Is continuous ketone monitoring on the horizon for Aussies?

For almost a decade, the Federal Government-funded initiative of continuous glucose monitoring (CGM) has been a gamechanger for diabetes management. But experts are now calling for more advanced monitoring to track the risk of diabetic ketoacidosis (DKA).
 
Currently in Australia, measuring ketone is available via capillary ketone monitoring using point-of-care testing or urine ketone measurements, both subsidised through the National Diabetes Services Scheme since 2017.
 
But a diabetes expert from the United Kingdon says more is needed outside these options.
 
Recently in Australia for an international diabetes congress, Professor Ketan Dhatariya believes measuring glucose alone may not provide adequate warning of developing DKA, and self-monitoring patients may ‘miss or misinterpret’ the early signs of rising ketones.
 
‘Both of the current options in Australia rely on the individual doing the test,’ he told newsGP.
 
‘If somebody with type 1 diabetes feels unwell, they have to remember to do the ketone test, be it the capillary or the urine ketones – and that’s a major stumbling block because people might not remember when to test, and if they do test, often they delay it for a long time, and then certainly don’t often retest.
 
‘The difference is the capillary is by far the best because it gives you immediate real-time values of what your ketones are, but urine testing gives a breakdown product of the ketone that’s in the blood, so there’s always a delay.
 
‘And ketones in people with type 1 diabetes can be very harmful because if they appear too quickly in the blood, they can lead to DKA, a potentially life-threatening condition.’
 
In 2023–24, DKA accounted for around 9400 hospitalisations among Australians with type 1 diabetes, making it one of the most recorded complications in this population. These figures come as gaps remain in patient understanding of ketone risk and how to test levels.
 
Professor Dhatariya details in recent research the benefits of emerging technology that includes continuous ketone monitoring to accompany the CGM device, which alerts the user when their ketone concentrations increase.
 
‘This technology allows the user, and anybody who’s got access to their data, to see when ketone concentrations are starting to rise and if they remain high for some time, so that people can be proactive,’ he said.
 
‘With the use of this device, you can see the ketones start rising. You can take action before the levels become high enough that they become unwell and require hospital admission.’
 
In the United States, the Food and Drug Administration recently approved the first device to continuously monitor both glucose and ketone levels. However, the Therapeutic Goods Administration (TGA) is yet to give the green light for similar devices in Australia.
 
RACGP Specific Interests Diabetes Chair, Dr Gary Deed, agrees the added ketone monitoring technology would be beneficial, but with roadblocked TGA approval, GPs can for now ‘watch this space’.
 
‘That technology may come here to Australia, and it may create an opportunity to better support people at risk of DKA,’ he told newsGP.
 
‘A notification system would reduce risk [of rising ketone levels] and ... we welcome the acknowledgement that technology is moving forward, but with anticipation of Australian approval.
 
‘Although the evidence is emerging, it’s probably pre-emptive for GPs to be too concerned about it.’
 
In the meantime, both experts say GPs have an important role in helping patients understand when and why ketone testing matters.
 
‘Number one, we want to make sure the technology is accurate,’ Dr Deed said.
 
‘We don’t know how many manufacturers are coming to the Australian market, but there’s obviously standards the TGA needs to apply to these particular devices, and for them to give levels that are accurate for clinical management. 
 
‘So once a level is identified, these patients need education about what to do.’
 
While there is a cohort of people with type 2 diabetes who are at risk of developing DKA, including those using SGLT2 inhibitors, people on ketogenic diets with diabetes, pregnant women with pre-pregnancy diabetes and certain populations, Professor Dhatariya says the ‘vast majority’ who will benefit from the new technology will be patients with type 1 diabetes.
 
‘Diabetes management is primary care based, and what we’ve never had is the ability to do continuous ketone monitoring, so the difference is it’s not reliant on the individual doing the test – the machine will give you the data all the time,’ he said.
 
‘It’s going to be a very steep learning curve, because unlike when CGM was first launched, everybody was familiar with the numbers because they’d been doing capillary glucose measurements for many years, so you understood what a glucose number reading meant.
 
‘Because continuous ketone measuring is new, most GPs and patients are not necessarily familiar with what the numbers mean, when people should take action and what that action should be.
 
‘What we hope is that over time, just as with CGM, people learn what the numbers are and understand the nuances of continuous ketone monitoring.’
 
In anticipation of the new continuous ketone monitoring technology, Professor Dhatariya’s paper provides information for healthcare professionals on what actions to take when numbers are read on patients’ devices.
 
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