What is the management approach for a patient with ketonuria (presence of ketones in urine) and +2 ketones?

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Last updated: June 3, 2025 • View editorial policy

From the Guidelines

The management of a patient with ketonuria and +2 ketones should focus on addressing the underlying cause, which is typically related to insulin deficiency or metabolic stress, and initial treatment involves increasing fluid intake and insulin administration to suppress ketogenesis, as recommended by the most recent guidelines 1, 2. The presence of ketones in the urine, especially at a level of +2, indicates a potential risk for diabetic ketoacidosis (DKA), a serious complication of diabetes that requires prompt medical attention. According to the guidelines for laboratory analysis in the diagnosis and management of diabetes mellitus 1, individuals prone to ketosis should measure ketones in urine or blood if they have unexplained hyperglycemia or symptoms of ketosis.

Key Management Steps

  • Increasing fluid intake, with oral rehydration using water or sugar-free fluids if the patient is alert and able to drink, or intravenous fluids (normal saline) if they are severely dehydrated or unable to take oral fluids.
  • Insulin administration is crucial to suppress ketogenesis, with subcutaneous rapid-acting insulin (like lispro, aspart, or regular insulin) at 0.1-0.2 units/kg if blood glucose is elevated, or with dextrose-containing fluids if glucose levels are normal or low, as suggested by the executive summary of guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus 2.
  • Electrolyte replacement, particularly potassium, may be necessary as insulin therapy can cause potassium to shift into cells.
  • Frequent monitoring of blood glucose (every 1-2 hours), urine ketones, and electrolytes is essential to guide therapy adjustments. The underlying cause of ketosis should be identified and addressed, whether it's uncontrolled diabetes, starvation, excessive alcohol consumption, or a high-fat/low-carbohydrate diet, and management goals include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis, as outlined in the standards of medical care in diabetes-2020 3.

Monitoring and Adjustment

  • Blood ketone testing methods that quantify β-hydroxybutyric acid are preferred over urine ketone testing for diagnosing and monitoring ketoacidosis, as stated in the guidelines for tests of glycemia in diabetes 4.
  • The presence of ketones may indicate impending or established ketoacidosis, a condition that requires immediate medical attention, and patients with type 1 diabetes should test for ketones during acute illness or stress or when blood glucose levels are consistently elevated.

From the FDA Drug Label

Regardless of dose strength, insulin enables carbohydrate metabolism to occur and thus to prevent the production of ketone bodies by the liver The management approach for a patient with ketonuria and +2 ketones involves insulin therapy to prevent the production of ketone bodies by the liver.

  • The goal is to enable carbohydrate metabolism to occur, thus reducing ketone production.
  • Adequate insulin dosage is necessary to effectively utilize carbohydrates, proteins, and fats. 5

From the Research

Management Approach for Ketonuria

The presence of ketones in urine, also known as ketonuria, is a common complication in patients with diabetes mellitus. When a patient presents with +2 ketones in their urine, it indicates a moderate to high level of ketones, which can be a sign of diabetic ketoacidosis (DKA) or other metabolic disorders.

Diagnosis and Treatment

According to 6, 7, 8, 9, 10, the diagnosis of DKA is confirmed when all three criteria are present: hyperglycemia, ketosis, and metabolic acidosis. The mainstays of treatment for DKA include:

  • Restoration of circulating volume
  • Insulin therapy
  • Electrolyte replacement
  • Treatment of any underlying precipitating event

Key Considerations

Some key considerations in the management of ketonuria include:

  • Frequent monitoring of patients to correct hypovolemia and hyperglycemia
  • Replacement of electrolyte losses
  • Careful search for the precipitating cause of DKA
  • Education of patients, healthcare professionals, and the general public to prevent DKA
  • Novel approaches to patient education incorporating a variety of healthcare beliefs and socioeconomic issues

Special Populations

In special populations such as pediatrics, obstetrics, and patients with chronic kidney disease, the management of DKA may require additional considerations, as discussed in 10.

Prevention

Prevention of DKA is crucial, and this can be achieved through:

  • Early detection of diabetes and ketonuria
  • Improved patient education and follow-up care
  • Access to medical advice and diabetes education programs
  • Implementation of measures such as home glucose and ketone monitoring, as mentioned in 6

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Diabetic ketoacidosis and hyperosmolar hyperglycemic state.

Medizinische Klinik (Munich, Germany : 1983), 2006

Research

Diabetic ketoacidosis.

Nature reviews. Disease primers, 2020

Research

Comprehensive review of diabetic ketoacidosis: an update.

Annals of medicine and surgery (2012), 2023

Research

Diabetic ketoacidosis.

Disease-a-month : DM, 2023

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.