Continuous ketone monitoring guidelines released

A panel of international experts in the management of diabetic ketoacidosis (DKA) has developed a set of practical recommendations on how a novel diabetes technology could improve outcomes for at-risk individuals. Published in The Lancet Diabetes & Endocrinology, the guidelines on continuous ketone monitoring (CKM) aim to maximise the benefits of this emerging technology for people with diabetes.

DKA is a serious, potentially life-threatening complication associated mainly with type 1 diabetes, but it can also occur in and other forms of diabetes. Episodes are characterised by hyperglycaemia, hyperketonaemia and metabolic acidosis. In children and adults with type 1 diabetes, hospital admissions for DKA are more common than for severe hypoglycaemia. It remains one of the most preventable causes of morbidity and mortality for people with diabetes. 

While capillary blood ketone monitors and urine ketone strips are available for people at risk of DKA, evidence indicates that few people use them regularly or know how to respond to elevated levels. Awareness among healthcare professionals is also sub-optimal.

Given this background, the anticipated availability of CKM has the potential to transform diabetes management for many at risk of developing DKA. CKM technology will provide users with real-time information on their ketone levels and alert them when action is needed. Subgroups of people with diabetes at heightened risk of DKA, and who may benefit from CKM, include insulin pump users, people with complications (such as chronic kidney disease or cardiovascular disease) and women with pregestational or gestational diabetes.

In the absence of randomised controlled trials, the expert consensus group met to establish how CKM technology can be used effectively. Its recommendations included the following:

• Monitors should include trend arrows, similar to those used in continuous glucose monitoring.
• Ketone level terminology should be: normal, elevated, high and urgent high.
• To reduce alarm fatigue, an alarm should sound if ketone concentrations rise above the “urgent high” threshold of 3.0 mmol/L.
• Users should have a blood ketone meter to use if they experience symptoms of elevated ketones that do not match their CKM readings.
• CKM users should receive education on what elevated ketones mean and what actions to take.

By establishing a set of guidelines, the panel hope to help standardise the integration of CKM into practice once it becomes available. Healthcare professionals and the type 1 diabetes community will be able to refer to the recommendations as the technology is rolled out, so that its benefits can be realised as quickly as possible. 

The full study can be read here.