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Education needed for ketone testing in type 1 diabetes

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January 23, 2017

Ketone self-monitoring rates were high among very young children, whereas older adults infrequently checked their ketones, even when blood glucose was high, according to findings published in Diabetes Care.

Anastasia Albanese-O’Neill, PhD, ARNP, CDE, assistant professor in the College of Nursing at the University of Florida Health, and colleagues evaluated data from the T1D Exchange Clinic Registry on 2,995 children aged 4 to 12 years and adults aged 18 to 89 years (mean age, 27 years) with type 1 diabetes (mean duration, 18 years) to determine ketone-monitoring behaviors.

Anastasia Albanese-O'Neil
Anastasia Albanese-O’Neill

All participants completed an online questionnaire about their behaviors between October and November 2015.

Among the participants, 62% reported keeping urine ketone test strips at home, 18% had a blood ketone meter at home and 32% reported no testing supplies. According to questionnaire results, 20% of participants “never” and 30% of participants “rarely” checked their ketones.

Fifteen percent of all participants, 53% aged 6 years and younger, 33% aged 6 to 12 years, 17% aged 18 to 25 years, 7% aged 26 to 49 years and 11% aged at least 50 years reported “always” checking their ketones of checking “most of the time” when their glucose levels were near 300 mg/dL.

Among participants reporting on checking ketones when nauseated and/or vomiting, 21% of all participants, 68% of those younger than 6 years, 57% of those aged 6 to 12 years, 23% or those aged 18 to 25 years, 9% of those aged 26 to 49 years and 9% of those aged at least 50 years reported “always” checking, whereas 38% of all participants reported they “never” checked. Nearly half (45%) of participants reported “never” checking ketones when they had a fever.

“Although reported ketone self-monitoring among very young children with [type 1 diabetes] (or their parent caregivers) adhered most closely to clinical guidelines, ketone monitoring among adult participants was infrequent when blood glucose was high, when nauseated and/or vomiting, and when fever was detected,” the researchers wrote. “Overall, the reported rate of ketone monitoring is low, which suggests a need for more robust diabetes education related to this self-care behavior for patients with established [type 1 diabetes].” – by Amber Cox

Disclosure: The researchers report no relevant financial disclosures.

itj+ Perspective

Zachary T. Bloomgarden
Ketone testing is infrequently recommended for adults with type 1 diabetes, and this is reflected in a recent study reported in Diabetes Care. When might this be a relevant investigation? The combination of insulin deficiency and glucagon excess (particularly with elevation in other counterregulatory horomones) in the presence of increased fatty acid availability accelerates the physiologic process of ketogenesis, which ordinarily plays a role in providing an alternative circulating fuel as availability of glucose declines. When the type 1 diabetic patient with illness has markedly reduced carbohydrate intake and reduces insulin dosing, ketoacidosis can develop even in the setting of modestly elevated glucose levels (in the 200-300 mg/dL range and not the 500 mg/dL range as with typical ketoacidosis), so having urine ketone test strips available is useful, along with a discussion of approaches to acute illnesses.
This has recently become a topic of greater importance with the realization that the SGLT2 inhibitors can increase the likelihood of development of ketoacidosis, most likely by potentiating glucagon secretion, but possibly by direct renal effects as well (see Bloomgarden ZT. J Diabetes. 2016;doi: 10.1111/1753-0407.12353). Although much less of an issue in type 2 diabetes, these agents may occasionally cause insulin-requiring type 2 diabetic patients to develop ketoacidosis, so that recommending urine ketone test strips for such patients may be reasonable as well.

Zachary T. Bloomgarden, MD, MACE
Clinical Professor
Department of Medicine
Icahn School of Medicine at Mount Sinai
Disclosure: Bloomgarden reports serving as a consultant for Astra Zeneca, Janssen, Merck and Novartis; a speaker for Astra Zeneca, Janssen and Merck; and a stockholder in Baxter International, CVS Caremark, Novartis, Roche Holdings and St. Jude Medical.