Intended for healthcare professionals

Practice Practice Pointer

Diabetic ketoacidosis: not always due to type 1 diabetes

BMJ 2013; 346 doi: (Published 10 June 2013) Cite this as: BMJ 2013;346:f3501
  1. S Misra, specialty registrar metabolic medicine1,
  2. NS Oliver, consultant diabetologist 2,
  3. A Dornhorst, consultant diabetologist2
  1. 1Department of Metabolic Medicine and Clinical Biochemistry, Imperial Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK
  2. 2Department of Diabetes and Endocrinology, Charing Cross Hospital, Imperial Healthcare NHS Trust, London, UK
  1. Correspondence to: S Misra smisra{at}
  • Accepted 14 May 2013

This article discusses how to diagnose and manage patients with ketosis prone type 2 diabetes

Summary points

  • Patients presenting with diabetic ketoacidosis may have type 1 or type 2 diabetes

  • Diabetic ketoacidosis should be treated with insulin in accordance with nationally agreed guidance

  • After treatment of diabetic ketoacidosis, patients found to have type 2 diabetes may not require lifelong insulin treatment

  • Consider ketosis prone type 2 diabetes in older, overweight, non-white patients who present with diabetic ketoacidosis at their first presentation of diabetes; this diagnosis is also a possibility in patients with any features that are atypical for type 1 diabetes

  • Discharge all patients on insulin and arrange for specialist follow-up

  • Under specialist supervision consider whether insulin can be down-titrated on the basis of clinical progress and, where possible, C peptide and antibody measurements

Who gets diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is not just the hallmark of absolute insulin deficiency in type 1 diabetes—it is increasingly being seen in people presenting with type 2 diabetes.1 2 This is at odds with traditional physiological teaching—that clinically significant ketosis does not occur in the presence of insulin concentrations associated with type 2 diabetes because there will always be sufficient insulin to suppress lipolysis (fig 1).3 Current knowledge suggests that some people with type 2 diabetes may develop acute reductions in insulin production, which, coupled with insulin resistance, can cause DKA, usually without a precipitant.4 This is particularly so in African-Caribbean and other non-white ethnic groups.5 6 This potentially life threatening presentation of type 2 diabetes is referred to as ketosis prone type 2 diabetes (also Flatbush or type 1b diabetes). Clinicians should be aware of this variant of type 2 diabetes because observational studies in African-Caribbean people presenting with ketoacidosis indicate that 20-50% have type 2 diabetes.2

Fig 1 Physiological effects …

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