7 Things You Should Know About Ketones if You Live with Diabetes

Ketones are chemicals that form when your body starts to burn fat for energy. 

People with type 1 and type 2 diabetes (T2D) are at risk, but it’s more common for those with T1D to develop ketones. The American Diabetes Association (ADA) explains that high levels of ketones can poison the body. If you have ketones, you need to take them seriously because they can cause a dangerous condition called diabetic ketoacidosis (DKA).

This guide covers what ketones are, what to do if you think you have them and some tips to help prevent them.

1. Why do ketones happen?

Ketones are produced when your body doesn’t have enough insulin. Without enough insulin, glucose (sugar) builds up in your blood and can’t get into your cells. Instead, the cells start burning fat for energy. This process creates ketones, which can end up in your blood and urine.

The ADA says that when there are too many ketones in your blood, it makes your blood more acidic. This is a warning that your diabetes isn’t being managed well or that you’re getting sick. 

Don’t think of this as a personal failure. Diabetes that isn’t managed well can happen for many reasons. Maybe it’s because you’re not working closely enough with your health care team, or your access to r medicines and other important resources is limited. You might not fully understand what to do or don’t have the right guidance. The list goes on! While you are responsible for taking care of yourself, your health care team plays a huge role in helping you stay healthy. Diabetes isn’t your responsibility alone.

The good news is that now that you are aware of ketones, you can take action.

2. Why are ketones dangerous?

Having ketones in your body usually means you need more insulin. It’s important to check your blood sugar regularly to see how much insulin you should take. If ketones build up, it can cause a dangerous condition called DKA.

Signs of DKA include:

• Moderate or large ketones
• Nausea
• Vomiting
• Stomach pain
• Fruity breath
• Breath that smells like nail polish remover
• Fast breathing
• Extreme fatigue or tiredness

If not treated quickly, DKA can lead to a serious, life-threatening coma or even death. High ketone levels are toxic, so if you notice these signs, it’s crucial to see a doctor right away.

3. When and how should you check for ketones?

You should check for ketones anytime your blood sugar is above 13.9 mmol/L (250 mg/dL) or if you’re feeling sick, even with minor illnesses like a cold. There are different ways to check for ketones, each with its own advantages and disadvantages. 

• Blood ketone meter test: The most accurate method is using a blood ketone meter, which measures BHB, the main ketone present during DKA. Using a blood ketone meter is similar to checking your blood sugar—you take a small blood sample. These meters usually cost between $30 and $60, and the test strips cost about $1 each. You can find them at stores like Walmart or online on Amazon. 
• Urine ketone test strips: A less accurate method is using urine ketone test strips, which detect ketones in urine. These strips are inexpensive—around a quarter each—and are available at drug stores. Keep in mind that urine tests are less dependable because ketone levels take longer to appear in urine, and hydration levels can influence the results. 
• Breath ketone meter: Another option is to use a breath ketone meter, which measures acetone, a type of ketone in your breath. This method is easy to use and only requires buying the device once. But breath meters tend to cost more, around $200. Still, it might be worth it if you want to check your ketones often. 

Knowing how to check your ketone levels is a vital part of managing your diabetes safely. Keep at least one of these ketone measurement methods readily available, just in case. Make it a standard part of your diabetes toolkit.

4. When should I worry about ketones with high blood sugar?

Ketones usually form when your blood sugar is high. This indicates that your body needs more insulin, or you might need to adjust your diabetes treatment plan or medications. When you’re sick and have high blood sugars, you should be extra cautious.

When you’re sick, your body releases stress hormones. These hormones can increase your blood sugar levels. That’s why it’s important to check your ketone levels when you’re ill. 

5. Can ketones form with normal or low blood sugar levels?

Unfortunately, yes—ketones can be present when your blood sugar is normal or low. That’s surprising, isn’t it?

High ketones with normal blood sugar levels are called euglycemic diabetic ketoacidosis (EDKA). EDKA is sometimes associated with fasting, surgery or pregnancy or when someone uses an SGLT2 inhibitor (commonly prescribed in people with T2D) like:

• Bexagliflozin (Brenzavvy®)
• Canagliflozin (Invokana®)
• Dapagliflozin (Farxiga®)
• Empagliflozin (Jardiance®)
• Ertugliflozin (Steglatro®)

In this situation, your blood sugar might remain normal or even drop, but your body can still produce ketones. It’s not necessarily a reason to worry or to change your medicines, but it is something to be aware of and communicate with your doctor about along the way. The goal is to stay healthy and be aware, not to live in fear.

6. What should you do if you have ketones? 

If you used an at-home test and it tells you that you have ketones, there are a few things you should do right away:

• Hydrate, hydrate, hydrate: Drink 8 ounces of water or a carb-frees and caffeine-free beverage every 30 to 60 minutes to help flush out the ketones
• Identify your insulin needs: Check your blood sugar levels and take a correction dose of insulin if needed. If you are unsure, give your doctor a call. Do not stack your insulin (take small doses of fast-acting insulin back-to-back in a short amount of time) or rage bolus (overshoot your correction dose)
• Call your health care team to talk through your treatment plan: don’t assume you can handle ketones alone
• Go to the emergency room or urgent care: If you are nauseous or vomiting, are having trouble breathing, feeling confused or have fruity breath, head to the emergency room or urgent care immediately. Don’t drive yourself. Get someone to drive you there. If you don’t have anyone to drive you, call 911.

7. Get ahead of ketones: follow a diabetes routine you feel good about

Ketones can be a scary part of living with diabetes, especially for those with T1D. It’s important to stay vigilant about ketones and take proactive steps to manage them. You can do this by following a personalized diabetes management plan developed with your health care team, drinking enough water every day, staying active and making time for community and connection. 

While ketones can sometimes happen, there are many ways you can be prepared for them and even prevent them from becoming a problem. 

Living with diabetes can be a chore. You’re not in this alone! Connect with people who understand what it’s like to live in the highs and lows—join Beyond Type 1’s community apps.

This educational resource is made possible through the support of Abbott Diabetes Care. Beyond Type 1 retains complete, independent editorial control over all content.