I’m T2DM fairly recently on MDI. In the past, I never really concerned myself about DKA. Well, I think that is something that needs changing.
I know there are urine strips, meters and I just read about a device the uses breath.
Looking forward to your expertise.
@Luis3, the best way to stay out of all kinds of trouble is to monitor your blood sugar with a CGM. If you keep your BG in range, you don’t have to worry about ketones.
Of the 3 types of measuring you mentioned, blood ketone meters are the most accurate method of measuring ketone levels.
The urine strips are cheap, and inaccurate. How many diabetics here still measure their sugars with urine strips?
A good meter isn’t that expensive, the downside to meters is the cost of the strips. They’re far more expensive than blood glucose strips.
I use the Freestyle Precision Neo for blood ketones. It’s proven accurate and reliable
I agree with @Helmut that the best way to avoid DKA is to keep your glucose in range. I still think there’s a need to be aware of ketone testing.
In the rare time that I need to check ketones, I find it to be critical. Last year, I woke up one morning and felt some mild nausea. I finger-sticked and my blood sugar came up in high at 262 (14.6).
Luckily, I had a blood ketone meter and strips on hand. My ketone level came in at 4.7 mmol/L, with 5.0 mmol/L marking a threshold of concern. My Loop system lost its glucose data stream while I slept and reverted back to programmed pump basal rates. I must have needed a lot more insulin via basal modulation delivery and I wasn’t getting it.
Anyway, by taking timely action with drinking water, administering Afrezza as well as an IM injection, and preemptively changing out the infusion site, I felt like I avoided a trip to the hospital.
I use a Precision Xtra blood meter and strips. This meter doubles as a glucose meter and is built by Abbott. It’s probably at least ten years old and continues to function dependably. I buy the test strips at Amazon. They are individually foil wrapped so they stay fresh.
You seem to be active, so ketones are going to be present.
Whenever you burn fat, you produce ketones.
It only becomes a problem when there is no insulin and it gets out of control, changing the acidity of your blood.
It doesn’t really cause much concern for type 2 because you still make some insulin, but I do know DKA can happen in type 2 as well.
Like everyone else said, stay on your glucose control and it will be a non issue.
I don’t even know why we bother testing ketones, because if they are high, we’re just gonna try to get our glucose in range.
At a hospital, it’s a different story depending on the level
Another reason to keep a ketone testing system on hand, even if T2D, is the growing use of the SGLT-2 inhibitor drugs. They’re known by the brand names Jardiance, Invokana, and Farxiga.
What these drugs do is lower the threshold where the kidneys start to flush out excess sugar. This threshold is normally around 180 (10) and the SGLT-2 inhibitors lower that number. In essence, this class of drugs give you the ability to pee out excess sugar.
Unfortunately, it’s been observed that diabetic ketoacidosis (DKA) can present itself at normal blood sugar levels. This is known as euglycemic or normal-sugar-level DKA. Only by testing for and observing a high ketone level will the patient realize the threat of DKA.
If you’re taking a SGLT-2 inhibitor, no matter the diabetes type, you should keep a blood ketone meter on hand and use it if you’re ever suspicious of high ketones.
Thanks, Terry, I just read an article on Diatribe about sick day readiness. I know for a fact that when I get a cold even, that I am more prone to higher BG levels, probably more insulin resistant.
I don’t obsess over things like DKA, I just know that it can happen. I haven’t been ill lately, but recent medical tests have reminded me how easy it is for BG to get out of range.
Thanks again, Terry.
In my experience, I’ve never required accuracy when it comes to ketones. A general indicator (urine strips) is plenty good enough. I use it to inform my decisions, but I don’t have a detailed treatment plan that relies on exact numbers. It mostly just eases my curiosity as to whether I’m feeling flu-ish because I’ve actually caught a contagion, or if it’s diabetes related.
I know my point of no return when it comes to ketones and DKA. Vomiting indicates the point in which I need professional intervention, no matter the EXACT concentration of ketones. If I’m vomiting without concerning ketones, then I keep my butt at home and try to get over the flu.
If I’m vomiting WITH high ketones, I rush to the hospital because I’m nearing the point where it will hurt to breathe Thankfullyy, that hasn’t happened since I was in puberty, though!
Basically, I ignore the results if they’re one of the first two color blocks, indicating negative or trace amounts of ketones. That means I don’t need to change my behavior any, other than to correct BG if necessary. However, if it turns one of the darker colors, then I’m going into my ketone response regiment. I become really insulin-resistant with high levels of ketones, so I immediately halve my correction factor and I:carb (double the insulin dose). I also start chugging the electrolyte drinks. (You do NOT want intravenous potassium in the hospital! It’s like mainlining battery acid.). Coconut water is my preferred choice, because of the high potassium levels. If my BG is back to normal and I still have concerning ketones, then I keep consuming carbs/electrolytes and dosing insulin until the problem resolves.
Maybe it’s just because I was trained with urine strips as a child, but I don’t have a plan that indicates I behave differently with 4.7 vs 5.0 mmol/L… so why does the accuracy matter? I like having the urine strips around the house anyway, the ones with like 14 test spots, because they’re a good indicator of other health factors too. It’s nice to KNOW if I have a UTI and see that my kidneys are still healthy.
I think it’s a given that blood strip ketone analysis is “best”, but the question really is what test method is most appropriate for you, not necessarily “best”. Personally, I’m way more likely to pee on a strip that costs pennies, rather than potentially waste a blood strip that costs dollars.
Thanks, Robyn, I may purchase some urine strips, just because. That throwing up would be a really indicator for me, because I hate throwing up and seldom do it. Twice from food poisoning and one other time.
I learned not to drink alcohol past a certain point because of worshiping the ceramic god (toilet).
ugh!
I’ve lived with T1D for 37 years and have not experienced even one episode of DKA. Will Dubois, a contributor to DiabetesMine, wrote about his experience with DKA. He spent time in the hospital, some of it in the ICU.
Wil has written books about living with diabetes and is well-informed about diabetes issues. This paragraph, published in 2019, jumped out at me.
What happened? I still don’t know. A lot of it is a blur. Something made me sick. I did throw up, but my sugar was at a normal level when it happened. But then things went south. My blood sugar level started rising and wouldn’t stop. I threw insulin at it, but it all happened so fast. So frickin’ fast. It only took a few hours, coasting just below 300 mg/dL, to send me into a full-blown metabolic crisis that left me in the hospital for three days, two of them in the ICU.
… it all happened so fast. So fricken’ fast. [my emphasis]
Many of us have little to no experience with DKA. We don’t really understand the vulnerability we face. DKA doesn’t happen very often, so we think the threat is extremely low. Yet when it does happen, we often waste time and remain ignorant as the actual event unfolds.
I agree with @Robyn_H’s assessment that urine ketone strips are good enough for us. I think the blood ketone measurement, however, carries more weight when reported to your doctor’s office over the phone during a DKA scare. My memory of colored reagent pads with blood glucose testing is that it requires comparison to a standard color panel at a certain elapsed time and judgment of color gradients is important.
If you’re doing this when impaired by DKA itself, your ability to execute any procedure correctly and make judgements are impaired. Whether you decide to use urine or blood to check for ketones, it would be good practice to conduct a test or two at least once per year or more to retain familiarity.
It will also reinforce your memory about where your ketone test supplies are located. If I haven’t used some supplies for a long time, say two or three years, the likelihood of me finding them is greatly reduced.
I didn’t normally have urine ketone strips around. I always felt I would know. I went into a coma at my diagnosis and never, ever want to feel like that again. Which is why I hate the highs and will gladly suffer the lows!
That agony is something I will do anything to prevent. Which is now, why I have a blood testing ketone meter. I have been in a few studies using type 2 drugs and it is a requirement for ketone testing. I find the Precision meter very reliable and easy. I have been getting the strips from the study but have gotten them on Amazon once.
And yes, keeping your sugar levels in a good place is the best way to avoid DKA but things don’t always play fair when dealing with diabetes. Nothing wrong with being prepared!
My second bout with DKA was a large steroid injection in my hip and we thought we had a good game plan but it didn’t go as planned. Pushing fluids, pushing massive insulin amounts, changing infusion sets, taking injections, nothing was working & ended up in the ER with my second run of DKA in at the time 43 years. And of course I didn’t have any urine testing strips and 3 calls to different drug stores before we found one that had them on the shelf. Nightmare! Better safe than sorry!
Assuming your Type 2 diagnosis is correct, you are at very low risk for DKA. But it is possible and my advice would be to just buy the urine strips. They cost about $10-$15 for a bottle of 50. Unfortunately once you open the bottle the strips degrade fairly quickly and most of the strips will end up in the garbage. They used to sell individually wrapped strips but they were much more expensive. I always have a bottle of Ketone strips on hand but can’t remember the last time I used one. As @Robyn_H said, Trace or Small Ketones are meaningless and can show up after an overnight fast. Medium bears watching and Large can eventually lead to an emergency. There are instances of DKA with BG’s that aren’t super high and some of the injectable non-insulin medications are associated with DKA in Type 1’s at relatively normal BG’s. Not sure whether there is the same risk for T2’s taking those meds.
I am late stage type 2. My Beta cells weren’t destroyed by the immune system or pancreatitis, but are just worn out from years of over secretion of insulin.
I had good BG levels from diagnosis for a decade, then progressed to Metformin, later Lantus and recently multi daily injections. I suspect I am more at risk than your average T2DM, maybe not as much as type 1 DMs.
This is timely article posted today at Diabetes Mine. Diabetic Ketoacidosis Without High Blood Sugar? Yikes!
I have the urine strips and only the past year added a meter. The way I looked at it, the urine strips were easy and while might be inaccurate but they tell you if you have ketones.I never had so I didn’t worry about accuracy. I went ahead though and finally got a meter just in case the urine strips say I have some ketones I can then test to see how much. The urine strips are really easy to use and cheap to use.
A type 2 rarely gets DKA because DKA isn’t really from high blood sugars so much as lack of insulin. Which is also why you can actually get DKA with low blood sugars if insulin is absent. But since a type 2 almost always still makes some insulin, even though insulin resistant, they usually don’t have an issue.
However a few type 2’s do get something similar called HHS " Hyperosmolar hyperglycemic syndrome " and it’s actually a more deadly form.
When buying a $10 bottle of 50 ketone test strips I end up throwing 48 of them away because I use them so rarely (usually only when I’m sick is there a chance I might need them)…
I hate to be cynical because we’re supposed to have ketone test strips and glucagon kits around just in case… BUT they will almost certainly be thrown away expired/gone bad rather than used.
I’m apparently a freak, because I actually do use mine. I test at least once a week just to make sure things are okay, and any time I feel unwell. But l am checking all 14 parameters on my strips, not just the ketones.
I’ve bought glucagon for 30 years and they always end up in the trash. I recently stopped wasting the money.
I have never liked the idea of causing the kidneys to excrete glucose, so I have never been tempted to use SGLT2 drugs. The possibility of euglycemic DKA with in range blood glucose levels should be carefully explained to any type diabetic before taking this c
Now that’s scary, Marie. As to DKA I wonder if it is more common in type 2 DMs whose disease has progress to the point they are secreting very little insulin and are on a bolus/basal regime.
That HHS syndrome may not be a worry for me as I am not obese with a high BMI. I am in the age range, so it is something to consider.
Thanks for posting that article. I read lots of scientific papers on our condition. The more we know the better we can cope.
