Ketone Monitoring in Diabetes: Making The Case For When and How to Test

A consensus session at the 2026 Scientific Sessions of the American Diabetes Association (ADA) addressed evolving standards for ketone monitoring in diabetes, emphasizing earlier identification of elevated ketone levels as a primary strategy for diabetic ketoacidosis (DKA) prevention across both type 1 and type 2 diabetes.¹

Viral Shah, MD, Indiana University, presented the session "ADA Evidence Synthesis on Ketone Monitoring and Treatment" in New Orleans, Louisiana.

The session arrives as dual glucose-ketone continuous monitoring technology has received CE mark approval in Europe, with Abbott's FreeStyle Libre Duo among the first such devices, raising expectations for eventual US availability and prompting renewed clinical guidance on monitoring thresholds, education requirements, and patient stratification.

Ketone Monitoring Recommendations and Patient Stratification

The ADA consensus establishes universal diabetes education on ketones as a minimum standard: every individual with diabetes should receive instruction at least once yearly on what ketones are, what elevated levels indicate, and how to manage them at home, with the explicit goal of reducing hospital utilization.¹

“I think we have recognized that DKA is not just the problem in type 1 diabetes. It's also common in type two diabetes,” Shah explained. “If we want to prevent the DKA, we need to think about how we can identify the ketone or the rise in the ketone at an earlier stage so that we can do an intervention and prevent it, and I think that's why here we had a session around how to identify the elevated ketone levels, why to do it early.”

He framed DKA prevention as the field's central priority, noting elevated ketones must be identified early enough to permit outpatient intervention. Beyond universal education, the consensus identifies a higher-risk subgroup for whom a written ketone monitoring plan is recommended. These individuals require a documented protocol specifying when to check ketones, how to check them, and what actions to take when levels are elevated.

The guidance is designed to bridge the gap until continuous ketone monitoring becomes widely available in the US market. Shah noted once dual glucose-ketone devices reach US patients, the monitoring question will be partially resolved by default, as ketone data will be available alongside glucose in real time.

Blood Versus Urine Ketone Testing, Barriers to Capillary Monitoring

Shah addressed why blood ketone testing has not displaced urine testing in routine care despite its known advantages. Urine ketones measure acetoacetate rather than beta-hydroxybutyrate, the primary ketone elevated in DKA, and appear later in the clinical course.¹

Beta-hydroxybutyrate rises first; acetoacetate appears in urine hours afterward, creating a diagnostic lag. The measurement discordance also complicates treatment monitoring: as beta-hydroxybutyrate is successfully converted to acetoacetate during treatment, urine ketone readings can paradoxically increase, potentially misleading patients managing ketosis at home into believing their condition is worsening rather than improving.

Capillary blood ketone testing avoids this problem but faces 3 distinct barriers: cost, access, and education. Test strips can run between $1 and $4 each and expire quickly, making the investment difficult to justify for patients who have never experienced DKA.

"People think, 'I never had a DKA before, why would I buy a machine going to cost me a few hundred dollars and I'm not going to use it?'" Shah said. He acknowledged urine testing will remain a practical necessity in resource-limited settings globally, while continuing to advocate for broader capillary access where feasible.

The convergence of continuous ketone monitoring technology and updated clinical consensus positions the field for a meaningful shift in how ketone elevation is detected and managed. Availability of dual glucose-ketone monitoring in the US will represent a significant inflection point, particularly for the type 1 population and for type 2 patients at elevated DKA risk.¹

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

3. Abbott. Abbott secures CE Mark for world's first dual glucose-ketone sensing technology for people with diabetes. May 27, 2026. Accessed June 6, 2026. https://www.prnewswire.com/news-releases/abbott-secures-ce-mark-for-worlds-first-dual-glucose-ketone-sensing-technology-for-people-with-diabetes-302782795.html