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NICE Guidance on ketone testing

In this article, William Willis from Inside Biometrics Ltd reviews the current guidance on ketone testing from the National Institute for Health and Care Excellence (NICE).

NICE is widely recognised for providing the NHS and patients with advice on effective and good value healthcare. In 2015 they published five updates of diabetes clinical guidelines, emphasising the importance of the treatment of diabetes and its complications to patients and the NHS. Three of these updates gave new recommendations on blood glucose monitoring and the need to measure ketones as part of diabetes management. These specific guidance are detailed in the following documents: NICE guidelines for adults with type 1 diabetes (NG17), pregnant women (NG3) and children and young people (NG18).

1. NG17 recommends (§1.11.1) that ketone monitoring in blood or urine should be considered as part of 'sick-day rules' for adults with T1D, to facilitate self-management of an episode of hyperglycaemia. Educating people with type 1 diabetes about sick day rules is clearly important so that they can take appropriate precautions when they are most at risk of developing diabetic ketoacidosis (DKA).

2. NICE’s recent clinical guideline NG3 'Diabetes in pregnancy: management from preconception to the postnatal period' 2015 recommends that women with Type 1 diabetes who want to be or who are pregnant should be offered a blood ketone meter and advised to test for ketonaemia if they become hyperglycaemic or feel unwell and to seek urgent medical advice if they become hyperglycaemic. https://www.nice.org.uk/guidance/ng3/chapter/1-Recommendations. The occurrence of diabetic ketoacidosis in pregnancy is known to compromise both the foetus and the mother. It can be problematic as it has been reported as occurring at lower blood glucose levels and more rapidly than in non-pregnant patients often causing delay in the diagnosis. NG3 also recommends pregnant women with diabetes should test their blood glucose frequently.

3. The final NICE guideline NG18 (Diabetes (type 1 and type 2) in children and young people: diagnosis and management, 2015) advised that:

• Children and young people or their carers should check their blood glucose at least 5 times a day

• All children and young people with Type 1 diabetes should be offered a blood ketone meter and they or their carers should test for ketonaemia if they become ill or hyperglycaemic.

https://www.nice.org.uk/guidance/ng18/chapter/Key-priorities-for-implementation#blood-glucose-and-hba1c-targets-and-monitoring-for-children-and-young-people-with-type-1-diabetes

NICE guideline NG18 also advises that children and young people with Type 1 diabetes can develop DKA even when their blood glucose is at normal levels (euglycaemic DKA).

https://www.nice.org.uk/guidance/ng18/chapter/1-Recommendations#diabetic-ketoacidosis-2

Here is the challenge for existing testing practice as without a high glucose result, a subsequent ketone test would not usually be prompted. The KEYA® test strip’s 2-in-1 measurement overcomes this challenge as ketones are measured during every blood test, regardless of glucose concentration, providing a simple solution to at risk patients.