Stay Healthy this Flu Season: Treating Ketones with T1D

‍Editor’s Note: The information provided here is for information purposes only. It’s important to speak with your diabetes care team to determine a safe way to treat ketones with diabetes.

While hypoglycemia (low blood sugar) is a serious consequence of too much insulin in the blood, hyperglycemia (high blood sugar level) is also a complication with dangerous levels of ketones, where insulin is needed to bring blood glucose levels down safely, and medical attention may be required.

What You Need to Know about Ketones

Upon diagnosis of type 1 diabetes (T1D), patients should receive an individualized diabetes management plan that includes instructions for premeal insulin bolusing and correction bolusing, as well as knowledge on how exercise, stress, and sickness affect blood sugar levels. T1Ds also need guidance on sick days and information about ketones.

What are Ketones?

Ketones are chemicals the body produces when there is insufficient glucose for energy. This can happen during fasting, an intense workout, or by consuming a very low-carb diet. They most frequently happen when your body is fighting off an illness.

Glucose levels can spike due to a number of reasons: 

• Hormones
• Stress
• Dehydration
• Reduced food and drink
• Certain medications and antibiotics

Interesting Fact: When blood sugar levels remain elevated over time, it can trigger large ketone production, even if you don’t have diabetes!

Most importantly, high ketone levels can be toxic.

How Ketones are Made

Without adequate insulin, the body begins to break down fat as fuel, causing a buildup of acids called ketones in the bloodstream. When blood sugar levels exceed safe levels, ketones may develop, causing a severe diabetes complication called diabetic ketoacidosis (DKA), which is left untreated can lead to coma or death.

Warning Signs of DKA

Signs of DKA often coincide with type 1 diabetes early symptoms.

• Frequent urination 
• Excessive thirst 
• Blurred vision
• Nausea, vomiting and stomach pain
• Confusion and lethargy
• Deep, rapid breathing 
• Fruity-smelling breath 

Interesting Fact: The acetone found in nail polish remover is also a type of ketone and has the same fruity smell. If someone's breath smells of acetone, they could have elevated ketones in their blood.

Causes of Ketones

Illness

Sometimes, a sickness or infection can create large ketones in the body. When ill, the body may need more insulin to manage ketone buildup.

Patients may also have a decreased appetite, as less glucose is available for energy.

Stress

Stress hormones can also impair insulin effectiveness, creating ketones.

Lack of Insulin Therapy

Even missed insulin doses can contribute to ketones, whether the insulin therapy is multiple daily injections or via an insulin pump. If the pump malfunctions with a tubing or distribution issue, these problems can lead to low insulin delivery and high ketone buildup in the blood stream. 

Treatment and Prevention for Ketones

Prevention

As high levels of ketones can make the blood acidic, here are the best ways to prevent ketones and DKA:

• Manage your diabetes with healthy food and exercise routines, and follow your doctor’s insulin regime.
• Monitor blood sugar levels often by checking and evaluating your glucose levels. Recording how meals and physical activity affect blood sugar levels is a good idea.
• Meet with your physician several times a year to evaluate your A1c and time spent in the target range. Read for "8 Tips for Better Time in Range."
• Work with your diabetes care team to adjust your insulin requirements as needed.
• Check for ketones when sick or stressed, and watch for the warning signs.
• Seek immediate medical attention if you suspect DKA.

Ketone Testing

Unfortunately, ketones are inevitable with diabetes; as impossible as it is to stay healthy 100% of the time, ketones are part of the diabetes baggage.

After staying healthy, the best way to cure ketones is to monitor and test for them. Ketones should be monitored when blood sugar levels remain high, especially during illness or extreme stress.

Consult your diabetes team on how often to test and how much insulin to administer as they vary from person to person.

There are two ways to test for ketones. Both ways require ketone test strips.

Urine Ketone Testing

After catching urine midstream into a cup, dip the ketone strip into the urine and hold it for 30 seconds. The ketone strips are color-coded, with elevated, high, medium and low levels. Urine ketone test kits can be purchased at a drugstore.

Blood Ketone Testing

A more convenient way to test for ketones without having to urinate is with a blood ketone test kit. This method uses a ketone meter (similar to a blood glucose meter) where the patient draws a drop of blood onto the ketone strip.

Treatment for Ketones

Whatever level of ketones you have, contact your doctor immediately and be prepared to act quickly.

Elevated ketones can rapidly lead to DKA, and you should seek emergency care if you have any early symptoms.

Treatment with Insulin

When an individual has high levels of ketones, insulin therapy is typically given through an IV, subcutaneous shot, or insulin pump.

Important Tip: You can over-correct for ketones with too much insulin, resulting in a life-threatening hypoglycemic episode, which is why it’s imperative to have a doctor’s guidance. Adjusting sugar levels too quickly can cause the brain to swell (cerebral edema). Equally important, have a trained team guide your insulin dosage, especially if you live alone. Someone must be aware of your situation and call 911 if necessary.

Treating with Fluids

Fluids can help flush high ketones out of your system. However, this can be challenging when you’re vomiting with abdominal pain and can’t keep liquids down.

Additional Electrolytes

Rebalancing and replacing lost minerals in the blood stream (sodium, potassium, calcium, magnesium, and chloride) is essential when you have ketones. Electrolytes provide important muscle, nerve and heart function. They also help keep blood pressure stable and move nutrients to the cells.

Monitor your blood sugar levels frequently. Even if you get a ‘normal’ ketone level – you could still have ketones.

Important Tip: When traveling with T1D, in addition to your typical diabetes supplies (pump, CGM, blood glucose test strips, etc.), it’s a good idea to bring ketone test kits and whatever else your diabetes team suggests. Check out our 8 Tips for Traveling with T1D.

What is a Ketonic Diet?

A person on a ketonic diet limits carbohydrates as a fuel source, resulting in a metabolic state called ketosis. In some cases, low carbohydrate diets that encourage ketone production are used to treat neurological disorders and aid in weight loss. However, there may be some complications and cellular damage as a result.

The National Institutes of Health (NIH) reports hyperketonemia is a condition caused by the accumulation of circulating ketones. “Complications of the brain, kidney, liver, and microvasculature were found to be elevated in diabetic patients who had elevated ketones compared to those diabetics with normal ketone levels.”

Final Thoughts

The more you know, the better equipped you are to handle urgent situations. Dangerous levels of ketones can quickly turn into a medical emergency. So, to avoid a trip to the ER, you should try to get them down safely with your doctor's instructions. Stay healthy and safe this flu season!