Podcast Summary: Diabetes Core Update

Special Edition – Continuous Ketone Monitoring

Date: April 7, 2026
Host: Dr. Neal Skolnik, American Diabetes Association
Guest: Dr. Guillermo Umpierrez, Emory University School of Medicine

Episode Overview

This special episode explores the emerging technology of continuous ketone monitoring (CKM) and its transformative potential for diabetes care, especially in preventing and managing diabetic ketoacidosis (DKA). Dr. Neal Skolnik is joined by Dr. Guillermo Umpierrez, a leading endocrinologist and expert on hyperglycemic crises, to discuss the clinical need for CKM, its role alongside continuous glucose monitoring, and practical implementation in high-risk diabetes populations. The episode also addresses the pathophysiology and diagnosis of DKA, rising trends in its incidence, and the characteristics of next-generation devices currently under FDA review.

Key Topics & Discussion Highlights

1. Why Continuous Ketone Monitoring?

[02:45]

• CKM enables real-time tracking of both glucose and ketone levels.
• Early ketone detection is crucial to identify and prevent severe DKA, which remains the leading cause of mortality in adolescents and young adults with type 1 diabetes.
• Particularly relevant for:
  • Type 1 diabetes (especially with poor control or during pregnancy)
  • Patients using SGLT2 inhibitors (both type 1 and type 2 diabetes)
• Dr. Umpierrez:

  "CKM allows real-time tracking of blood glucose and ketone levels... It helps you to detect the risk of diabetic ketoacidosis and prevent severe DKA." (02:45)

2. Rising Prevalence and Challenge of DKA

[03:48]

• Despite advances in diabetes care, DKA admissions are increasing, both in the US (~225,000/year) and globally.

• Many milder cases go unreported/admitted.

• Clinical need for better prevention tools is urgent.

  "Despite all the advances in monitoring and treatment, we still have numbers that are absolutely unacceptable." (04:12)

3. DKA Pathophysiology and Diagnosis

[05:12]

• DKA is mainly caused by insulin deficiency, leads to high glucose and alternative fuel production (ketones).
• Classic presentation:
  • Hyperglycemia (typically 600–700 mg/dL)
  • Polyuria, polydipsia, dehydration, nausea, vomiting, abdominal pain
  • Can progress to altered mental status/coma

Early Recognition

• Not all DKA presents with severe hyperglycemia, especially with SGLT2 use or tight glucose management.

• DKA diagnosis:

  • Hyperglycemia (>200 mg/dL)
  • Elevated beta-hydroxybutyrate (>3 mmol/L) or urine ketones >2+
  • Metabolic acidosis (low bicarbonate/pH)

  "Not everybody with diabetic ketoacidosis develops high ketones ... patients with SGLT2 inhibitors ... 20% of them don't have hyperglycemia ... silent diabetic ketoacidosis." (12:30)

4. Ketone Testing: Limitations and Advances

[08:54]

• Two major ketone bodies:

  • Acetoacetate (measured in urine; good sensitivity but lower accuracy)
  • Beta-hydroxybutyrate (measured in blood; gold standard, but not widely available in all hospitals)

• Modern CKM devices aim to directly and continuously measure blood beta-hydroxybutyrate.

  "The best thing ... is to first check blood glucose, but most importantly, the hallmark is increased concentrations of beta hydroxybutyrate." (09:44)
  "Half of the hospitals are still relying on acetoacetate for diagnosis ... Unfortunately, because we have tools now ... hopefully with continuous meters, we can detect early on..." (10:27)

5. Windows for Early Detection and Intervention

[11:35]

• Normal beta-hydroxybutyrate: <0.5–0.6 mmol/L.

• 0.6–1.5 mmol/L is a "yellow flag" (intervene, hydrate, adjust insulin).

• 1.5–3 mmol/L: Impending DKA; >3 mmol/L: Diagnostic for DKA.

• Not all rises are DKA: starvation, fasting, low-carb diets can elevate ketones.

• Early intervention (fluids, insulin adjustment) can prevent hospitalization.

  "Those levels above 0.6 to 1.5, this is like [a] yellow card ... from 1.5 to 3 you are impending DKA ... more than 3 correlate[s] with severe metabolic acidosis." (11:35)
  "Cognition is the key to prevent ... hospital admission, ICU admission." (15:29)

6. How Will CKM Fit Into Practice?

[16:14]

• New FDA-reviewed dual devices will combine continuous glucose and ketone monitoring via a single sensor/reader.

• Alarms for thresholds (<0.6, <1.5, >3) enable proactive management.

• Useful for:

  • Type 1 diabetes (especially poor control, pregnancy, history of DKA or admissions)
  • Select type 2 (SGLT2 use, very low-calorie diets)

• Intended to simplify life, not add complexity—one device, actionable data.

  "If we have a dual glucose/ketone meter ... the same needle, the same injection process ... extremely helpful." (16:14)
  "It's going to measure every minute ... alarms [for] both glucose and ketones every five minutes, 24/7..." (18:20)
  "Very few patients with type 1 are currently tested [for ketones] ... because it's not really available, it's expensive, and urine testing is kind of messy." (19:30)

7. Patient Selection for CKM Rollout

[20:47]

• Priority groups:

  • All type 1 diabetes
  • Type 1 or 2 with prior DKA/hyperglycemia admissions
  • Patients on SGLT2 inhibitors
  • Pregnant patients with diabetes
  • People on very-low-calorie or ketogenic diets

• Data from upcoming studies will fine-tune ideal candidates.

  "For everybody who has type 1 diabetes, it may be a good thing to do ... especially during pregnancy ... patients on a very low-calorie diet taking an SGLT2 ... increased risk of DKA." (21:10)

8. Looking Ahead: Impact and Final Thoughts

[24:01]

• CKM is poised to do for ketones what CGM did for glucose: enable early diagnosis, prevention, reduce readmissions.

• Readmission for DKA is high (30% within 90 days)—CKM could reduce this burden.

  "1/3 ... of patients with DKA are readmitted within 90 days. Can you imagine if you have something that may prevent ... that readmission?" (24:55)
  "New technology, new life for a lot of people with type 1." (25:04)

Notable Quotes & Moments

• “CKM allows real-time tracking ... it helps you to detect the risk of diabetic ketoacidosis and prevent severe DKA.”
  – Dr. Guillermo Umpierrez [02:45]

• “Despite all the advances in monitoring and treatment, we still have numbers that are absolutely unacceptable.”
  – Dr. Umpierrez [04:12]

• “Those levels above 0.6 to 1.5, this is like [a] yellow card ... from 1.5 to 3 you are impending DKA ... more than 3 correlate[s] with severe metabolic acidosis.”
  – Dr. Umpierrez [11:35]

• “It's going to measure every minute ... alarms [for] both glucose and ketones every five minutes, 24/7...”
  – Dr. Umpierrez [18:20]

• “1/3 ... of patients with DKA are readmitted within 90 days. Can you imagine if you have something that may prevent ... readmission?”
  – Dr. Umpierrez [24:55]

Suggested Further Exploration

• The next episode will feature practical case studies on CKM adoption.
• Visit diabetesjournals.org for recent research and practice recommendations.

Takeaway

Continuous ketone monitoring is an eagerly awaited, FDA-pending advance that will provide clinicians and patients with actionable real-time data, helping to close critical gaps in DKA prevention. This episode stressed its clinical rationale, outlined which populations will benefit most, and offered a preview of how integrated CKM/CGM devices will streamline diabetes management.