What are the management steps for high ketones in urine?

Management of High Ketones in Urine

For individuals with high ketones in urine, immediate management includes oral hydration, monitoring blood glucose and ketones every 3-4 hours, administering additional short or rapid-acting insulin if needed, and seeking medical advice if ketone levels increase or symptoms worsen. 1, 2

Assessment of High Ketones in Urine

• High ketones in urine indicate increased fatty acid metabolism and may suggest impending or established diabetic ketoacidosis (DKA), especially in individuals with diabetes 1
• The presence of urine ketones is highly sensitive for DKA with high negative predictive value, making it useful for ruling out DKA 1
• Blood β-hydroxybutyrate (bOHB) testing is more accurate than urine ketone testing as bOHB is the predominant ketone body in DKA 3, 4
• Urine ketone tests using nitroprusside-containing reagents only detect acetoacetate and not β-hydroxybutyrate, which may underestimate total ketone body concentration 1

Management Algorithm for High Ketones in Urine

For Individuals with Diabetes:

1. Immediate Steps:

   • Increase oral fluid intake to prevent dehydration 2
   • Monitor blood glucose and ketone levels every 3-4 hours 2
   • For elevated blood glucose (>200 mg/dL), administer additional short or rapid-acting insulin 1, 5
   • For normal blood glucose but elevated ketones, consume some carbohydrates along with insulin to suppress ketone production 2

2. When to Seek Medical Attention:

   • If unable to tolerate oral hydration due to vomiting 1
   • If blood glucose levels do not improve with insulin administration 1
   • If altered mental status is present 1
   • If ketone levels continue to increase despite interventions 2
   • If symptoms of ketoacidosis develop (abdominal pain, nausea, vomiting, Kussmaul respiration) 1

For Non-Diabetic Individuals:

• Assess for other causes of ketosis such as:
  • Fasting or low-carbohydrate diet 2
  • Pregnancy (up to 30% of first morning urine specimens from pregnant women may show ketones) 2
  • Prolonged exercise 6
  • Alcohol consumption 1

Special Considerations

• Individuals treated with SGLT2 inhibitors are at increased risk for DKA, even with relatively normal blood glucose levels (euglycemic DKA) 1
• Pregnant individuals may present with euglycemic DKA and should seek immediate medical attention if ketones are elevated 1
• Individuals on ketogenic diets may have persistently elevated ketones without clinical significance 6, 7

Monitoring Recommendations

• Blood ketone testing is preferred over urine ketone testing for diagnosis and monitoring of ketosis 3, 4
• If using urine ketone testing, early morning and post-dinner urine samples provide the most reliable detection of ketosis 6
• For individuals with type 1 diabetes, history of DKA, or those treated with SGLT2 inhibitors, ketone testing should be performed during illness or when blood glucose exceeds 200 mg/dL 1

Important Caveats

• False-positive urine ketone results can occur with highly colored urine 1
• False-negative readings can occur when test strips have been exposed to air for an extended period 2
• Urine ketone levels may continue to increase even as DKA is resolving, as β-hydroxybutyrate is converted to acetoacetate during recovery 4, 8
• Currently available urine ketone tests are not reliable for diagnosing or monitoring treatment of ketoacidosis 2