffness or aches
- Being very tired
- Nausea and vomiting
- Stomach pain
The ADA also lists confusion. Not everyone has every sign, and many of these signs can have other causes.
The difference is the meter reading. ADA notes that some cases of euglycemic DKA may be missed. If you have DKA symptoms, check ketones if your care team has told you how, and do not let a normal blood sugar reading stop you from getting help. Our guide to ketones in urine explains what home ketone results mean.
How Do Doctors Check for Euglycemic DKA?
Doctors use the same tests as for any DKA. MedlinePlus lists an arterial blood gas test, a basic metabolic panel, a blood glucose test, a blood pressure check, and an osmolality blood test. The ADA criteria require high ketones and acid in the blood, plus either high blood sugar or a known history of diabetes.
The consensus report says blood beta-hydroxybutyrate, the main ketone made in DKA, can be measured directly. Urine strips measure a different ketone, and the report says relying on urine tests can underestimate ketone levels early in DKA.
Doctors also look for other causes of high ketones. The consensus report lists starvation ketosis, alcoholic ketoacidosis, and ketosis linked to pregnancy or severe vomiting during pregnancy as conditions to consider.
A record of your readings, ketone results, meals, and symptoms can help your care team. Our blood sugar journal prompts can help you keep one.
How Is Euglycemic DKA Treated?
The CDC says people with DKA are treated in the emergency room or admitted to the hospital. Treatment includes fluids, electrolytes (minerals in the body), insulin, and medicines for the cause, such as antibiotics for an infection.
The consensus report says hospital care for DKA linked to SGLT2 inhibitors follows the same steps as typical DKA, with one key difference in fluids:
- In typical DKA, dextrose (sugar) is added to IV fluids once blood sugar falls below 250 mg/dL, to prevent low blood sugar and allow insulin to continue until ketones clear.
- In euglycemic DKA, dextrose should be added to IV fluids or started at the same time as the saline fluids.
The report also says SGLT2 inhibitors are stopped on admission. It says restarting them after DKA in type 2 diabetes is not routinely recommended because there is not enough safety data. Your care team decides which medicines fit you after a hospital stay, so do not restart or stop any medicine on your own.
MedlinePlus says most people respond to DKA treatment within 24 hours, though recovery sometimes takes longer. ADA 2026 advises a follow-up visit within 1 month of leaving the hospital, or within 1 to 2 weeks if diabetes medicines were changed. If you need a clinician, see our guide to finding a diabetes doctor near you.
How Can You Lower Your Risk?
These steps come from the ADA, the CDC, and the consensus report:
- Know your medicines. Ask whether any of them is an SGLT2 inhibitor and what sick-day rules apply to it.
- Ask before fasting or very low-carb eating, especially if you take an SGLT2 inhibitor.
- Stay hydrated with water or sugar-free fluids, as the ADA suggests.
- Talk with your care team about alcohol. The consensus report lists drinking too much alcohol as a risk factor.
- Tell your surgical team about every medicine you take before any procedure.
- Keep taking insulin as directed. The ADA says never to stop unless your doctor tells you to.
- Check ketones when your plan says to, such as when you are sick or have DKA symptoms.
Our diabetes sick day rules guide covers what to ask. ADA 2026 also says structured diabetes self-management education that includes problem-solving is effective at reducing DKA admissions. See diabetes self-management education and support.
When Should You Get Help?
Emergency: Call 911 or go to the emergency room for high ketones, trouble breathing, fruity-smelling breath, confusion or decreased alertness, or vomiting that keeps you from keeping food or drinks down, even if your blood sugar is normal or only a little high. The ADA says blood ketones of 1.6 mmol/L or higher need emergency care. If you are pregnant and think you may have DKA, get care right away.
Same day: Contact your care team right away if a home test shows ketones, as MedlinePlus advises. Also call if you take an SGLT2 inhibitor and feel unwell while eating or drinking much less than usual.
Prompt appointment: Book a visit before any planned surgery if you take an SGLT2 inhibitor, after any DKA hospital stay, or if you are planning a pregnancy and have diabetes.
Frequently Asked Questions
What blood sugar level is euglycemic DKA?
ADA 2026 and the 2024 consensus report define euglycemic DKA as DKA with blood sugar below 200 mg/dL. Ketones and blood acid still meet the DKA criteria. In one series in the consensus report, 35% of people taking SGLT2 inhibitors who had DKA had blood sugar below 200 mg/dL.
Which medicines can cause euglycemic DKA?
The 2024 consensus report says SGLT2 inhibitors have accounted for most cases in recent years. Their generic names end in -gliflozin. ADA 2026 also links euglycemic DKA to eating much less than usual, pregnancy, alcohol use, and liver failure. Never stop a prescribed medicine on your own. Ask your care team about sick-day rules.
Is euglycemic DKA dangerous?
Yes. It is a form of DKA, which MedlinePlus calls life-threatening. ADA notes that some cases of euglycemic DKA may be missed. With treatment, the consensus report says deaths from DKA have fallen below 1%. Call 911 for emergency warning signs, even if your blood sugar looks normal.
Can a keto diet cause euglycemic DKA?
Ketones alone do not mean DKA. MedlinePlus says the liver normally makes ketones after a long time without food. But the ADA lists fasting and very low-carb eating as risk factors for ketones in people with diabetes, and the consensus report lists both as DKA risk factors for people with type 2 diabetes who take SGLT2 inhibitors. Ask your care team before starting a very low-carb diet.
Can euglycemic DKA happen during pregnancy?
Yes. ADA 2026 says pregnant people may develop euglycemic DKA and that severe vomiting can make DKA harder to diagnose. It advises pregnant people at risk to learn the warning signs and seek medical care right away if DKA is a concern.
Can you check for euglycemic DKA at home?
Home tests cannot confirm DKA, but they can tell you when to get help. The ADA prefers a blood ketone meter and says blood ketones of 1.6 mmol/L or higher need emergency care. The 2024 consensus report says urine ketone tests can underestimate ketone levels early in DKA. Ask your care team which test to use.
References
- Centers for Disease Control and Prevention. “Diabetic Ketoacidosis.” Accessed October 2026.
- American Diabetes Association. “DKA: Signs, Symptoms, and Treatment.” Accessed October 2026.
- American Diabetes Association. “Managing Ketones with Diabetes.” Accessed October 2026.
- MedlinePlus. “Diabetic Ketoacidosis.” Accessed October 2026.
- American Diabetes Association Professional Practice Committee for Diabetes. “16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026.” Diabetes Care. 2026;49(Suppl. 1):S339–S355. Accessed October 2026.
- American Diabetes Association Professional Practice Committee for Diabetes. “6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes—2026.” Diabetes Care. 2026;49(Suppl. 1):S132–S149. Accessed October 2026.
- Umpierrez GE, Davis GM, ElSayed NA, et al. “Hyperglycemic Crises in Adults With Diabetes: A Consensus Report.” Diabetes Care. 2024;47(8):1257–1275. Accessed October 2026.
- Munro JF, Campbell IW, McCuish AC, Duncan LJP. “Euglycaemic Diabetic Ketoacidosis.” British Medical Journal. 1973;2(5866):578–580. Historical context only. Accessed October 2026.
Next Steps
If you take an SGLT2 inhibitor, ask your care team or pharmacist for written sick-day rules. Make sure they cover what to do before surgery, what to do when you cannot eat, and when to check ketones. Keep the plan with your ketone supplies.
For adults with type 2 diabetes or prediabetes who want lifestyle education alongside clinical care, the Done With Diabetes™ program offers a lifestyle education protocol that organizes learning about meals, movement, sleep, and stress. It does not diagnose or treat DKA or diabetes, interpret ketone or glucose results, change medicines, or replace emergency or clinical care.