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March 14, 2008

Hyperglycemia and DKA, Other

Question from Denver, Colorado, USA:

My 12-year-old daughter has had type 1 for seven years. Her A1c is consistently under 7%. She uses a pump and has been using a CGM for six months as part of a study. She is 4 feet, 11 inches and weighs 85 pounds. Overall, she is very healthy and has very good control. We have always tested for ketones if she is high or sick. Moderate to large ketones were usually present with illnesses only. Recently, however, she has moderate to large ketones (we usually test with urine strips and will verify with blood strips, if present) with the occasional high. I am certain she is not skipping boluses. The random highs are likely an imperfect carbohydrate count (I still do most carbohydrate counting). In the past, if she were high after a meal, we corrected and she was back to normal within a couple hours. Now, about half the time she’s running high, she also has ketones. We give extra insulin, extra fluids, and recheck for ketones a couple hours later, and the ketones are usually gone. I’m wondering if having ketones once or twice a week is a concern for her long term health/complications. Since it is inconsistent (and not the norm), it doesn’t seem like a basal/bolus issue or a sensitivity/correction issue. What do you think is going on?


From: DTeam Staff

Ketones are caused by either lack of insulin — or occasionally, dehydration alone. I typically encourage my patients to check for ketones if they have two unexpected high blood sugars, during the course of any illness, vomit even once, or have abdominal pain. I also encourage them to notify me if those ketones are moderate or large (dark purple on the ketone test strip). Your daughter’s ketones may be due to one of the above reasons. I would encourage you to review her insulin dosing carefully to ensure she is receiving adequate dosing of insulin. I would also encourage you to make sure she stays well hydrated. Both of these will help to avoid ketones in the future, hopefully.