Ketone education: it won’t change your A1C, but it Can save your life!
Fundamentals are key to avoiding DKA and are of key importance in pump therapy.
A recent study published in Pediatric Diabetes, out of Sweden, found that rates of DKA were higher in children and adolescents with type 1 diabetes. This may strike some of us as another study of the obvious since the risk factor that rises most with pump therapy is DKA risk. However, it does point to the importance of DKA prevention and pump troubleshooting in preventing DKA overall.
I cannot tell you how many times I talk to a patient or other PWD who has had diabetes for years only to find that they don’t even know what ketones are and have never had supplies to test for them, or had supplies that expired and were never replaced due to disuse. First, we must have supplies to check for ketones, urine dipstick ketone measurement is widely available. There are also blood-based ketone meters that work just like glucometers. When purchasing these be sure that they give ranges for diabetes ketones rather than dietary ketones as the ranges may be different.
DKA (Diabetic ketoacidosis) rests on a three-legged stool: hydration, insulin delivery, physical stress
When one of those legs is weakened our ketone production and retention increases. Without proper hydration our insulin does not properly circulate into the blood stream and ketones can not be urinated out. Without sufficient insulin delivery our body produced ketones (The product of fat metabolism that leads to DKA) this can be caused by not elevating basal insulin on sick days, reducing insulin on sick days, or too low for too long during high-intensity activity, or by non-delivery or disconnection from an insulin pump. And finally physical stress itself. High physical stress and illness (the definition of physical stress) all increase ketone production. When these factors combine it is a life-threatening mix.
When we use long-acting insulin DKA risk on a typical day is very low because the insulin gets in reliably for a prolonged period, if a dose is not missed risk is minimized. However sick days, periods of reduced insulin needs and intense physical activity, dehydration or tissue damage at the injection site can all increase risks of DKA even for patient on injection therapy.
When using an insulin pump it is important to be area of the use of ketone testing to troubleshoot pump issues. Because we are not using long-acting insulin in pumps we are on the ketone clock. If we go more than a few hours without insulin delivery we can build up ketones, and this can happen rapidly. Being sure to properly fill and prime a pump to avoid gaps in insulin delivery, practicing safe disconnection time, and to check for ketones at the time of any unexpected severe high blood sugar are al key troubleshooting skills to prevent DKA with pump use.
This is why, at IDS we specifically educate our patients on DKA. We teach the physiology of what DKA is, how to treat elevated ketones effectively, pump troubleshooting, sick day management and when to seek medical attention for elevated ketones.
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