Diabetic ketoacidosis (DKA) and ketones
Please note that how you manage your or your child’s type 1 diabetes is a personal decision between you and your healthcare team. Breakthrough T1D Canada content is for informational purposes only and is not a substitute for professional medical advice. Please contact your doctor or other qualified health provider with any questions you may have regarding type 1 diabetes or any medical condition.
What is diabetic ketoacidosis (DKA)?
If the body does not have enough insulin, it can lead to a condition called diabetic ketoacidosis (DKA), which can be a serious, life-threatening condition.
DKA occurs when a severe lack of insulin means the body cannot use glucose for energy and starts to break down fat instead. Organic compounds called ketones are the by-product of the breakdown of fat and, if left unchecked, can build up and cause the blood to become acidic.
The main symptoms of DKA include:
- feeling thirsty
- needing to urinate more frequently
- stomach pain, feeling sick or being sick
- diarrhea
- breathing more deeply than usual
- breath that smells fruity (like candy, almonds or nail polish remover)
- feeling tired, sleepy or confused
- blurred vision
DKA is very serious and can be fatal. It requires immediate medical attention.
How to reduce risk of DKA
DKA can occur when someone with T1D is ill, stressed, during a growth spurt or puberty, or if they haven’t taken enough insulin.
Monitoring ketone levels can help to detect high ketone levels and know when to seek medical attention.
DKA can also occur around the diagnosis of T1D. Nearly 45% of T1D diagnoses in children in Canada occur with DKA. Screening for T1D, along with education about the signs and symptoms of T1D for those at risk of the disease, can reduce the incidence of DKA at diagnosis.
When to check for ketones
Many healthcare providers suggest checking for ketones if a person with T1D is ill, especially if they are vomiting, have stomach pain, or a fever. It’s also important to monitor ketones when blood glucose is above target.
If blood glucose is high, test for ketones before exercising. The presence of ketones in someone with T1D shows that there’s not enough insulin in the body to use the sugar. Exercise would only burn more fat, make more ketones, and make hyperglycemia (link to page when ready) worse, raising the risk of DKA.
How to check for ketones
You can check for ketones in urine with test strips or in blood with a ketone meter. Monitoring blood ketones is preferred over urine ketones because it provides more precise information. Because urine may have been in the bladder for some time, the results from urine tests may show levels that are either higher or lower than the ketone levels currently circulating in your body.
It is also very important to know that urine test trips degrade over time. If you are using this method, look at expiration dates carefully and discard containers open longer than 6 months.
What ketone levels mean
Ketone levels can indicate if you are at risk of DKA. At-home urine test strips will change color to show the level of ketones in urine.
They typically report results as negative, trace, small, moderate, or large.
- Negative or trace are considered normal for people with T1D
- Small means it is a good idea to call your diabetes care team and follow the plan you have in place for treating ketones
- Moderate is a sign of diabetic ketoacidosis risk and indicates that you should call your diabetes care team right away and follow the plan you have in place for treating ketones
- Large is considered a medical emergency and indicates that you should call your diabetes care team immediately and potentially go to the emergency room
Blood ketone meters provide a number to indicate ketone levels. The following ranges are generally used:
- Less than 0.6 is considered normal for people with T1D.
- 0.6 to 1.5 mmol/L is a range when ketones should be closely monitored. If you or your child is experiencing illness, it’s also a good idea to call your diabetes care team and follow the plan you have in place for treating ketones.
- 1.5 to 3.0 mmol/L is a sign of DKA risk and indicates that you should call your diabetes care team right away and follow the plan you have in place for treating ketones.
- More than 3.0 mmol/L is considered a medical emergency and indicates that you should call your diabetes care team immediately and possibly go to the emergency room.*
Treating elevated ketones
If testing shows you have elevated ketones in urine or blood, follow the plan you and your diabetes care team have in place for treating ketones. Treatment typically includes increasing insulin and fluid intake.
Ketones and illness
Being sick isn’t enjoyable for anybody, but for people with T1D it can pose extra problems and put them at increased risk of DKA.
Illness stresses the body. During times of mental or physical stress, like when sick with the flu, covid or another serious infection, the body makes and releases stress hormones to fight the illness. This can also affect blood glucose levels. On these days, both blood glucose levels and ketone levels should be closely monitored, usually every 2-4 hours.