From Awareness to Action: Structured Ketone Monitoring in Diabetes Care, With Viral Shah, MD

Clinicians broadly understand the importance of ketone monitoring, yet structured action plans remain inconsistently implemented in practice. At the 2026 Scientific Sessions of the American Diabetes Association, Viral Shah, MD, Indiana University, led an evidence synthesis session and presented a 5-step clinical framework designed to close the gap between awareness and actionable bedside guidance, while outlining how continuous ketone monitoring will reshape automated insulin delivery (AID) algorithm design.¹

The session builds on a broader ADA consensus effort to move ketone monitoring from a reactive diabetic ketoacidosis (DKA) response tool to a proactive, structured component of diabetes management, with implications for both clinical algorithms and next-generation device development.

Ketone Action Plan and Threshold-Based Home Management

Shah outlined a 5-step clinical decision framework developed by the ADA Evidence Synthesis team to give clinicians a practical implementation structure. The steps address:

• Identifying which patients should measure ketones
• Specifying the testing modality (capillary, continuous, or urine)
• Defining threshold-based action zones
• Determining whether home management is appropriate
• Executing a structured home treatment protocol to prevent DKA progression.

Ketone thresholds were assigned evidence-based designations. Levels < 0.6 mmol/L are considered normal. The range of 0.6 to 1.5 mmol/L represents an elevated but lower-urgency zone requiring increased monitoring. Levels from 1.5 to 3.0 mmol/L are concerning and warrant active intervention to prevent further rise. Values exceeding 3.0 mmol/L indicate progression toward DKA.

Shah emphasized the majority of elevated ketone episodes are manageable at home when patients are properly educated and empowered, and the consensus document lays out specific home management principles aimed at reducing hospitalizations by intervening before the yellow-to-red transition occurs.¹

Glucose-Ketone Dissociation and AID System Integration

Shah addressed a significant shift in the field's mechanistic understanding: the assumption glucose must rise before ketones does not hold across all patients. A recent publication in Diabetes Technology and Therapeutics demonstrated 3 distinct dissociation patterns among insulin-treated individuals with diabetes: ketones rising before glucose, simultaneous rises, and glucose preceding ketones.¹ This means a patient can develop clinically significant ketosis at glucose levels of 150 to 200 mg/dL, well below the thresholds historically associated with DKA risk.

Shah noted the euglycemic DKA entity, recognized in SGLT2 inhibitor use and pregnancy, represents one end of this spectrum, but dissociation occurs more broadly than those contexts alone.

"It's not that someone has to have a blood sugar of 300 to develop ketosis," he said. The implication for practice is direct: glucose monitoring alone provides an incomplete metabolic picture, and ketone data should be considered a parallel vital marker rather than a downstream indicator.

Regarding device integration, Shah noted pump manufacturers have already announced partnerships with Abbott in anticipation of US continuous ketone monitor availability, with the stated goal of incorporating real-time ketone data into AID algorithms.¹ Specific applications include refining insulin suspension logic to prevent prolonged interruptions capable of driving ketone accumulation.

He said the algorithmic details will largely remain proprietary, but expressed confidence the field is moving toward individualized insulin delivery informed by both glucose and ketone inputs in real time.

Editors’ note: Shah reports relevant disclosures with Sanofi, Novo Nordisk, Lilly, Dexcom, Insulet, Tandem Diabetes Care, Medtronic, Sequel Med Tech, Abbott Diabetes, Roche, Biomea Fusion, and T1D Scout.

References

1. Shah V. ADA evidence synthesis on ketone monitoring and treatment. Presented at: American Diabetes Association 2026 Scientific Sessions; June 6, 2026; New Orleans, LA.

2. American Diabetes Association. Standards of care in diabetes. Diabetes Care. 2026. https://professional.diabetes.org/standards-of-care