Alcoholic Ketoacidosis: What to Know About This Medical Emergency

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Alcohol is one of the most commonly used psychoactive substances in the world. Its use and abuse have numerous effects on the brain and body and can even lead to death. In fact, alcohol use and addiction is the third leading cause of preventable death in the U.S.⁷One cause of preventable death associated with alcohol use is alcoholic ketoacidosis (AKA), a form of metabolic acidosis. In AKA, alcohol use leads to dangerously high levels of acid in the blood, which then causes several complications throughout the body. If treated early, AKA resolves quickly and completely. If left untreated, however, it can lead to sudden death.³

What is Alcoholic Ketoacidosis (AKA)?

Alcoholic Ketoacidosis occurs due to alcohol use. Although it is fairly common, it normally presents in emergency rooms (rather than detox centers) and is oftentimes not diagnosed at all or incorrectly diagnosed.³

What is Ketoacidosis?

Ketoacidosis occurs due to excess ketones in the body, which are produced when the body does not have enough protein or carbohydrate stores. The body normally breaks down carbohydrates, proteins, and fats into glucose–the body’s primary energy source. When the body is depleted of carbohydrates and protein stores, fatty acids are released from fatty tissue. This allows the body to meet energy requirements in the absence of carbohydrates and protein; however, it results in a larger than usual amount of acids in your body.

It should be noted that ketoacidosis is very rare⁹ and not a significant risk factor for AKA unless someone is also chronically abusing alcohol.

How Alcohol Affects Ketoacidosis

Alcohol specifically contributes to ketoacidosis in many ways. The first is malnutrition. For some heavy drinkers, alcohol is a primary energy source. This leads to depleted levels of both carbohydrates and protein.

Heavy alcohol use can also impair the liver’s ability to synthesize and release glucose. These two factors decrease the body’s normal levels of readily available energy, and it responds by breaking down fat and producing ketones.

Alcohol also contributes to ketoacidosis through water loss. Vomiting caused by alcohol consumption can lead to dehydration, which may, in turn, cause low blood pressure and stress response from the body that causes further ketone production.

These factors combined lead to an abnormally elevated level of ketones in the body and an overall change in the body’s pH balance.^3,5

The liver’s inability to synthesize and release glucose can also lead to dangerously high levels of lactate. Excess levels of lactate can result in lactic acidosis, which further complicates AKA.^3,5 Excessive use of alcohol can also lead to other medical issues such as alcoholic cirrhosis.

Signs of Alcoholic Ketoacidosis

Common signs and symptoms of alcoholic ketoacidosis include:³

Increased heart rate
Increased respiratory rate
Low blood pressure
Tender abdomen
Only mild altered mental state (vs severe altered mental state)

A fruity or sweet odor on someone’s breath, also known as ketone odor, is another sign that might be easier to identify.¹

Who Is At Risk of Alcoholic Ketoacidosis?

The “characteristic history” of those who present with alcoholic ketoacidosis have:^3,5

A history of AKA
Had chronic alcohol abuse and a recent binge drinking episode
Been binge drinking accompanied by severe nausea, vomiting, and abdominal pain

Alcohol Abuse and Binge Drinking

The primary risk factor for AKA is chronic alcohol abuse and a recent binge drinking episode.³

Whether someone binges or drinks excessively can be a difficult measure given society’s widespread use and acceptance of alcohol. The definition for a standard drink is important because the casual use of the term “drink” can be misleading. What someone may consider being a drink or two might actually be closer to 3 or 4 drinks. A “double,” for example, is usually two or more drinks in a single glass.¹⁰

Some alcoholic beverages may also contain much more alcohol than the “standard” amount. Alcohol can be as high as 8-12% by volume in some beers, for example. Many cocktails, including mojitos, margaritas, or martinis, contain more than 1 standard drink in a single glass.

These are examples of when calculating alcohol consumption isn’t always straightforward. They are important, however, when making distinctions between normal and excessive levels of alcohol consumption. Someone may think they are consuming 3-4 drinks a day when, in actuality, they are consuming closer to 6 or more. Having six or more drinks would be considered a binge drinking episode.

Alcohol Use Disorder (AUD) is a term used by mental health professionals to diagnose individuals with more severe alcohol problems. AUD indicates more severe functional impairments that result from excessive drinking.

If you think you or someone you know might be drinking excessively but are unsure, there are other symptoms to watch out for, including:²

Cravings for alcohol
Drinking more than intended
Continued drinking despite the mental and physical health complications drinking is causing (e.g., liver or heart disease, malnutrition, anxiety, or depression)
Engaging in unsafe behaviors while intoxicated (e.g., driving or operating machinery under the influence, having unprotected sex, etc.)
Impairment to occupational functioning (e.g., job loss, working drunk or hungover)
Relationship impairments (e.g., friendships, parental roles, romantic relationships)
Spending excess money and/or time obtaining or consuming alcohol

Those who meet the criteria for AUD are more at risk AKA. If you or someone you know has these risk factors and displays any of the signs and symptoms of AKA, they should receive treatment immediately.

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Treatment for Alcoholic Ketoacidosis

Direct treatment of AKA depends on the symptoms that present. In the absence of severe alcohol withdrawals, treatment can be as simple as saline (water and salt solution) and intravenous dextrose, a carbohydrate type.³

This kind of medication is used to supply the body with a readily available form of energy and decrease ketones’ levels in the body. Due to potential electrolyte imbalances that sometimes accompany alcoholic ketoacidosis, potassium and some other electrolytes (magnesium and phosphate) may also be administered. Because chronic alcohol use depletes the body of B vitamins, intravenous B vitamins are also recommended as a form of therapy for AKA.³

You may not yet know if they will experience AKA. Considering the many risks of chronic alcohol abuse, including AKA, severe withdrawals, alcohol-related liver damage, heart, pancreatic, and brain diseases, if you have an alcohol use disorder, you should seek treatment for your alcohol problems before future health issues arise. Call 800-948-8417 Who Answers? to speak to a treatment specialist today.

Motivational Interviewing

If you’re unsure about treatment, motivational interviewing may be a good first step. Motivational interviewing is a non-judgmental therapeutic approach that encourages you to examine your problematic alcohol use and evaluate your need for treatment. It can, also in some cases, reduce drinking frequency.⁶

Medically-Supervised Detox

Once you have decided to seek treatment, selecting the appropriate course will depend on your situation. If you have an alcohol use disorder (AUD) and have drunk excessively over a long period of time, you may require medically supervised detoxification. Medically supervised detoxification can reduce the risk of severe withdrawal symptoms (which can contribute to AKA development) and the risk of relapse.

Medically supervised detox is part of a general approach to addiction treatment called medically-assisted treatment (MAT). MAT is supported by the scientific community to successfully treat alcohol and other drug addiction and involve supervised detoxification, treatment planning, and counseling.

The primary goal of supervised detoxification is to minimize the severity of withdrawal symptoms to prevent more serious complications like AKA. Supervised detox can also ensure comfort and prevent relapse.

Medications

Some common medications used in medically supervised detox include:^2,4

Benzodiazepines (e.g., Librium)
Baclofin
Gamma-hydoxybutryic acid and alpha-2 antagonists (e.g., Clonidine, Dexmedetomidine)

When you have completed medically supervised detox, other medications may be introduced to reduce alcohol cravings and prevent relapse. Commonly prescribed medications include:

Acamprosate
Naltrexone
Disulfiram
Gabapentin
Topiramate

Behavioral Therapy

Medications for treating alcoholism are not considered stand-alone treatments. Behavioral therapy is also encouraged during the treatment of AUD. Results show that therapy and medication in combination have the lowest rates of relapse.⁶ Therapy for alcohol addiction varies, but the most studied and effective is cognitive behavioral therapy (CBT).⁶

Long-Term Effects of AKA

The long-term health of someone who has developed AKA depends more on the underlying abuse of alcohol than the effects of AKA itself.¹ The primary cause of death in patients who have developed AKA are underlying malignant diseases that are associated with chronic alcohol abuse, such as:¹

Liver disease
Pancreatitis
Gastrointestinal bleeding
Severe alcohol withdrawals.

Diseases like these can both cause future health complications and/or death as well as contribute to the development of AKA.¹

It is important to seek treatment for chronic alcohol abuse to prevent these kinds of complications and avoid the psychological and social consequences commonly associated with chronic alcohol abuse. Call 800-948-8417 Who Answers? to find a rehab center or talk to a treatment specialist about your options today.

References

Howard, R. D., & Bokhari, S. R. A. (2020). Alcoholic ketoacidosis (AKA). StatPearls [Internet].
Jesse, S., Bråthen, G., Ferrara, M., Keindl, M., Ben-Menachem, E., Tanasescu, R., Brodtkorb, E., Hillbom, M., Leone, M. A., & Ludolph, A. C. (2017). Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta neurologica Scandinavica, 135(1), 4–16.
McGuire, L. C., Cruickshank, A. M., & Munro, P. T. (2006). Alcoholic ketoacidosis. Emergency Medicine Journal, 23(6), 417-420.
Mirijello, A., D’Angelo, C., Ferrulli, A., Vassallo, G., Antonelli, M., Caputo, F., … & Addolorato, G. (2015). Identification and management of alcohol withdrawal syndrome. Drugs, 75(4), 353-365
Noor, N. M., Basavaraju, K., & Sharpstone, D. (2016). Alcoholic ketoacidosis: a case report and review of the literature. Oxford medical case reports, 2016(3), 31-33.
Ray, L. A., Meredith, L. R., Kiluk, B. D., Walthers, J., Carroll, K. M., & Magill, M. (2020). Combined pharmacotherapy and cognitive behavioral therapy for adults with alcohol or substance use disorders: a systematic review and meta-analysis. JAMA network open, 3(6), e208279-e208279.
Tucker, J. A., Chandler, S. D., & Witkiewitz, K. (2020). Epidemiology of Recovery From Alcohol Use Disorder. Alcohol research : current reviews, 40(3), 02.
S. Centers for Disease Control and Prevention. (2018, February 01). Alcohol & Substance Misuse. Retrieved December 7, 2020.
von Geijer, L., & Ekelund, M. (2015). Ketoacidosis associated with low-carbohydrate diet in a non-diabetic lactating woman: a case report. Journal of medical case reports, 9(1), 224.
National Institute on Alcohol Abuse and Alcoholism. (n.d.). What Is A Standard Drink?. Retrieved January 2021.