Testing For and Managing Ketones

A fundamental component of spreading diabetic ketoacidosis (DKA) prevention is to address ketones. Below are the commonly recommended steps for ketone checking and handling. Please make sure to speak with your healthcare provider for your personalized ketone prevention and management protocols.

When should you check for ketones?

It is essential to check for ketones when preventing and assessing risk for DKA. Diabetes providers typically recommend checking for ketones with any blood glucose values above 13.9 mmol/L250 mg/dl. If you have hyperglycemia and any symptoms of nausea, vomiting, or abdominal pain, it is even more imperative to check for ketones.

When you have a failed pump site or forgets to take insulin doses, it is especially important to check for ketones. Without background or basal insulin, the body does not have enough insulin to help the cells use glucose as fuel, resulting in the breakdown of fat for alternative energy or ketones.

Other times it is vital to check for ketones is when you are sick or have an infection. Even if blood glucose values are in range, but you have a stomach illness, it is essential to check for ketones as well. Blood glucose may stay in target range, but ketones can still present when you’re sick. Additionally, your blood glucose may be low during stomach illness and ketones can still present.

Checking for Ketones

The frequency of checking for ketones depends on the situation:

• When you’re sick (but not vomiting), negative for ketones and blood glucose levels (BGs) are not elevated, it is only recommended to check for ketones every four to six hours.
• When you have a failed pump site, forgot to take insulin, have been vomiting or have very elevated BGs that are not coming down, it is recommended to check for ketones every hour.

You can check for ketones by using urine strips (economical option), a blood meter (accurate option), or breath samples (less common). A blood meter is more accurate as urine results can be delayed. Instructions for popular urine and blood ketone checking methods are described below:

Urine Ketone Strips

1. Collect urine in a cup.
2. Dip the strip into the urine.
3. Remove from the urine.
4. Wait 15 seconds.
5. Match the color on the strip to the guide on the bottle.

Blood Ketone Meter—Learn more about ketone meters and checking for ketones here

1. Wash and dry hands.
2. Insert the strip into the ketone meter.
3. Use the lancet device to prick a finger for a blood sample.
4. Place blood sample into the ketone strip.
5. Wait for results.
6. Interpret results:
   < 10.8 mg/dL0.6 mmol/L: Negative
   10.8-27 mg/dL0.6-1.5 mmol/L: Small
   >27 mg/dL1.5 mmol/L: Moderate-Large
   >54 mg/dL3.0 mmol/L: Very large

Managing Ketones

If ketones are moderate-large or above, it is important to call your health care team for next steps.

If ketone levels are trace to moderate via a urine test, or below moderate levels via blood testing, it is vital to:

1. Change infusion set if on an insulin pump (if applicable).
2. Take a bolus correction based on your healthcare team’s instructions. Typically, this amount of insulin will be higher than your usual correction dose. Some chose to take correction doses via a syringe even if using a pump site to ensure insulin delivery when ketones are present.
3. Increase fluid intake. Children need one ounce per year of age per hour. Teenagers and adults should have one full glass (8 ounces) of fluid every 30-60 minutes.
4. Hydrate with low to no carbohydrate fluids if experiencing hyperglycemia. My favorites are water, Gatorade zero and Nuun hydration tablets.
5. If nauseous or unable to keep down fluids, try to eat ice chips or a sugar-free popsicle slowly. If you have a Zofran prescription for DKA prevention, this would be the time to take it.
6. Do not exercise. Try to rest and relax.
7. Monitor for symptoms of DKA and seek medical attention if needed.
8. Recheck ketones every hour until ketones results are negative.

This piece is part of Beyond Type 1’s resources on DKA + managing ketones—find the complete collection of resources here.

WRITTEN BY Julia Blanchette PhD(c), RN, CDE, POSTED 06/19/19, UPDATED 11/10/22

Julia has lived with type 1 diabetes for 20 years. She works as a certified diabetes educator and certified insulin pump and continuous glucose monitor (CGM) trainer. She is also finishing up her PhD in nursing science at Case Western Reserve University which is focused on financial stress, mental health and self-management in young adults with type 1 diabetes. In her spare time, she enjoys helping with Camp Ho Mita Koda where she is the healthcare director, exploring Cleveland and writing. You can follow her on Twitter @JBlanchetteCDE or on Instagram @nursejebcat.