Diabetes Management: Effects of Persistent Ketosis
As I have stated on multiple occasions, ketones are not your friends. They are the portents of bad things to come… the persistence of ketones affects your diabetes. As always, a review of biology/biochemistry is a must when we talk about ketones. Ketones result when the body breaks down fat for energy. They are the breakdown products of fatty acids and accumulate in the blood. Ketosis (or accumulation of ketones) occurs when the body is unable to use the more efficient pathway to metabolize glucose and provide energy. Much more energy (ATP) is produced via glycolysis (pathway in which glucose is broken down into energy), However, if insulin is not available to move glucose from the blood into the cells, the glycolysis pathway becomes blocked and the body finds other, less efficient ways to produce energy by breaking down fat and muscle.
Think back when you were first diagnosed with type 1 diabetes. Many kids and teens had symptoms of increased urination, drinking, and weight loss. Why? The pancreatic beta cells cannot keep up with insulin production due to destruction. As a result, fat and muscle is broken down for energy. You lose weight, the glucose remains in the blood and can’t get into the cells. Because so much concentrated glucose is in the blood, you become thirsty and drink large amounts of fluid. As a result of the increased drinking, you begin to urinate more frequently and the cycle continues until either insulin is received or you develop diabetic ketoacidosis. We have discussed Diabetic ketoacidosis, where large amounts of ketones result in a very acidic environment in the blood. The low serum pH (acid) causes mental status changes (lethargy, coma, etc.) and becomes life threatening if not treated with fluids and insulin.
You already know that you are at increased risk of developing ketones when you are ill. What about the persistence of ketones if you are not managing your diabetes appropriately? How does the presence of ketones affect you in the long run? I am amazed at the number of kids and teens that have high blood sugars that manage to stay out of the hospital. We are talking about average blood sugars in the 300s and 400s with hemoglobin A1c’s > than 12. What happens in the short and long run to those who have high blood sugars consistently and persistent ketosis, if they check either urine or blood ketones. (A word about checking ketones: the most ideal way to determine presence of ketones is through the use of the Precision Extra monitor that checks for ketones via capillary blood. We use this monitor for all patients that employ basal bolus therapy with either the insulin pump or multiple injections with Lantus/Levemir.) The big problem here is that kids with extremely high blood sugars often walk around with small-large ketones. Often, the only way I find this out is by smelling the breath of my patients upon examination (smells like nail-polish remover-acetone). This is called “ketosis.” Ketoacidosis occurs when the balance tips causing the blood to become acidic. Any inciting factor can cause this to happen because the situation is not stable. Thus, in terms of short term problems, the person with insulin-dependant diabetes that walks around with persistent ketosis is in danger of tipping over into DKA and requiring an intensive care unit hospitalization. In addition, it is much harder to determine an appropriate insulin dose due to the insulin resistance that occurs with persistent ketosis (because of ketones in the blood stream, insulin is not as effective as it would normally be and larger amounts need to be administered). Increased fluids are also necessary to eliminate ketones. Concentration in school and athletic performance also is compromised due to high blood sugars and ketones. There are more lost school days as a result of ketones because you are sent home to clear them.
What about long term concerns? High blood sugars and ketones accelerate complications related to diabetes as it is much more difficult for the diabetes team to manage insulin and related therapy. As a result of lost glucose in the urine, you may not achieve your ideal height. If you are a woman and choose to have a family in the future, it will also be much harder to achieve the tight diabetes control that is necessary to have a healthy baby (and healthy mother). Ketones make everything more difficult to manage.
The key point to remember is that ketones develop when there is a mismatch between glucose and insulin; lack of insulin results in ketone production, which causes increased difficulty in stabilizing blood sugars and managing diabetes. It is important to break this cyclical pattern to achieve the best possible diabetes control.
Guidelines for Treatment of Ketones (as recommended by Children’s National Medical Center):
Have available equipment: urine ketostix (we recommend individually foil wrapped strips) or Precision extra meter for blood ketone testing (strips that test for B-hydroxybuterate)
Increase ingestion of sugar free fluids (water, diet soda, etc.) Suggest 8 oz. every hour
Additional insulin administration depends on the type of insulin regime:
a. Traditional NPH/Regular/rapid acting insulin (2 or 3 injections)/day: if blood sugar is >/= 250 mg/dl and if ketones are >/=moderate, suggest administering ~20% of total daily dose as regular or rapid acting insulin. May repeat in 3-4 hours if ketones remain moderate or large.
b. Basal/bolus therapy: if ketones are >/=moderate, use correction factor plus 20% extra as rapid acting insulin. Give via injection if on an insulin pump for safety purposes and change catheter site.
c. Be careful if blood sugar is /=moderate. You still require extra insulin but will need to raise blood sugar with glucose in order to safely give the insulin (and avoid a low).
If vomiting occurs and you are unable to keep fluids down, IV fluid administration is advisable. This means a trip to the emergency department.
Observe for signs of dehydration (decreased urination, decreased tears, dry mucous membranes). This also means a trip to the emergency department for IV fluids.
Don’t wait too long or Diabetic ketoacidosis may develop.
Please call your diabetes team for specific recommendations that may be unique to your institution.
Fran Cogen, M.D., C.D.E., is the director of the Childhood and Adolescent Diabetes Program at Children’s National Health System. She wrote about diabetes for HealthCentral.