From the Guidelines
Urine ketones greater than 80 mg/dL indicate moderate to severe ketosis, which requires immediate medical attention, especially if you have diabetes. Contact your healthcare provider or go to an emergency room right away. If you have diabetes, check your blood glucose levels and follow your sick day management plan, which typically includes taking insulin as prescribed and drinking plenty of fluids 1. For type 1 diabetes patients, continue taking insulin even if you're not eating, as insulin deficiency worsens ketosis. Consume small amounts of carbohydrates if possible, such as juice or crackers, to help reduce ketone production.
Elevated ketones occur when your body burns fat for energy instead of glucose, often due to insulin deficiency or severe carbohydrate restriction. This can lead to diabetic ketoacidosis (DKA), a potentially life-threatening condition characterized by high blood sugar, ketones, and acidosis 1. Even if you don't have diabetes, persistent high ketone levels can indicate other serious metabolic problems requiring medical evaluation.
Key Considerations
- Individuals prone to ketosis, such as those with type 1 diabetes or a history of DKA, should measure ketones in urine or blood if they have unexplained hyperglycemia or symptoms of ketosis 1.
- Specific measurement of b-hydroxybutyrate in blood should be used for diagnosis of DKA and may be used for monitoring during treatment of DKA 1.
- Blood ketone determinations that rely on the nitroprusside reaction should not be used to monitor treatment of DKA 1.
Management
- Follow your sick day management plan, which typically includes taking insulin as prescribed and drinking plenty of fluids.
- Consume small amounts of carbohydrates if possible, such as juice or crackers, to help reduce ketone production.
- Contact your healthcare provider or go to an emergency room right away if you have diabetes and experience moderate to severe ketosis.
From the Research
Urine Ketones Greater Than 80
- Urine ketones greater than 80 can be an indicator of diabetic ketoacidosis (DKA) 2, 3, 4
- DKA is a life-threatening complication of type 1 and type 2 diabetes resulting from an absolute or relative insulin deficiency 4
- The diagnosis of DKA is confirmed when all of the three criteria are present: 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis 2
- Traditionally, DKA has been diagnosed by the triad of hyperglycemia, metabolic acidosis, and elevated serum or urine ketones 4
- However, hyperglycemia has been de-emphasized in recent guidelines because of the increasing incidence of euglycemic DKA 4
- Treatment of DKA involves fluid and electrolyte replacement, insulin, treatment of precipitating causes, and close monitoring to adjust therapy and identify complications 3, 4, 5, 6
- The use of sodium-glucose cotransporter-2 inhibitors modestly increases the risk of DKA and euglycemic DKA 4
- Recent studies suggest that large volumes of normal saline may lead to undesirable outcomes such as hyperchloremic metabolic acidosis, and balanced fluids may be a better choice for initial fluid resuscitation in DKA patients 5, 6
Management of DKA
- Fluid resuscitation is a cornerstone of DKA management, with traditional guidelines recommending isotonic normal saline for initial volume replacement 5
- However, recent studies suggest that balanced fluids, such as lactated Ringers, may be a better choice for initial resuscitation in DKA patients 5, 6
- Treatment involves fluid and electrolyte replacement, insulin, treatment of precipitating causes, and close monitoring to adjust therapy and identify complications 3, 4, 5, 6
- Electrolytes, phosphate, blood urea nitrogen, creatinine, urinalysis, complete blood cell count with differential, A1C, and electrocardiography should be evaluated for all patients diagnosed with DKA to identify causes and complications of DKA 4
Prevention and Education
- Prevention strategies include identifying diabetes before DKA develops, educating patients to manage high-risk situations, and ensuring uninterrupted access to therapies for diabetes 4
- Patient education should include information on how to adjust insulin during times of illness and how to monitor glucose and ketone levels, as well as information on the importance of medication compliance 3