Ketones + Ketoacidosis

High levels of ketones are toxic to the body.
If you’re experiencing these, you should seek out medical attention.


What Are Ketones?

Ketones are chemicals that build up when your body starts to burn fat for energy. The most common cause of ketones in diabetics is insulin deficiency. Without enough insulin, glucose builds up in the blood stream and can’t enter cells. The cells then burn fat instead of glucose. This results in ketones forming in the blood and eventually spilling into urine.


Why Can Ketones Be Dangerous?

Having ketones can indicate that your body needs more insulin. (Always monitor your blood sugar levels to know how much insulin you need.) If you have a build up of ketones, this can lead to Diabetic Ketoacidosis (DKA). Signs of DKA include moderate or large ketones, nausea, vomiting, abdominal pain, fruity or acetone (think nail polish remover) breath, rapid breathing, flushed skin, and lack of energy. If left untreated, it can lead to a serious and life-threatening diabetic coma or death. High levels of ketones are toxic to the body and if you’re experiencing these, you should seek out medical attention.

Symptoms of Ketoacidosis:
Frequent Urination, Frequent Thirst, Blurry Vision
Dry Mouth, and Fatigue


Causes of Ketoacidosis:
Eating Too Much Food Relative to the Amount of
Blockage In Insulin Pump Tubing, Disconnected Insulin
Pump Infusion Set, and Illness or Stress


When Should You Check for Ketones?

You should be checked anytime your blood sugar is above 240 mg/dl (13.3 mmol/l) or any time you are sick. This includes any minor illness such as a cold.


Testing for Ketones

There are two ways to test for ketones: urine testing and blood testing. Just as blood glucose testing proved to be superior to urine glucose testing, so too is blood ketone testing proving to be better than urine ketone testing. Ketones appear first in the blood, then in the urine after being filtered by the kidneys. Thus the body has been producing ketones for a while before you can detect them in the urine. Children with Diabetes® highly recommends blood ketone testing over urine ketone testing.

Since ketones in the blood can be detected well before ketones in the urine, there is the possibility to treat sooner than you would if you waited for urine testing to show a positive result. Blood ketone testing can be easier for parents who have very young children with diabetes who do not always have the ability to urinate on command. Also, being able to test with a finger stick eliminates the need to find a bathroom to test if you’re away from home or when kids are at school.

Whether you choose blood or urine ketone testing, it’s important to keep a fresh stock of test strips on hand at all times. You don’t want to find yourself or your child sick and then discover that you have nothing to check ketones.

(Content / Pricing Needs to be updated) At this time, however, blood ketone testing is more expensive than urine ketone testing. For example, a Precision Xtra® meter costs about $65 in the United States and the ketone test strips cost about $30 for eight, or about $3.75 per test. The NovaMax® Plus meter costs about $60 and a box of 10 ketone strips costs about $25, or about $2.50 per test. (Note that both meters are often heavily discounted.) In contrast, urine test strips can cost as little as 16 cents per strip (vial of 100 Ketostix®) to as much as 40 cents per strip (package of 20 foil wrapped Ketostix®). While sometimes insurance in the US will cover the cost of the blood ketone test strips, they still cost more than urine test strips. Regardless of this additional cost, the clinical benefits described in recent studies still argue for using blood ketone testing.

Precision Xtra® meter NovaMax® Plus meter



Blood Ketone Reading Indications


Above 1.5 mmol/l
Readings above 1.5 mmol/l in the presence of hyperglycemia indicate that you may be at risk for developing
diabetic ketoacidosis (DKA). Contact your healthcare provider immediately for advice.

Readings between 0.6 and 1.5 mmol/l may indicate the development of a problem that may require medical
assistance. Follow your healthcare provider’s instructions.

Below 0.6 mmol/l
Readings below 0.6 mmol/l are in the normal range.

Sources: Documentation from the Precision Xtra® and NovaMax® Plus

Urine Ketone Testing

Urine ketone testing uses urine ketone strips to determine the presence of ketones in the urine. These strips are made by many companies, and some familiar brands are Clinistix®, Ketostix®, and Keto-Diastix®. To use urine ketone strips, you either collect a urine sample and dip the test strip into the urine, or you urinate on the test strip. You then wait a specific amount of time and look for a color change in the strip. The color will indicate the amount of ketones in the urine.

Urine test strips typically expire 90 days after a vial of test strips is opened. For that reason, if you use urine ketone strips, you may wish to consider getting a box of individually foil wrapped ketone test strips. While foil wrapped ketone strips are more expensive per strip than a vial of ketone strips (about 40 cents per strip versus as little as 16 cents per strip for a vial of 100), you will likely throw away less strips due to expiration dates and could save money in the long run. Most pharmacies carry vials of ketone strips, but may need to order a box of foil wrapped strips.

This graphic shows a close up of the color chart used to determine the amount of ketones in the urine for Ketostix, one brand of urine ketone test strips:

mg/dl 5 15 40 80 160

Can You Get Ketones With A High Blood Sugar?

Ketones typically accompany high blood sugar. They indicate that your body needs more insulin. Most often if your body needs more insulin, it means you probably have a high blood sugar. Also, when an illness is present, your body releases hormones in response to the stress. These hormones lead to elevated blood glucose. That is why it’s recommended to test ketone levels during illness.


Can You Get Ketones With A Normal or Low Blood Sugar?

Ketones can also be present when your blood sugar is normal or low. These are sometimes referred to as “starvation ketones” or “nutritional ketones.” During an illness or extreme diet change, if you have a significant decrease in carb intake, this can lead to the body using fat for energy because there are not enough carbs present to burn. Your blood sugar could remain normal or even be low in this case but your body could still be producing ketones.


What Should You Do If You Have Ketones?

It is recommended that you drink 8 ounces of water or carb/caffeine free beverage every 30-60 minutes to help flush out he ketones. Again, ketones are a sign that your body needs more insulin. Some people might already have an insulin dosing plan in place related to ketones. It’s typically a percentage of your daily long-acting dose or percentage of your total daily basal volume (for pump users) based on whether ketones are small, moderate or large. It is always best to call your endocrinologist to
verify what they recommend when ketones are present.


Additional Information

1 The value of 240 mg/dl [13.3 mmol/l] is a frequently used guideline. Your diabetes team might advise you to use a different value.