Call your senior or the diabetes on call team if you aren't sure what to do, or if there is a clinical concern.

If patient is using an insulin pump (continuous subcutaneous insulin infusion) please refer to Insulin Pump section

Type 1 diabetes or pancreatic diabetes

  • Ketones can develop if insulin deficient due to insulin omission or increased requirements due to intercurrent illness
  • If ketones accumulate, there is a risk of developing diabetic ketoacidosis (DKA)
  • Capillary ketones should be checked if capillary blood glucose (CBG) is >14mmol/L.

 

Type 2 diabetes

  • Much less likely to develop DKA unless they have a severe intercurrent illness or are on an SGLT2 inhibitors (SGLT2i) ("-gliflozins")
  • There is a small risk of euglycaemic DKA with SGLT2i
  • SGLT2i should be stopped if patients are fasting, have a reduced oral intake or are unwell with an acute illness.

 

Other reasons for raised ketones

  • Other reasons for raised ketones include starvation, alcohol, sepsis and a ketogenic diet.
  • Always consider DKA but raised ketones can simply be a sign of acute illness and highlights the need for an urgent medical review.

 

Management of ketones in type 1 or pancreatic diabetes

Ketones < 0.6

  • Considered normal
  • No extra intervention needed

 

Ketones 0.6 – 1.4

  • Slightly raised
  • Encourage to drink sugar free fluids
  • Consider a correction dose of short acting insulin to correct hyperglycaemia
  • Repeat CBG and ketones in 2hrs
  • If rising, contact diabetes on call in hours or senior out of hours

 

Ketones 1.5 – 2.9

  • Raised
  • Encourage to drink sugar free fluids
  • Give an extra correction dose of short acting insulin at 10% of their total daily dose (TDD*) of insulin to correct hyperglycaemia
  • Repeat CBG and ketones in 2hrs
  • If rising, contact diabetes on call in hours or senior out of hours

 

Ketones > 3

  • Very raised
  • Check venous blood gas - if acidotic, treat as DKA
  • If not acidotic
    • Encourage to drink sugar free fluids
    • Give an extra correction dose of short acting insulin at 20% of their TDD* of insulin to correct hyperglycaemia
    • Repeat CBG and ketones in 2hrs
    • If rising, contact diabetes on call in hours or senior out of hours

 

  • *Total daily dose (TDD) of insulin can be calculated by adding up all the long and short acting insulin a person takes in a 24hr period
  • Avoid correction doses closer than 2 hours apart as there is a risk of insulin stacking and hypoglycaemia

 

Call your senior or the diabetes on call team if you aren't sure what to do, or if there is a clinical concern