Moderate ketones just from a mis-timed meal bolus?

Type 1 and LADA
1

Okay folks, I’m a little worried. We just tested our son and he had moderate ketones just two hours after his meal.

My son was in range for most of the day – both on Dex and finger stick – and spent a significant portion of the day between 80 and 120. He spent an hour between 180 and 200, but that’s it. He was low just before eating dinner tonight, which consisted of pasta and ice cream. I tested him via finger stick numerous times today, and the number was pretty close to Dex.

I bolused for the meal about 10 minutes after he finished it because he started out at 65. And he just kept rising. I just kept piling on the insulin. 1 unit, 2 units, 3 units, 3.5 units. He kept rising and once he hit 300 on Dex I tested him with a finger stick and he was 413. This was just 2 hours after he had eaten and just 1 hour after he crossed the 200 threshold on Dex. So I tested his blood ketones. They were 1.6 mmol/L – on the low end of moderate.

So we did the basic routine: extra insulin given by injection, changed his site, sips of regular water, upped his basal. I’m not freaked out by the number per se; I trust that we can handle the protocol and will recognize any early signs that things are getting more serious.

But I’m spooked. I’ve always heard that it’s very hard to develop ketones from just a mistimed meal bolus, and that you actually need to be deprived of basal insulin in order to start developing them. I also assumed you needed to have high BG for more than an hour or two before you started to get ketones. But based on his blood sugar all day, he was not low on insulin at all during the day. And he doesn’t seem to be sick. He could be growing – but again, I’d assume that if his blood sugar is mostly in check all day, then he wouldn’t develop ketones.

The only things I can think of are that he had a high spike overnight last night, and apparently his ketones then were 0.6. So maybe he never cleared them even after a whole day of normal blood sugar?

The other issue is maybe he ate too few carbs today? His dinner was carb-heavy but we ran out of oatmeal this morning so we scrounged up two tortillas, amounting to just 20 g of carbs. So he probably only ate 50 g of carbs before we hit dinnertime. His usual carb intake is probably around 85 to 100 g per day (excluding fiber).

So what’s going on? I’m pretty freaked out if he’s this prone to ketones, that he could spiral into DKA really rapidly.

2

from a clueless T2, so just an opinion till the clever ones comes.
what i’ve read, with a pump, ketones can come on quick, from a crook site, as you would know.
If things don’t look right, swap out to a new site. or correct with a pen, till any issues are resolved.

dehydration is very important with high BG/ketones and you were handling that.

the more I’m hearing about a mix of separately injected long acting, 50/50 or 75/25 with a pump basal rate to top up, the more I like it. levemir, lantus or with the new Tresiba
I would google untethered and talk to your Dr
http://www.childrenwithdiabetes.com/clinic/untethered.htm

this is worth reading and may help reassure you.( of course you are following the protocals and heading to hospital if it gets bad. you really don’t want to see above 3. but there is a safety marging with ketones, normal people can run up to 5 and although you’d want to be on a drip by then. I’ve read life threatening DKA starts about blood ketones of 10)
https://c.ymcdn.com/sites/www.ispad.org/resource/resmgr/Docs/CPCG_2014_CHAP_13.pdf

594×506 111 KB

3

So we sometimes think that ketones are only associated with DKA, but they often occur in trace or marginal levels and simply reflect our bodies burning fat. This regularly happens overnight as most of us don’t eat while asleep and during exercise (particularly when fasted). And insulin modulates ketone production. Insulin suppresses ketone production. So when you are fasted and you have low levels of blood sugar (like a 65 mg/dl) and low levels of insulin your body turns into a fat burning machine. This may just have been what happened to your son. So even though he had carbs, he may not have had much insulin to take up that glucose and he just kept generating ketones. But ketones production may not have been triggered by the high blood sugar but by being active all afternoon in a fasted state.

And in general insulin will “beat down” emerging DKA so the fact that you got on top of things with the insulin mean that you basically averted any chance of DKA. You did exactly the right thing. High blood sugars with lack of insulin (and possibly dehydration) are the risk factors for DKA. Your actions were perfect, you gave insulin and hydrated.

1 Like
4

Update: So we tested him at 11:30pm, which was about 3 hours after he had the moderate ketones. HIs BG was 115 and his ketone levels were 0.2 mmoL/L, or trace levels. So they cleared extremely fast, which is a relief.

Still, I’m a little freaked out that he was able to generate them so quickly. It tells me we’re entering a new stage in the disease, where we constantly have to keep ketoacidosis in the back of our minds. Before this, no matter how sick he was or how high his BG (he’s been HIGH on Dexcom for hours after a site failure or a pump malfunction), his ketones were always trace. We knew he was making enough residual insulin to keep him out of DKA.

I’m also a little sad because combined with his rapidly escalating insulin needs, this suggests to me that his honeymoon is over. I know there was nothing we could do to prevent this happening, and it’s pretty much a honeymoon in name only (more like honeymooning with an abusive deadbeat), but I’m still sad.

1 Like
5

I am seriously considering the untethered approach; not just because of the risk of DKA, but also because our son is so active he frequently dislodges his pump sites. Even without the risk of DKA, having to deal with those spikes will mess up his avg BG.

The only downside is that we use openAPS and the way it compensates for impending lows is by turning off basal. We’ve found this to be a really effective “brake” on plummeting blood sugars; while we do see the dreaded “double arrows down” from time to time, they’re sort of weak sauce. Instead of plummeting by 30 every 5 minutes, he’s usually dropping by at most 15 or 20, which means he rarely goes low. With long-acting in his system, I’m worried we may lose that braking ability. Plus Levemir had a really peaky effect for our son. But now that he needs so much more insulin I suspect we could give him 1 unit of Levemir or even 2 a day and it wouldn’t drop him low.

I may try it out.

6

Try to take heart in the fact that your son’s ending honeymoon removes one unpredictable factor from the numerous other unpredictable variables that you try (and IMO do a stellar job!) balancing. Hang in there! :heart:️

7

I’m getting closer and closer to trying the untethered approach with Tresiba for my daughter. Our $600+ box of Tresiba pens are waiting in the fridge… Just feel like I need to smooth out a few basal settings on her pump first.