Management of Elevated Ketones with Normal Blood Glucose
The primary concern is distinguishing between starvation ketosis and euglycemic diabetic ketoacidosis (euDKA), as the latter requires immediate insulin therapy and intensive monitoring despite normal glucose levels. 1, 2
Immediate Clinical Assessment
Check blood pH and bicarbonate immediately - this is the critical differentiating step that determines your management pathway. 2, 3
- If pH <7.3 and bicarbonate <15 mEq/L: This is euglycemic DKA requiring emergency treatment regardless of normal glucose 4, 2
- If pH ≥7.3 and bicarbonate ≥15 mEq/L: This is likely starvation ketosis, manageable with oral carbohydrates 4, 1
Measure beta-hydroxybutyrate in blood rather than urine ketones, as it is the preferred and most accurate test for ketoacidosis. 4, 1
Key Clinical Red Flags Requiring Emergency Intervention
Look specifically for these features that indicate severe illness: 1
- Altered mental status, lethargy, or difficulty arousing
- Kussmaul respirations (deep, labored breathing)
- Severe dehydration
- Vomiting or inability to tolerate oral intake
- Abdominal pain
Management Algorithm Based on pH/Bicarbonate
For Euglycemic DKA (pH <7.3, HCO3 <15 mEq/L):
Initiate continuous IV insulin infusion at 0.1 units/kg/hour even with normal glucose - this is essential to clear ketones and resolve acidosis. 4
- Do NOT wait for hyperglycemia to start insulin 2, 5
- Add dextrose-containing IV fluids (D5 or D10) from the start to prevent hypoglycemia while continuing insulin to clear ketones 2, 6, 5
- Aggressive IV fluid resuscitation is critical 4
- Monitor blood glucose every 2-4 hours and adjust dextrose concentration to maintain glucose 150-200 mg/dL while continuing insulin 4
Resolution criteria: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH ≥7.3, and anion gap closure 4
For Starvation Ketosis (pH ≥7.3, HCO3 ≥15 mEq/L):
Provide 150-200 grams of carbohydrate daily (45-50 grams every 3-4 hours) to suppress ketone production. 4
- Use liquid or soft carbohydrate-containing foods if regular food not tolerated: sugar-sweetened drinks, juices, soups, ice cream 4
- Increase fluid intake to prevent dehydration, including sodium-containing fluids like broth or sports drinks 4
- Continue insulin in type 1 diabetes patients - never omit insulin during illness 4
- Reassess clinical status after feeding 1
Critical Medication Review
Immediately discontinue SGLT2 inhibitors (dapagliflozin, empagliflozin, canagliflozin) if present - these are a common cause of euglycemic DKA. 7, 6, 5
- SGLT2 inhibitors cause euDKA by promoting urinary glucose excretion while stimulating ketogenesis 6, 5
- This can occur in both diabetic and non-diabetic patients on these medications 7
- Permanent cessation is recommended after an episode of euDKA 6
Common Precipitating Factors to Identify
The underlying trigger must be treated concurrently: 4, 5
- Reduced food intake, fasting, or persistent vomiting
- Infection (especially urinary tract infection)
- Insulin pump failure or reduced insulin doses 2
- Surgery, trauma, or major illness
- Gastroparesis or dehydration
Monitoring During Treatment
Draw blood every 2-4 hours for electrolytes, glucose, BUN, creatinine, and venous pH. 4
- Venous pH is sufficient; repeat arterial blood gases are unnecessary 4
- Follow anion gap closure as marker of resolution 4
- Ketonemia takes longer to clear than hyperglycemia - do not stop insulin based on glucose normalization alone 4
Critical Pitfall to Avoid
Do not use the nitroprusside method (standard urine ketone strips) to monitor treatment response - it only measures acetoacetate and acetone, not beta-hydroxybutyrate, and may falsely suggest worsening ketosis during treatment. 4