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Implications of Continuous Ketone Monitoring in Clinical Practice
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- In this review, the authors focus on the potential of continuous ketone monitors to minimize the risk of diabetic ketoacidosis (DKA). They discuss current approaches to diagnosing DKA, such as urine and blood testing, and the strategies for its prevention and management. Additionally, they explore the characteristics of an ideal ketone monitor — a device that would provide continuous, accurate, and real-time ketone-level readings — and how it could address the limitations associated with urine, capillary blood, and breath testing. The authors also discuss how to interpret continuous ketone monitoring information and which populations would benefit from these devices. They further examine the potential of continuous ketone monitoring as a diagnostic tool and its role in hospital settings.
- Overall, the authors present an intriguing device that could become a part of routine care, especially for individuals with type 1 diabetes. Further research is needed to determine the best ways for users to respond to continuous ketone monitoring information and to assess the impact of continuous ketone monitor use on DKA-related hospitalizations.
abstract
This abstract is available on the publisher's site.
Access this abstract nowDiabetic ketoacidosis (DKA) is a life-threatening complication usually affecting people with type 1 diabetes (T1D) and, less commonly, people with type 2 diabetes. Early identification of ketosis is a cornerstone in DKA prevention and management. Current methods for ketone measurement by people with diabetes include capillary blood or urine testing. These approaches have limitations, including the need to carry testing strips that have a limited shelf life and a requirement for the user to initiate a test. Recent studies have shown the feasibility of continuous ketone monitoring (CKM) via interstitial fluid with a sensor inserted subcutaneously employing an enzymatic electrochemical reaction. Ketone readings can be updated every 5 minutes. In the future, one would expect that commercialized devices will incorporate alarms linked with standardized thresholds and trend arrows. Ideally, to minimize the burden on users, CKM functionality should be integrated with other devices used to implement glucose management, including continuous glucose monitors and insulin pumps. We suggest CKM provision to all at risk of DKA and recommend that the devices should be worn continuously. Those who may particularly benefit are individuals who have T1D, are pregnant, on medications such as sodium-glucose linked transporter (SGLT) inhibitors that increase DKA, people with recurrent DKA, those with T1D undertaking high intensity exercise, are socially or geographically isolated, or those on low carbohydrate diets. The provision of ketone profiles will provide important clinical insights that have previously been unavailable to people living with diabetes and their healthcare professionals.
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Continuous ketone monitoring: Exciting implications for clinical practice
Diabetes Obes Metab 2024 Sep 24;[EPub Ahead of Print], YW Kong, D Morrison, JC Lu, MH Lee, AJ Jenkins, DN O'NealFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Continuous Ketone Monitors: A Potential Airbag for Individuals with Diabetes
Diabetic ketoacidosis (DKA) is a serious acute complication that can be life-threatening for individuals who are insulin-dependent. Despite advancements in treatments and advanced diabetes technologies, epidemiological studies have shown that the incidence of DKA is on the rise. A critical factor in preventing worsening metabolic decompensation is the timely measurement of ketone levels. Yet, it is well recognized that many individuals living with diabetes often neglect to measure their ketone levels.1,2
Building on the concept of continuous glucose monitoring (CGM), enzymatic reactions that quantify beta-hydroxybutyrate levels in the interstitial fluid could provide a window into an individual’s physiology. With the potential for passive data collection, the burden of remembering to measure ketone levels could be alleviated. A small study has shown the feasibility of this approach.3
Based on experiences with CGM, a more strategic approach to integrating continuous ketone monitors (CKM) into clinical care can be considered based on the differences in the analytes being measured. In a special issue of Diabetes Obesity and Metabolism, Kong et al highlight some of these factors in their article entitled “Continuous ketone monitoring: exciting implications for clinical practice.”4 Rather than the wealth of real-time glucose data that is crucial for decision-making and incorporation into algorithmically modulated insulin delivery, CKM data would only be meaningful if pre-specified thresholds are breached. Although the authors suggest the use of trend arrows, one could speculate that such a feature could be toggled on or off, thereby allowing for personalization of the data received. Individuals with recurrent DKA may already be struggling with healthcare engagement, and more is not always better.
CKM could also provide individuals with type 1 diabetes access to adjunctive insulin agents, like sodium-glucose co-transporters. As regulatory approval has expanded to individuals without diabetes who have chronic kidney disease and/or heart failure, now is the time to expand the arsenal of tools to those with type 1 diabetes. Yet, given the increased risk of DKA associated with these agents, CKM could be the safety net needed.
The authors have provided a mockup of how data from a CKM could be viewed on retrospective reports, aligning these reports with the current color schemes and standards used for CGM. This approach may allow for more rapid adoption by clinicians, as data interpretation may seem less onerous. In addition to the proposed ambulatory ketone profile, which includes 14 days of data overlaid on a 24-hour cycle, assessing a 2-week period that shows the time spent in various “ranges” on an individual day may help clinicians hone in on specific days with elevated ketone levels and discuss factors that may have led to ketone detection (an infusion set failure, insulin omission, etc), similar to how current reports help with meal-time excursions.
With any new technology or treatment, the question of cost will be raised. However, to appropriately assess cost, one must consider the utilization of emergency rooms and hospital admissions, including intensive care units. Recurrent rates of DKA are known to occur in certain populations; prioritizing access to CKM for these individuals would undoubtedly be a financially sound decision.
Continuous glucose monitoring and automated insulin delivery have revolutionized the care of individuals with diabetes. The former allows for the detection of patterns, while the latter alters the trajectory of glucose levels. Years ago, diabetes technologies were compared to self-driving cars. As the authors rightly point out, CKM is similar to an airbag for folks with diabetes; you hope you don’t need it, but it can be lifesaving. Personally, I can’t wait for the day when these technologies are fully integrated into clinical care.
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