The increasing use of technology for treating type 1 diabetes (T1D) has improved glycemic control; however, it hasn’t eliminated the risk for diabetic ketoacidosis (DKA). In fact, without early recognition, insulin pump malfunctions can directly lead to DKA. Currently, patients test ketones at home using urine test strips that measure acetoacetate (the primary ketone body) and fingerstick blood monitors that measure beta-hydroxybutyrate (BHB, the primary circulating ketone body).
A wearable device that continuously measures interstitial BHB levels, similar to how continuous glucose monitors (CGMs) track glucose, has been shown as feasible and offers the potential for preventing DKA.
Abbott Diabetes Care is currently developing a two-in-one wearable sensor that combines CGM and continuous ketone monitoring (CKM).
At the recent Advanced Technologies & Treatments for Diabetes (ATTD) 2025 meeting, two endocrinologists who live with T1D themselves debated whether CKM is an “unmet need” in managing T1D. Taking the pro side was Jennifer Sherr, MD, PhD, professor of pediatrics and medical director of Pediatric Diabetes at Yale School of Medicine, New Haven, Connecticut. Arguing against was Steven Edelman, MD, clinical professor of Medicine at the University of California, San Diego.
Yes, Continuous Ketone Monitoring Is Needed to Prevent DKA
Sherr began by noting that frequent ketone monitoring is a key component of both pediatric and adult sick day guidelines.
In surveys of 2995 children and adults with T1D, more than half of children younger than 13 years reported checking ketones during illness with vomiting — presumably because their parents are involved — whereas 50% of the adults reported “never” checking for ketones during vomiting illness.
Similarly, when blood glucose levels were above 300 mg/dL, more than half of adults older than 26 years reported “never” checking ketones, whereas adherence was again better in the children.
And in another survey of 333 adults with T1D in Switzerland and Germany, one third weren’t familiar with the term “DKA,” and two thirds reported never testing ketones.
“If people aren’t testing, how can we avoid DKA?” Sherr asked.
There are several barriers to current ketone testing methods. With the increased use of CGMs and automated insulin delivery, people today are less likely to carry around backup glucose meters and are more resistant to performing fingerstick tests, Sherr said.
Urine ketone strips may be less burdensome, but humidity can affect their accuracy. Cost can also be a barrier, particularly for a supply that the person might think they’ll never use. And, when someone is sick, it may be difficult to remember previous instructions for testing, she noted.
Sherr advised clinicians to always ask patients if they’ve had ketones since their last visit, whether they have strips at home, and to remind them of sick day precautions, including a way to contact staff in the event of an emergency.
This is increasingly important with the use of insulin pumps and automated insulin delivery (AID) systems, which can malfunction. “Insulin infusion sets are the Achilles heel of any subcutaneous insulin delivery device. As we see greater integration of AID, the problem is going to continue to grow,” Sherr said.
Considering these factors, there are “clear-cut” benefits to CKM, including passive data collection to guide clinical care and its use as a safety net for people with repeated DKA episodes. The devices could also help to establish equity in recommended treatments by giving providers more confidence to prescribe technologies to all.
In addition, she said CKM could allow for safer integration of sodium-glucose cotransporter 2 inhibitors into T1D management, currently limited in part due to the DKA risk.
Thresholds for intervention haven’t been established, but the pediatric guidelines suggest a level > 3.0 mmol/L (“large” in urine ketones) would be pragmatic. That could also be used as the threshold for an alarm to avoid alarm fatigue, she said.
As for the cost, she pointed to a study showing that BHB blood ketone monitoring reduced DKA hospital admissions. “I can imagine the same will hold true here, with decreased cost to the healthcare system overall and…increased productivity” with fewer missed work and school days.
“An ounce of prevention is worth a pound of cure,” Sherr concluded.
No, Continuous Ketone Monitoring Isn’t Necessary
Edelman stated he “wholeheartedly” supports the development of CKM, but it does not reach the level of “a real unmet need.” He also pointed out that his viewpoint as an adult endocrinologist shapes his perspective, contrasting that of Sherr, who approaches the issue from a pediatric provider’s standpoint.
He cited a 2024 article titled Unmet needs in the treatment of type 1 diabetes: Why is it so difficult to achieve an improvement in metabolic control? “In this entire well-written article by some excellent diabetes investigators and clinicians, DKA is rarely mentioned,” he noted. In fact, it was only mentioned twice, and neither with a recommendation for ketone testing.
Accurate fingerstick ketone monitors that measure both BHB and glucose are currently available and can be used as backup when CGMs fails. “What’s obvious to me is we underuse them. I think every patient should carry a meter that measures beta-hydroxybutyrate and glucose. We have this technology here now,” Edelman said.
Moreover, CGM itself is effective in reducing DKA. In an administrative database study Edelman co-authored, lowering the glycated hemoglobin from above 11% to less than 8% in adults with T1D led to a 12-fold reduction in DKA incidence. At the time of that study, in 2019, only a minority were using CGMs, he noted.
Today, he said, “CGM is the backbone of hybrid closed-loop AID systems, and they have also been shown to reduce DKA. CGM allows for an efficient and focused way to identify and treat problems with glycemic control and to identify patients who may be at risk for DKA.”
Another study showed a significant drop — greater than 50% — in hospital admissions for DKA and diabetes-related coma in T1D and type 2 diabetes with the introduction of flash glucose monitoring in France.
Similar results were seen in two pediatric studies of CGMs, one showing a 53.2% reduction in DKA and the other a 45% reduction. “So, CGM is an excellent tool to reduce DKA,” Edelman said.
Previous data suggest that about 12% of DKA admissions are for “repeat offenders” who return to DKA multiple times, often due to psychosocial or adherence problems. “I think it’s fair to say that these folks aren’t wearing CGMs. They’re not following sick day rules. They haven’t been educated, and they haven’t been motivated. CKM is not going to be worn by these folks, in general,” he said.
Indeed, there are social determinants of DKA, particularly in indigent populations. “What these folks need are the basics: access to insulin, supplies, healthcare providers who know something about diabetes, diabetes technology. These…have not been out there for a lot of groups that are just not served very well.”
There’s also the potential for CKM to add to “diabetes distress” with added alerts, alarms, and trend arrows. “This is not a reason not to develop CKM. It’s just another area where we’re going to have to focus on education.”
“CKM may be ‘overkill’ for the majority of people with T1D,” Edelman concluded.
Sherr has received research contracts, does consulting for, and/or serves on advisory boards for Abbott Diabetes, Breakthrough T1D, Dexcom, Insulet, Medtronic, National Institutes of Health, Provention Bio, Ypsomed, Vertex, Cecelia Health, Mannkind, Medtronic Diabetes, StartUp Health, and Diabetes Moonshot. Edelman serves on the board of directors of Senseonics.
Miriam E. Tucker is a freelance journalist based in the Washington, DC area. She is a regular contributor to Medscape Medical News, with other work appearing in The Washington Post, NPR’s Shots blog, and Diatribe. She is on X @MiriamETucker and BlueSky @miriametucker.bsky.social.
