Diabetic ketoacidosis in dogs (i.e. DKA in dogs) is a potentially life-threatening complication of diabetes mellitus. To help dog parents recognize and understand DKA, integrative veterinarian Dr. Julie Buzby explains the causes, symptoms, diagnosis, and treatment of diabetic ketoacidosis in dogs.
Recently, as I ran through my normal Monday morning routine, I opened an email from our local emergency hospital. It alerted me that one of my longtime patients, a sweet older Beagle name Bea, had been hospitalized over the weekend for diabetic ketoacidosis (DKA).
I knew she was receiving the best of care, but her diagnosis of diabetic ketoacidosis genuinely worried me. Don’t get me wrong, dogs can certainly recover from diabetic ketoacidosis. But knowing that roughly 70% of dogs survive this diagnosis didn’t ease my worry; the other 30% haunted me, especially because sweet Bea was her mom’s whole world.
I jotted myself a note to call Bea’s mom, Charlotte, and the emergency hospital to get an update during my first break in the appointment schedule.
Let’s talk about why I was so concerned…
What is diabetic ketoacidosis in dogs?
As you may have guessed from the fact that diabetic ketoacidosis (DKA) has “diabetic” right in the name, DKA is a serious and life-threatening complication of uncontrolled diabetes mellitus.
In some cases, the affected dog had previously been diagnosed as being diabetic. So the DKA diagnosis is upsetting but not as shocking to the dog’s family.
However, in many cases, the vet makes the diagnosis of DKA at the same time as the diagnosis of diabetes mellitus. For these dog parents, a diabetic ketoacidosis diagnosis is a double whammy. They find out their dog is sick with DKA, a major, life-threatening illness. And at the same time, they also learn that their canine companion has a chronic medical condition, diabetes mellitus.
I’ll explain more about diabetic ketoacidosis soon. But first, you need to understand the basics of diabetes mellitus in dogs (i.e. “sugar diabetes”—not to be confused with diabetes insipidus in dogs or “water diabetes”).
Diabetes mellitus in dogs 101
Normally, the pancreas secretes the hormone insulin. Insulin acts like a key to unlock the door for glucose (i.e. sugar) to enter cells. Just like people, dogs use the simple sugar glucose as the main energy source within their cells.
In diabetic patients, one of two things happen. Sometimes the pancreas isn’t making insulin. Other times, the cells aren’t sensitive to the magical unlocking powers of the insulin the pancreas is making. Either way, the end result is that the cells are starving for energy, and there is a massive buildup of glucose circulating uselessly in the bloodstream.
If this situation persists for long enough,(and in many cases, the dog also experiences some other stressful event or illness at the same time), the body turns to breaking down fat stores for energy. This provides an adequate short-term solution to the energy crisis. And it allows red blood cells and brain cells to continue to function.
But, if the cells remain unable to use glucose and continue to have to rely on fat for energy, a byproduct of fat breakdown, ketones, can build up in the bloodstream.
Ketones, also known as ketone bodies, don’t cause any problems in small amounts or for short periods of time. After all, they are a normal product of breaking down fat in the body.
However, in dogs with uncontrolled diabetes, ketones keep building up. Ultimately, they accumulate in larger amounts than the body can handle. These high ketone levels in the blood lead to dangerous acid-base problems and shifts in vital electrolyte levels. Plus, they worsen dehydration and cause nausea and vomiting.
Diabetes + ketones = diabetic ketoacidosis
The build-up of ketones in the blood is known as ketosis, which is the first part of the word “ketoacidosis.” Since ketone bodies are acids, one of the most dangerous things about ketosis is that it goes hand in hand with acidosis (i.e. blood that is too acidic). When you add those two problems together, you get “ketoacidosis” which is the “KA” in DKA.
To understand why acidosis is such a problem, let’s think back to high school chemistry and biology for a minute. Dogs, and really all mammals, have many fail-safe mechanisms to help keep their blood at a very specific pH. The normal pH of a dog’s blood should generally be between 7.35 and 7.45. If you think about it, this is a very small range. It is truly a delicate balance.
If the blood pH falls even a tiny bit outside of this normal range—becoming either too basic or too acidic—havoc ensues. Many vital cellular processes don’t work correctly outside of the normal pH range. And as a secondary effect of ketoacidosis, a dog may develop dangerous shifts in electrolytes such as potassium and phosphorus.
All of these effects of ketoacidosis can be potentially life-threatening, and need to be addressed as soon as possible. So let’s take a look at the symptoms to watch for. That way you can hopefully catch DKA before it gets out of hand.
What are the symptoms of diabetic ketoacidosis in dogs?
Many of the signs of DKA on this list will overlap with the signs of diabetes mellitus. This makes sense since all dogs with DKA start out as diabetic. And then something—often a concurrent disease process or stress— pushes them into a state of diabetic ketoacidosis.
However, when compared to dogs who “just” have diabetes, the majority of dogs diagnosed with DKA are quite sick. And most demonstrate many more signs of severe illness.
Signs of diabetic ketoacidosis include any combination of the following:
- Increased thirst in dogs
- Increased urination
- Weight loss
- Muscle wasting
- Decreased appetite
- Depression or being a lethargic dog
- Cataracts in dogs
- An enlarged liver
- Increased respiratory rate and effort (dog is breathing fast)
- Dull mentation
- Stupor or coma
- A sweet odor to the breath
(A note about this last symptom of diabetic ketoacidosis: Some dogs will have a fruity odor to their breath that is from the buildup of acetone—one of the types of ketones—in their bodies. Not every dog will have this symptom, and interestingly, it seems that not every person can detect this specific odor. Researchers believe the ability to smell ketones is genetically linked.)
If you see any of these signs of DKA, please contact your veterinarian or make an emergency vet visit. As mentioned, diabetic ketoacidosis is a life-threatening emergency. And the sooner your vet can start treating your dog, the better.
How is diabetic ketoacidosis in dogs diagnosed?
Luckily, if you find yourself concerned that your pup might have diabetic ketoacidosis, this condition is easy to rule in or rule out. Your veterinarian can check for ketones in the urine or blood quickly and simply with an in-house dipstick test. If your dog has increased ketones in the urine or blood plus a high blood sugar level, this is diagnostic for diabetic ketoacidosis.
After diagnosing your canine companion with DKA, your vet will also want to run some blood work to check baseline electrolyte levels and assess how dehydrated your dog is. Plus, he or she may recommend comprehensive lab work to help determine if there is a concurrent illness at play.
What causes diabetic ketoacidosis in dogs?
We are all familiar with the idiom “the straw that broke the camel’s back.” And when it comes to DKA, there is almost always a “straw” in the form of an illness or stressor that pushes a dog from a state of uncontrolled diabetes into full-blown diabetic ketoacidosis.
The three most common concurrent illnesses are urinary tract infections, pancreatitis, and Cushing’s disease.
Diabetic ketoacidosis and urinary tract infections in dogs
Diabetic dogs are predisposed to urinary tract infections (UTI in dogs). Since insulin isn’t working as it should to let glucose into the cells, diabetic dogs have large amounts of glucose circulating uselessly in their bloodstream. This glucose spills into the urine, where it acts as a perfect food source for bacteria.
It is no wonder then that roughly one in five dogs with diabetic ketoacidosis will also have a UTI. Thankfully though, vets can easily treat most UTIs with either oral or intravenous (IV) antibiotics.
Diabetic ketoacidosis and pancreatitis in dogs
Pancreatitis in dogs is inflammation of the pancreas—the organ that sits tucked between the liver and gallbladder. Normally, the pancreas is responsible for making important hormones like insulin. And it also secretes enzymes that help digest food in the intestinal tract.
For reasons that we don’t always understand, the pancreas can become inflamed. And then it will release those digestive enzymes more haphazardly into the surrounding tissues instead of directly into the small intestines. As you can imagine, the tissues in the area don’t take too kindly to their digestive enzyme bath. The result is significant inflammation, abdominal pain, decreased appetite, nausea, and vomiting.
In addition to pushing a dog into DKA, pancreatitis can make treating diabetic ketoacidosis more challenging. The inflammation from the pancreas makes blood glucose more difficult to control. Also, dogs with DKA must be reliably eating to go home. Feeling crummy from pancreatitis can lengthen the time it takes to reach that goal.
Unfortunately, there is no magical medication to fix the pancreatitis. Instead treatment is supportive and aimed at decreasing the various symptoms. Dogs may benefit from anti-nausea medications like Cerenia for dogs. And the vet may feed a dog with pancreatitis a low-fat diet.
Diabetic ketoacidosis and Cushing’s disease in dogs
Cushing’s disease in dogs, also known as hyperadrenocorticism, is a common condition in older dogs. It is caused by the increased production of cortisol (i.e. stress hormones) from the adrenal glands. Cushing’s doesn’t generally make dogs feel sick. Instead, it causes signs like increased thirst and urination, an increased appetite, panting, thinning fur, and a pot-bellied dog appearance.
The extra stress hormones dogs with Cushing’s produce can lead to insulin resistance (i.e. poor response to insulin) and make diabetes more challenging to control. So, if your veterinarian suspects that your dog has Cushing’s, he or she will probably recommend additional blood tests to confirm or rule out this diagnosis.
However, if a dog is hospitalized for DKA, then generally it is a good plan to wait a few weeks to test for Cushing’s. This is the case because cortisol is a stress hormone. And the stress related to a dog’s DKA and time in the hospital can raise cortisol levels, make the test results hard to interpret.
Once your dog has recovered from the DKA, diagnosing and treating Cushing’s disease can help maintain good diabetic control long-term.
These three conditions—UTIs, pancreatitis, and Cushing’s disease—are the most common triggers for DKA. But keep in mind that almost any significant stress or illness could predispose a diabetic dog to developing diabetic ketoacidosis. For example, other illnesses that have been implicated include kidney infections (i.e. pyelonephritis in dogs), heart disease in dogs, liver or gallbladder infections, and cancer.
Whatever the concurrent condition, the vet will also need to diagnose and treat it while your dog is hospitalized. This means that he or she will also likely recommend comprehensive bloodwork plus additional testing.
He or she may add a urinalysis and urine culture to check for a UTI and help determine the best antibiotic for treating the UTI. Or the vet may perform an abdominal ultrasound to look for changes associated with pancreatitis and Cushing’s. If your vet wants to be extra thorough, or your dog’s symptoms necessitate it, the vet may also recommend a chest X-ray. This is a less common test for dogs with diabetic ketoacidosis, though.
What is the treatment for DKA in dogs?
After assessing your dog, the veterinarian will develop a treatment plan based on the severity of your dog’s DKA. While diabetic ketoacidosis is arguably the most dangerous complication of diabetes mellitus, it has a spectrum of severity.
If you catch the DKA early (before your dog is very sick), then occasionally less intense outpatient therapy might be a possibility. This would be much more likely if you already knew your dog had diabetes because you would know to watch for the signs of DKA. And if you get to the vet quickly, your vet could diagnose diabetic ketoacidosis while it was still mild.
However, most of the time, this is not the case. By the time a dog presents to the veterinarian and is diagnosed with DKA, he or she usually must be hospitalized for intensive care. Going further still, most diabetic ketoacidosis cases require (or would benefit from) hospitalization at a 24-hour emergency/specialty facility. You will understand why this is the case once we talk about the intense and time-consuming treatment regimen.
(As a side note, while worth it and necessary, the intensive treatment and monitoring also mean that the veterinary bills add up quickly. Most veterinarians would probably list DKA as one of the more expensive conditions to treat. I’m not saying this to discourage you, but rather to prepare you for the financial cost of diabetic ketoacidosis in dogs.)
Most dogs who present with diabetic ketoacidosis are very dehydrated. This happens for several reasons. The glucose in their urine pulls fluid out of their body. Plus, the dog is often not interested in eating and drinking normally, and might be vomiting or having diarrhea. When occurring together, these factors can quickly result in profound and life-threatening dehydration.
So, the first order of business for a DKA dog is rehydration with relatively high rates of intravenous (IV) fluids. (This is definitely a situation where subcutaneous fluids for dogs are not enough.)
Controlling the blood sugar
Once a dog has been on fluids for a few hours, the focus can turn to getting the blood sugar under control. This is where insulin therapy comes in. You may be familiar with long-acting insulin that you would give a dog twice daily with meals. But, while dogs with DKA will eventually need this type of insulin, it is not the treatment of choice while they are sick and in the vet hospital.
Using short acting insulin allows the veterinarian to have more control over how fast he or she brings down the blood sugar. The vet also doesn’t have to give short-acting insulin with food. This is good because dogs with DKA are almost never eating reliably when they first present to the hospital.
The vet can administer the short-acting insulin, also known as regular insulin, as a constant drip through an IV. Or he or she can give it every one to two hours as an injection into the muscle. Either way, during this phase of treatment, the vet must measure the blood sugar very frequently to ensure it is decreasing at just the right rate. It is important the blood sugar doesn’t drop too slowly or too quickly.
The frequent blood sampling during this intense phase of treatment means that sometimes the veterinarian will recommend placing a special sampling port. This port, also known as a central line or long line, allows the veterinary team to draw the dog’s blood without having to poke the dog over and over with a needle.
As we mentioned earlier, the acid-base level in the body must stay within a tight range. And the levels of many electrolytes within the body have a similar narrow “safe” window.
As the vet initiates treatment with fluids and insulin, most dogs will have rapid drops in their potassium and phosphorus levels. It is important to replenish these electrolytes to prevent life-threatening consequences such as arrhythmias and red blood cell destruction. Luckily, the veterinary team can easily add both potassium and phosphorus to IV fluids. This is a standard part of the treatment for a dog with DKA.
The normal range is quite small for both of these electrolytes, and overshooting the mark can be just as dangerous. Therefore, the veterinary team will need to check the dog’s electrolyte levels several times per day. This allows them to ensure the supplementation is staying at the right “goldilocks” range of not too little and not too much.
Restoring acid-base balance
Ketosis, and the associated acidosis, tend to improve over time with fluid therapy and insulin. However, occasionally the acid-base status will take longer to return to normal. In those situations, the vet may give the dog a basic medication, bicarbonate, intravenously to counteract the acidosis. This should bring the blood pH back into the normal range.
Symptomatic and supportive care
Many of the other common medications the veterinarian will administer to hospitalized dogs are aimed at treating the sick pup’s symptoms. Most dogs with DKA are not eating well and are experiencing nausea. To help solve those problems, the vet may administer injectable anti-nausea medications and provide appetite stimulants for dogs. Similarly, if there were any concurrent diseases like a UTI or pancreatitis, the vet would treat those as well.
The ticket home
For many dog parents dealing with a dog hospitalized for DKA, one of the most pressing questions is what needs to happen to bring their precious pup back home. The good news is that, despite the severity of DKA, a retrospective study of dogs with diabetic ketoacidosis demonstrated that 70% of dogs survive to be discharged from the hospital.
To earn their ticket home, though, a dog does have to check a few boxes. Once the dehydration resolves and the blood glucose levels and electrolyte levels normalize, the veterinarian can switch the dog to long-acting insulin. This is the insulin the dog will need twice daily at home for the rest of his or her life.
The main prerequisite for the switch is that the dog is reliably eating. This is the case because it is only safe to give long-acting insulin in conjunction with a meal. After starting the long-acting insulin, the veterinarian will monitor a newly-diagnosed diabetic dog for a period of time. This allows him or her to ensure the blood sugar doesn’t drop too low. If all is well, the dog gets to go home.
What happens after hospitalization for diabetic ketoacidosis?
At that point, you and your canine companion have overcome a giant obstacle by making it out of the veterinary hospital. This is cause for celebration, but it is important to remember that a dog with DKA will always be diabetic. And he or she will need some extra medical care and TLC for the rest of his or her life.
The great news is that with careful monitoring and a strong partnership with your veterinarian, most diabetic dogs can live long and happy lives. Yes, some studies show a mean survival time of roughly two years, which doesn’t sound so great. But I want to point out that this timeframe depends in large part on the other conditions the dog was dealing with and how old the dog was at the time of diagnosis.
So, take heart. Despite what it may seem like, it is possible for your beloved dog to live for many years after a diabetes diagnosis.
Your veterinarian will help provide you with instructions on how to manage your dog’s diabetes. And he or she will work closely with you to optimize diabetic control over time. Plus, a benefit of the ordeal you went through is that you will know to watch carefully for the signs of diabetic ketoacidosis in the future. (But thankfully, recurrence in dogs is much less common than recurrence of DKA in cats.)
An update on Bea
Before I got the chance to call Charlotte or the emergency hospital, my team alerted me that we’d received an email update about Bea. I was thrilled to read that she had turned the corner! She had eaten her last two meals, earning her the chance to switch over to her long-acting insulin in the evening.
If everything went as planned, that would mean she might even be able to go home the next day. I knew Charlotte would be over-the-moon-happy to spring Bea from the hospital. I called her right away to celebrate the good news!
Sure enough, Bea was scheduled for discharge the following afternoon. Charlotte was so relieved that Bea was coming home, but she confessed she was also feeling a little overwhelmed about Bea’s new diabetes diagnosis.
I assured her that we would be there with her every step of the way. We scheduled Bea for her first follow-up visit the following week. I was confident that with some extra veterinary TLC and her mom’s diligent care, Bea would be a diabetic success story.
Of course, I never want any of my patients to need extra vet visits. But knowing that Bea was in the 70% was all that mattered to Charlotte and me at that point.
Has your dog been diagnosed with diabetic ketoacidosis?
Please share any words of encouragement or support for other dog parents.