From the Guidelines
For a diabetic patient with mild ketonuria, the next step in treatment is to measure ketones in urine or blood and implement sick-day rules and/or seek medical advice if urine or blood ketones are increased, as recommended by the latest guidelines 1. The presence of mild ketonuria in a diabetic patient indicates a potential insulin deficiency or stress, which can progress to diabetic ketoacidosis if left untreated.
- Key considerations in managing mild ketonuria include:
- Increasing fluid intake, particularly water, to help flush out ketones
- Monitoring blood glucose levels more frequently (every 3-4 hours)
- Adjusting or initiating insulin therapy, typically with short-acting insulin, to help metabolize glucose and reduce ketone production
- Checking for pump malfunctions in patients on insulin pumps
- Monitoring electrolyte balance, particularly potassium levels
- Continuing prescribed diabetes medications and not skipping doses
- Following sick day management protocols, which include maintaining carbohydrate intake even if not eating normally According to the latest guidelines, 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.
- It is essential to note that blood ketone determinations that rely on the nitroprusside reaction should not be used to monitor treatment of DKA, as they may not accurately reflect the patient's ketone levels 1. In contrast to older guidelines, the latest recommendations emphasize the importance of measuring ketones in urine or blood in individuals prone to ketosis, such as those with type 1 diabetes or a history of DKA 1, which differs from the approach outlined in the 2004 study 1.
- The patient should seek immediate medical attention if symptoms worsen, including vomiting, abdominal pain, difficulty breathing, or confusion.
From the Research
Next Steps in Treatment for Diabetic Patient with Mild Ketonuria
- The presence of ketones in the urine of a diabetic patient indicates a potential risk for diabetic ketoacidosis (DKA), a life-threatening complication of diabetes 2.
- The next step in treatment would involve evaluating the patient's overall condition, including electrolyte levels, phosphate, blood urea nitrogen, creatinine, urinalysis, complete blood cell count with differential, A1C, and electrocardiography to identify causes and complications of DKA 2.
- Treatment for DKA typically involves fluid and electrolyte replacement, insulin therapy, and close monitoring to adjust therapy and identify complications 2, 3.
- It is essential to note that the use of sodium-glucose cotransporter-2 inhibitors can increase the risk of DKA and euglycemic DKA, even in patients with mild hyperglycemia or normoglycemia 4, 5, 6.
- Patients with type 1 or type 2 diabetes who experience nausea, vomiting, or malaise, or develop a metabolic acidosis while taking SGLT-2 inhibitors, should be promptly evaluated for the presence of urine and/or serum ketones 4.
- In cases of euglycemic DKA, treatment with intravenous insulin and fluids, and close monitoring of the patient's condition, can help resolve the metabolic abnormalities and prevent further complications 5, 6.