What should I do if my ketone levels are elevated?

Management of Elevated Ketone Levels

For elevated ketone levels (15 high), you should increase fluid intake, monitor ketone and blood glucose levels frequently, and seek medical attention if you have symptoms of diabetic ketoacidosis such as vomiting, abdominal pain, or altered mental status. 1, 2

Understanding Ketone Levels

• Ketone bodies are normally present in blood and urine but in very low concentrations, typically total serum ketones <0.5 mmol/L 2
• The three main ketone bodies are acetoacetate (AcAc), β-hydroxybutyrate (βOHB), and acetone, with βOHB being the predominant ketone body in diabetic ketoacidosis (DKA) 1, 3
• Elevated ketones indicate insufficient insulin and increased fat metabolism, which may suggest impending or established diabetic ketoacidosis in diabetic patients 4, 5

Initial Assessment

• Immediately check your blood glucose level to evaluate for hyperglycemia, which together with ketones may indicate impending or established DKA 6
• Blood ketone testing is preferred over urine ketone testing as it measures β-hydroxybutyrate directly, which is the predominant ketone in DKA 1, 3
• Normal ketone levels can be elevated during fasting, pregnancy, or following a low-carbohydrate diet 4, 7

Management Based on Patient Type

For Diabetic Patients:

• Increase oral fluid intake to prevent dehydration 2
• Monitor blood glucose and ketone levels every 3-4 hours 2
• For insulin-dependent patients, consider additional short or rapid-acting insulin if ketone levels increase or symptoms develop 2, 8
• If blood glucose is normal but ketones are elevated, consuming some carbohydrates along with insulin may help suppress ketone production 2
• If ketone levels increase above 1.5 mmol/L despite interventions, or if symptoms of ketoacidosis develop (vomiting, abdominal pain, rapid breathing), seek immediate medical attention 2, 1

For Non-Diabetic Individuals:

• Elevated ketones may represent a normal physiological response to fasting or a low-carbohydrate diet 4, 7
• If you're not diabetic but experiencing symptoms like excessive thirst, frequent urination, or unexplained weight loss along with elevated ketones, seek medical evaluation for possible undiagnosed diabetes 1
• During illness or stress, ketone levels may increase due to decreased food intake and increased counterregulatory hormones 1

Warning Signs Requiring Immediate Medical Attention

• Marked hyperglycemia accompanied by ketosis, vomiting, or altered level of consciousness 1
• Symptoms of diabetic ketoacidosis including:
  • Excessive thirst and urination 8
  • Nausea and vomiting 8
  • Abdominal pain 8
  • Weakness or fatigue 8
  • Fruity-scented breath 5
  • Confusion or difficulty concentrating 8
  • Rapid breathing 8

Important Considerations

• False-positive urine ketone results can occur with highly colored urine or with certain medications 1, 4
• Urine ketone tests using nitroprusside reagents only detect acetoacetate and not β-hydroxybutyrate, potentially underestimating total ketone body concentration 1, 4
• During treatment of DKA, blood β-hydroxybutyrate levels commonly decrease before acetoacetate levels, making urine ketone tests potentially misleading during recovery 5, 3
• Sustained hyperketonemia can increase oxidative stress and may lead to complications in various organs, particularly in diabetic patients 9