Throughout the last decade of living as a T1D, I’ve been vaguely familiar with the concept of diabetic ketoacidosis. I knew that if I was sick or if my blood sugar was extremely high, I needed to test for ketones. Every time my doctor asked if I had ketone test strips at home, I said yes. Though truth be told, they were almost always expired.

I knew DKA was bad. But, as a Type A person with well-controlled diabetes, I was never very concerned about it happening to me. 

Then, more recently, I started researching the condition. I read scientific articles about how diabetic ketoacidosis happens on a molecular level. And I realized, not only was I not immune to DKA just because my A1C was low and my numbers were generally in range, but there were things I was doing almost daily that increased my risk for the condition.

If you’re a person with type 1 and you think DKA isn’t a threat to you, think again. Here are five things that increase DKA risk that most of us are guilty of doing, whether we realize it or not.

Leaving Your Pump Set in Too Long

Pump supplies are expensive. And insurance companies love to send you just enough of them to squeak by before the next shipment finally arrives. So it makes perfect sense to want to stretch each order as far as it will go.

Most pump companies recommend leaving your site in for only two to three days at a time. I can honestly say that the only time I have consistently changed my site out more often than every three to four days was while I was pregnant. And that was largely because my reservoirs would only hold enough insulin to last me two days.

Of course, there is a reason pump companies make this recommendation, and it’s not all about tricking you into buying more sets. It’s because any foreign object stuck in your body causes inflammation. Over time, the inflammation around your set cannula increases and reduces the rate at which insulin is absorbed. Studies have shown that the rate of absorption drops steadily after three days, hence the recommendation to change your set on the third day.

Not changing your site puts you at risk of insulin deficiency, a state that causes DKA in type 1 diabetics. And because pump users rely only on short-acting insulin, your body can go from normal to critically low levels of insulin in under two hours. That means, by the time you get home from class or a concert and change that six-day-old set, you could already be throwing ketones. And if you wait any longer, the situation could become critical and land you in the hospital.

Delaying Your Insulin Dose

Pump users aren’t the only diabetics who put themselves at risk by delaying treatment requirements. If you use MDI to treat your T1D and find it hard to stick to your dosing schedule, you could be putting yourself at risk of DKA.

While it is less likely that someone on MDI would suffer from ketoacidosis just from missing a shot of short-acting insulin, it is possible if you miss or delay your long-acting dose. Most long-acting insulins break down completely after 24 hours. If you fail to take your next dose around the same time each day, you could start throwing ketones. If you also happen to have no short-acting insulin in your system at the same time, then you could quickly sink into DKA.

Using Bad Insulin

Whether you are on a pump or daily injections, using bad insulin is a risk all of us face. Insulin becomes less effective the older it is. It also breaks down quickly in warm temperatures. This is yet another reason why changing your set and reservoir every few days is so important.

But even if you do take extra steps to make sure your insulin is stored at the recommended temperature, used before the expiration date, and never left out of the fridge for too long, you are still at risk of using bad insulin. It is not at all unheard of for pharmacies to store insulin improperly. Some investigations have even found that insulin being shipped from the manufacturer tests poorly by the time it reaches the pharmacy.

If your blood sugars aren’t responding as you would expect to corrections and you’ve ruled out other possibilities, the insulin itself may be the issue. If the problem continues, its worth opening a new vial or pen to see if the correction from that container has better results.

Not Taking Sick Days Seriously

Most diabetics know that infection and illness can cause blood sugars to rise. But this is only one reason why being sick can increase your risk of DKA.

Infection can trigger the same regulatory hormones that are implicated in insulin deficiency-related DKA. That means, even if your blood sugars are only moderately elevated, your body could still be producing dangerous levels of ketones. 

Even if you don’t feel terribly ill or if your blood sugar isn’t above 250, you should still be consistent about checking ketones if you’re sick. Drinking plenty of water and taking your basal insulin (even if you aren’t eating) are also hugely important in avoiding DKA.

Putting Too Much Trust in Your Insulin Pump

If you use an insulin pump, you probably feel like that little machine is a part of you. It goes everywhere with you. It sleeps with you. It’s always there. So it can be easy to trust in your pump to have your back.

Be careful!

It’s important to remember that insulin pumps can malfunction in a shocking number of different ways. And just like with a bad set, any interference in the delivery of that oh-so-important short-acting insulin can have quick repercussions. 

Anything from air bubbles in your tubing to a bent cannula, to a mechanical malfunction, can cause a costly interruption in insulin delivery. If your blood sugar rises for no apparent reason and a pump correction isn’t helping, you don’t have time to wait. Check your pump, tubing, and site and make sure you have a backup supply of needles to use until you can be sure everything is functioning the way it should be.

Better to Be DKA Aware

Of course, we all know that living with diabetes means life often gets in the way of perfect diabetes management. But being aware of the causes of DKA, ketoacidosis symptoms, and knowing what can increase your risk are all important steps in avoiding this potentially life-threatening condition.