Ketone Testing & DKA

Type 1 & LADA
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I’ve been brushing up on DKA posts. And clearly, testing for ketones is part of figuring that out. But I’m a tad confused. Some people have blood ketone testing meters. There are also urine ketone strips. Many who test for ketones seem to be children? Do adults find themselves doing this?

I ask because we went to dinner at a friend’s tonight. Pump failure. Probably happened before we even left home. BG shot up to 330 at the highest. EH felt like crap, but as it was on the rise, he had been both injecting with his Omnipod and taking Afrezza. The pod eventually failed with an occlusion alarm (rarely happens to us). He took 24u of Afrezza total and 6 units of Novolog IM and had plenty of fluids and basically not much has happened. BG has decreased from 330 down to 230. It seems to be continuing downward slowly, we came home and replaced the pod with a new pod located elsewhere. He doesn’t feel like he’s coming down with an illness, no canker sores, nothing to trigger the immune response requiring more insulin.

Assuming that the pod dying only caused a deficit of 3 units of insulin, which were then injected upon realizing the failure (that pod was fresh at 5pm, it was occluded by 8pm, so it was easy to do the math on), I’m struggling to figure out why this happened. It was hot today, dehydration probably played a role. I think also when BG is really high it’s “sticky” and takes more insulin to reduce it.

When the BG is above 300, it seems like testing for ketones would be good. But of course I couldn’t find the strips (maybe I tossed them as they were opened and old?)

So my next question is what should we have on hand for this situation in the future? Is there a meter and strips for ketones that don’t expire quickly?

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As for the why BS rose so high, so quickly, and why replacing the 3 missed units didn’t just tale it back to normal??? Well we’ve had that fallacy right? “I’ll just replace the 3 units I missed and it’ll all be good” LOL!!!

We focus often on ketosis/ketones (the burning of fat for energy to correct a negative energy state), and a diabetic’s lack of glucagon/glycogen release, but the body has other pathways for gluconeogenisis (creating glucose from something other than carbs). It’s one of the reasons that rebound highs occur even when you don’t eat too many carbs, or have ketones. However, even if BS is high vs low, with no insulin to let sugar into the cells, the cells send signals telling the body they need sugar and the body produces more sugar.

I know I need more insulin for an extreme high than my normal ISF, or sliding scale, or correction bolus, or whatever you want to call it. I am going to through out random, round, wacky numbers to illustrate what I do. I have a “threshold” that if I am above, I ad X extreme high “addition” to my correction bolus. So my threshold is 200, my correction bolus is normally 1 unit for 50 points, and my extreme high “addition” is 40 units. That means that if I am at 200, I take a correction bolus of 2 units to get me to 100. If I am at 500, I would take a correction bolus of 8 units, plus my extreme high “addition” of 40 units for a total of 48 units to get me to 100.

If I am over my extreme high limit, I also typically do an IV injection. I have found that IV insulin effects are done within an hour for me.

I don’t test for ketones. I know what it feels like to have them. I can also smell and taste them. I don’t test for them because they don’t affect how I treat myself. If my BS is 340, and the ketone level was 0, or 1, or 3, I am still treating a BS of 340 exactly the same way. Likewise, if BS is 100 and I am exhausted, I feel ketones, and can smell and taste them, I am going to eat and take some insulin, and knowing my ketone level is 1 or 3 isn’t going to change that.

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No, I haven’t done that in years. It may be naive, but I see no reason to test for ketones. First of all, I wouldn’t know when to test for ketones. Most of those charts about testing ketones are very aptly titled ‘Sick day management’ or something alike and thus hardly ever apply to my situation. Some website encourage to check for ketones when your BG level is above a certain value. The UK’s NHS for example recommends to check ketones if your BG exceeds 11 mmol/l (~200 mg/dl). That’s absolutely ridiculous in my opinion. Many diabetics regularly spike above 11 mmol/l. The NHS also recommends checking in case you have ‘symptoms of DKA’, which include ‘needing to pee more than usual’ and ‘feeling very thirsty’. Those symptoms don’t worry me enough to check ketone levels.
I also don’t have ketone strips and I see no point in buying them, because they would expire before a situation occurs in which it might be useful to check ketones.
So I’ll leave the question what you should have on hand for the future to people who have more experience with ketone testing.

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I would do that or take even less insulin and add more insulin later if needed, because it usually doesn’t take as much insulin as the missed units to bring my BG back to normal. YDMV.

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I used to test for ketones, @TravelingOn, until I started coming around here where I realized it’s really a pretty unnecessary task. When it comes to dosing for insulin I’ve missed, I might take into light consideration how much I think I’ve missed, but I also treat the number I see in its own right. So if I see a 300 because I’ve eaten cookies, and I know I’ve bolused adequately, then adding another pump or manual injection of top of it might be useless (IV—different discussion). But if I see a 300 and know my pump has been suspended for 2 hours, I’m giving myself a heap of insulin for the 300 and probably adding at least some of what I missed in basal. I used to be so stinking conservative when it came to those kinds of highs because I couldn’t understand how I would ever need so much insulin for something I’ve calculated to be far less. Now I understand the route I took to get that high is as important as the end value (which I can also assume is a moving value and probably not the final product).

Don’t know if that made any sense. If I see a number that is high and know I’m missing insulin, I hit hard with aggressive boluses. I’ve got snacks ready in case I need them, and I leave the ketone sticks at the store. I don’t plan on staying high long enough to have that be a problem.

I made that last part up. :yum:

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I don’t test just because I’m high. If I’m way higher than normal it’s likely because of (a) underestimating carbs in my last meal, or (b) a site/pod problem. And both are easily fixed.

I do keep a box of blood ketone strips on hand, in case I’m so sick I can’t eat, and then I use my “sick day guidelines” that let me know how much to increase my basal based on ketones and BG. My last box expired three years ago, and I used one strip.

I wouldn’t bother with pee sticks. They’d be as reliable as a pee stick for sugar. As in, “That’s so an hour ago.”

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Since my son’s diagnosis we have tested for ketones exactly twice. It was when he was sick with a stomach bug, couldn’t keep anything down, was actively throwing up. Under those conditions I think testing for ketones is helpful because it leads to increasing the amount of insulin you give over the next couple of days, and helps you understand how close he is to things getting worse and making the call to go to the emergency room, which we have never had to do. The worst experience was the first, when he was puking, had low blood sugar and extremely high ketones. uugh.

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We do not test for ketones either.

If the BG is very high then we give insulin in quantities that we consider good size doses as well as drink a good amount of water.

I do like to bypass the pump when BG is very high as I consider it entirely possible the “pump” (pump, infusion site, insulin, whatever just want it all different) is to blame so I prefer a syringe or pen for a very high BG. Unless it is obvious like a forgotten bolus. But that is different. Even then a syringe is faster than the pump so if over 300 then I really prefer pen or syringe.

If ketones are present that is what we would do for treatment anyhow.

If the BG is very high and does not respond in maybe 4 hours and stays very high then we would call in to the Endo. Ketones or not.

That might be something I may ask our Endo about. I am not familiar at all with the concept of low BG and high Ketones. I have heard it mentioned a few times but just not something I know anything about.

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As far as a ketone meter, the Precision Xtra (or similar Abbott meter) has strips that come individually wrapped in foil. They don’t expire too fast and are nice and compact since you can carry five of them around instead of 50.

I do test for ketones. But I don’t base it on blood sugar level. I base it more on how I’m feeling. If I’m feeling sick to my stomach and my blood sugar is high, then I’ll test for them. If my blood sugar is high and not coming down after a ridiculous amount of insulin and I’m starting to feel off, then I’ll test for them. If I was sick and dehydrated, I’d test for them. When I was taking an SGLT-2 inhibitor and felt off, I tested for them. But if I’m just high and know the cause and don’t feel like I might throw up, then I don’t test.

I know people with Type 1 who say they never get ketones and therefore never test for them. I can see myself coming to that conclusion if I never had ketones. But I seem to develop ketones quite quickly in the absence of insulin, and have had situations where my ketones have been high, and the usefulness of knowing this is that high ketones tend to require extra insulin to get rid of them and bring blood sugar down. And, if you know you have high ketones, you know to watch for symptoms and get medical assistance if, say, you start throwing up or feeling really ill.

Also, I was diagnosed as a kid, and I think kids and parents tend to get more education on this type of thing than adults do. I remember having to test my urine for ketoens every time I used the bathroom when I was in the hospital at diagnosis. I think one of the criteria for me being able to go home was for my urine to be clear of ketones, and my hospital stay was four days. And I remember having to test for them when I was sick to determine how much (if any) extra insulin I’d need. So I think it’s been drilled into me more than it might have been had I never had those types of experiences.

The ketone strips I use cost $25 or so for 10 strips. I use less than 10 strips most years. So keeping them on hand is worth $25 a year, in my opinion.

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Thanks to everyone (x10 because I really do appreciate you all!) for their thoughtful and helpful answers. I feel like we basically followed the outline, but somehow along the way I became concerned about the ketone thing. Interestingly, this is the first pump failure/massive sticky above 300 high in memory.

In the end it was 32 units of Afrezza, 6 units of Novolog IM, 4 units from new pod, 3 from probably bad pod.

Here was the graph of ick:

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From everyone’s stories, it seems as if it really is a YDMV thing. I wonder what the science behind individual ketone development is? I read an article that summed up the outline of how it works which might help someone else who stumbles across this thread. Diabetic Ketoacidosis: myths, tips, and lesser known facts

I agree that as an adult diagnosis there was little to no education about sick days, ketones or DKA. Honestly, we’d never heard of it before here.

I’ll check into the ketone meter Jen mentioned - the individual wrapped strips are appealing, although with the pee strips in the past he never showed signs of ketones - so maybe EH doesn’t make them.

My takeaway: insulin needs are not linear, they go up exponentially with higher BG, don’t be afraid of an aggressive bolus, and more water is a good thing to decrease dehydration.

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Sorry for the late response but we have a digital ketone meter for school and home (we keep it in the pack that goes with him) but we’ve only used it once since buying it. Ketone steips are worthless.

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Wow, that is kind of scary! I’m guessing EH wasn’t near DKA when diagnosed, then? Still…everyone with T1 should receive education about DKA, especially when on a pump! I learned about it when diagnosed, but it was also emphasized a lot during my pump training (~15 years after diagnosis).

I know there are different levels of insulin production among T1s…those diagnosed as adults tend to produce more insulin for longer than those diagnosed as kids. So maybe that’s part of why there are individual differences. I had a site failure that led to a 25.6 mmol/L (460 mg/dl) blood glucose level a few weeks ago and I noticed that my ketone level was only 0.2 mmol/L, which is totally normal. Usually that type of site failure would have resulted in a high ketone level (>0.5 mmol/L) for me that would probably last for several hours. At the moment I’m taking a small background dose of Tresiba (10 units a day) in addition to my pump’s basal (which I’ve lowered by 10 units). So my guess is that those who have a small amount of their own insulin production are probably a lot more protected from ketones developing than those who have no measurable insulin production. But that is just a guess on my part…I’ve never actually had any tests to see whether I still make measurable insulin or not.

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I assume he wasn’t near DKA, but honestly I have no idea. He had lost about 40 pounds and was drinking gallons of water everyday for months. And unfortunately training for a half marathon at the time, so we chalked it all up to that! Our then dermatologist and friend mildly freaked out because he’d had a mole removed and the punch biopsy site would not heal up - turns out when your BG is over 400 for a long time, that’s what happens. So she insisted that he go to the GP and get bloodwork done. He did and it was diabetes. They thought T2, but were not sure, so we were sent home with a bag of Metformin and insulin and syringes. At some point shortly thereafter the GP called back and said it was T1, and to use the insulin. My dad has a stroke the same week, so it’s all a tad fuzzy now. But I am positive that the education was non-existent.

We were 26, preparing for a giant life change, and didn’t take it particularly badly or deal with it particularly well. Just didn’t know better! Hence my enjoyment of FUD and my thankfulness for all of your shared knowledge. I think endos don’t often know what it’s like to live with it, and they miss the finer points.

The pump info from here has helped to identify what was going on and how it works. Without this I wouldn’t know ketones were a thing or the risks they carry. We didn’t even have a real pump trainer here in SLO. The woman we saw who was certified made a major math error in calculating EH’s basal and he believes it would’ve killed him. So no knowledge gained there.

It’s bizarre when you think on it - insulin is serious stuff, as is not having insulin on board. But that doesn’t guarantee training upon diagnosis. And always everyone’s diabetes may vary. But still!

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That is really scary. I mean the best part of Cody getting diagnosed has been all the classes and amazing people at our endo’s office, who have kids with diabetes and just get it. Without their education and support, this would have been an even scarier transition. I am glad our small collection of people are able to have an impact! Go FUD

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Wow, such different experiences! My mom took me to our GP because I’d been drinking a ton for the past couple weeks and for the past few days had lost weight and was acting lethargic. The doctor sent us downstairs for bloodwork, and within an hour or so my mom got a call to take me to emergency immediately. I was admitted from there and I think my parents spent most of the four days I was admitted learning about diabetes. Plus, I had yearly two-day appointments at the Children’s Hospital for diabetes education stuff, as well as seeing my own doctor every three months.

When I started on a pump, I had an entire afternoon of training at the diabetes clinic and several follow-up calls with the nurse. For each subsequent pumps I’ve received, I’ve had about an hour of training each time and contact with the trainer as-needed.

Insulin is really important and dangerous, not to mention most people don’t know how to give an injection. The idea of just being handed insulin and told to use it with no guidance is crazy! I’m glad you guys got here unscathed!

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This is exactly why every T1 diabetic needs to have ketone testing supplies (or someone who can run and get them quickly if sick). I never test for them when high and just treat the high, but I learned the incredibly hard way that you can be not that high (or high at all) when having a stomach bug and get into severe DKA. I almost died as a result and ended up in the ICU for the better part of the week. Ketones present in that situation do change what you’d do for treatment, since they mean you probably need IV fluids and glucose in order to support more insulin (which at that rate, might as well get by IV too). Glucagon plus insulin might work too.

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I am too. Really, really glad. I often reflect on people who don’t end up on FUD. You can’t best care for yourself (or family) if you don’t have access to education. And I know there’s a huge swath of the American population that doesn’t have access to excellent healthcare (for whatever reason).

And @cardamom - you’re right. The thought of being in a terrible place health-wise, and going it solo, makes it really necessary to have an understanding of what could happen and how to prevent it and when to call it and go in for assistance.

@Chris and @Jen it sounds like there are great educational programs in place where you’re at! That’s cool.

(I’m changing the title of this thread to reflect the discussion about DKA as well…)

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After reading the other responses here, I realized I left out a key piece of “I don’t test for ketones” plan of action. If I am sick enough that I can’t keep down liquids, I recognize that I am NOT able to care for myself - I go to the emergency room.

I am lucky enough to say that degree of sickness hasn’t happened often, and it has been years since it happened last. However, it is a piece of diabetic medical advice that has been given to me since I was first diagnosed, it has never been contradicted in all these years, and it continues to be given to me today by my providers.

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That seems like good advice. I had never heard it when EH was first diagnosed. But I’ve learned it here and keep it in mind. There’s probably been a few sick days with vomiting like that in the past but we didn’t know better. Also fingersticks fall to the wayside when you’re young and puking - so who knows what that BG was back then. Now we know better. We also drink less. Hehe.

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