Cannabis, DKA and Vomiting? New Diagnosis Proposed

As a diabetes specialist in a rural clinic, many of my clients’ use marijuana to help them cope with chronic neuropathy.

Due to hyperemesis and other factors, people with type 1 diabetes who use cannabis on a regular basis, may present to the emergency room with diabetes ketoacidosis (DKA).

However, their unusual labs might cause some initial confusion in determining the correct diagnosis.

In a study that appeared in Diabetes Care, researchers followed people with type 1 admitted to the emergency department for DKA over a five-year period. On admission, they checked to see if they were cannabis positive. Of the 68 people with type 1 in DKA (out of 172 DKA events) who had cannabis in their system, the lab results were surprising.  Usually, people in diabetes ketoacidosis have a low pH (less than 7.3) and a low bicarbonate, due to the presence of excess ketone bodies.  However, for those with positive cannabis, their pH (mean 7.42 vs 7.09) and bicarbonate (mean 19.2 mmol/L vs 9.1 mmol/L) respectively, were both elevated compared to non users. But their glucose levels, anion gap and beta-hydroxybutyrate were similarly elevated in both groups.

The authors speculate that this paradoxical presentation may be due to vomiting syndromes associated with cannabis use

Frequent marijuana use can lead to cannabinoid hyperemesis syndrome (CHS).  CHS is defined as recurrent nausea, vomiting and cramping abdominal pain that is sometimes associated with at least weekly cannabis use. A common treatment for this syndrome is hot bath or shower. 

With heavier marijuana use, people are at risk for cyclic vomiting syndrome (CVS), in which they experience unrelenting nausea and vomiting. The most effective treatment for this is to abstain from cannabis for at least a few weeks. People with type 1 diabetes and gastroparesis are especially at risk for both CHS and CVS.  A person with type 1 and gastroparesis is also more at risk for other neuropathies and the associated chronic, often debilitating pain.

The authors are eager to share their findings and suggest screening for cannabis for those admitted with type 1 in hyperglycemic crisis, especially if the person presents with an elevated pH and bicarbonate. The researchers suggest a new term, “Hyperglycemic ketosis due to cannabis hyperemesis syndrome” or HK-CHS. 

The diagnostic criteria for hyperglycemic ketosis due to cannabis hyperemesis syndrome (HK-CHS) would include:

  • Elevated glucose
  • Elevated anion gap
  • pH of 7.4 or greater
  • Bicarbonate of 15 mmol/L or greater

in the presence of ketosis in those presenting with DKA.

Due to fears of opioid addiction and with the legalization of marijuana in many states, people with diabetes are turning to cannabis to manage their chronic neuropathic pain.

As diabetes specialists, we can encourage having open and honest conversations about marijuana use. If people are experiencing excess vomiting associated with cannabis use, we can help explore other options to manage chronic pain including referral to a pain management clinic and mental health support as needed.

Want to learn more about this topic?

Level 2 | Hyperglycemic Crises, DKA & HHS Standards | 1.0 CE

Annual Webinar Recorded on December 15th

This course discusses common causes of hyperglycemia crises. Topics include hyperglycemia secondary to medications and insulin deprivation. The difference and similarities between Diabetes Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome are also covered. Treatment strategies for all situations are included.


  1. Common causes of hyperglycemic crises.
  2. The difference and similarities between DKA and HHS and treatment strategies
  3. Causes and treatment of hyperglycemic crises.

Intended Audience:  A great course for healthcare professionals in the field of diabetes education looking for a straightforward explanation of identification and treatment of hyperglycemic crises.

Instructor: Beverly Thomassian RN, MPH, CDCES, BC-ADM is a working educator and a nationally recognized diabetes expert.

Enroll in our entire Level 2 – Standards of Care to join us for the below Annual Live Webinar Updates. All courses air at 11:30 a.m. (PST)

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