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Figure 4 . In ketosis-prone states ( for example , fasting , low-carb diets , pregnancy , SGLT2 inhibition ) the liver generates ketones from fatty acids to feed energy-hungry organs and preserve glucose availability for the brain .

The anion gap is calculated using the formula ([ Na +] + [ K +]) − ([ Cl− ] + [ HCO3− ]).

TREATMENT

DIABETIC ketoacidosis is a serious illness and needs to be treated in hospital , without delay . Where possible , urgently transfer all patients with suspected ketoacidosis to an appropriate ED / hospital . The RACGP recommends that all practices have an established emergency action plan for DKA , as they do for myocardial infarction or an acute abdomen . 19

Once in emergency care , patients with DKA will generally receive aggressive crystalloid fluid replacement in combination with an infusion of fast-acting insulin to bring the glucose and ketone levels down and to correct acidosis . In EKA , fluid replacement and insulin are supported by IV dextrose . In some cases , patients require ICU / HDU admission .

MONITORING KETONES

KETOACIDOSIS cannot be detected by glucose monitoring alone . The RACGP and Australian Diabetes Society recommend that if individuals with type 1 diabetes become sick or experience very high blood glucose concentrations ( defined as capillary blood glucose persistently greater than 5mmol / L for more than 8 – 12 hours ), they should undertake self-measurement of ketones ( see figures 7 and 8 ) with a course of predetermined actions directed by the results ( for example , OzDAFNE Ketones and Illness Guidelines ; see table 1 ). 19

Table 1 . Action plan for the management of ketonaemia in unwell individuals with type 1 diabetes Blood ketone level Urine ketone level What does it mean ?

Over 3.0mmol / L Large DKA likely : seek urgent medical attention

Modified from OzDAFNE Ketones and Illness Guidelines 21

Emerging modern technology has recently produced several straightforward methods to measure blood ketone levels on capillary blood samples ( for example , on finger prick samples ). Blood ketone strips that work in a similar fashion to a normal glucose strip also work with some glucose monitoring devices , although the majority of devices are glucose only .

Urinary ketone dipsticks are also widely accessible from pharmacies ; however , these are less sensitive and specific than blood ketone measurement . In addition , breath ketone analysers ( that measure breath acetone ) have become available ( largely to optimise ketogenic diets ). These devices appear less reliable , are not quantitative of ketonaemia , and are not recommended for the management of diabetes .

Self-monitoring of blood ketone levels is not recommended in patients with type 2 diabetes , those receiving SGLT2 inhibitors , or in non-diabetic individuals , including pregnant women .

PREVENTION OF KETOACIDOSIS

ROUTINELY educate all patients with type 1 diabetes , and those with type 2 diabetes on SGLT2 inhibitors , about ketoacidosis . Ensure that all patients have a clear understanding of ketoacidosis ’ common precipitating causes , how to mitigate these risks , how to promptly recognise the signs and symptoms of DKA , and the potential seriousness of non-adherence ( for example , stopping insulin or decreasing the dose excessively ).

Remind all patients with type 1 diabetes , and those with type 2 diabetes on SGLT2 inhibitors , of the potential dangers of prolonged fasting and very low-carbohydrate or ketogenic diets . Take particular care in establishing a clear plan for ‘ sick days ’ for all people with type 1 diabetes , which includes appropriate adjustment of insulin dosage and self-measurement of capillary blood ketones .

Ensure all patients with type 2 diabetes have a practical ‘ sick day ’ plan which identifies therapy that should be paused if they become unwell ( SADMANS-DOG rules , see table 2 ).

SADMANS-DOG lists several classes of drugs that should be temporarily stopped in conditions that could lead to complications . Once the person is feeling better and able to eat and drink for 24 – 48 hours , these medications can be restarted . As part of this plan , provide specific education to those taking SGLT2 inhibitors ; these patients require information and education about when treatment with SGLT2 inhibitors should be temporally paused ( see box 3 ). 22

It is generally recommended that people with type 2 diabetes who develop EKA while taking an SGLT2 inhibitor , should not be prescribed further therapy with any SGLT2 inhibitor . 23 Although the trigger event may have dissipated , individuals who develop EKA while taking an SGLT2 inhibitor should be considered ‘ ketosis prone ’. Mitigation with appropriate ketone monitoring has been suggested as an alternative , but the safety of this strategy has not been tested .

PROGNOSIS OF KETOACIDOSIS IN ADULTS

WITHOUT prompt diagnosis and treatment , DKA is a potentially life-threatening disorder in adults with type 1 diabetes . Most adults respond rapidly to emergency