Ketone testing not required for type 2 diabetes, DSN says

Routine ketone monitoring is not recommended for people living with type 2 diabetes, according to a Mansfield-based diabetes specialist nurse (DSN).

Katie Bowling has emphasised that ketone testing is unnecessary for type 2 diabetes in light of NHS England’s latest guidance on blood glucose and ketone meters, testing strips and lancets.

Since becoming a DSN in 2011, Katie said: “I have never had anyone on my caseload with type 2 diabetes that has gone into diabetic ketoacidosis (DKA),” highlighting the rare occurrence of the potentially life-threatening condition in people with type 2 diabetes.

DKA is a serious condition where a lack of insulin causes harmful substances called ketones to build up in the blood, mainly affecting people with type 1 diabetes.

Katie continued: “Cases of DKA are particularly rare in type 2 diabetes. There may be instances where you would be concerned about a risk, for example people who take SGLT2 inhibitors, but routine practice would be to ask people to be vigilant for the symptoms of DKA rather than routinely monitoring.”

She noted that cases of DKA would be managed in hospital rather than in primary care, as it is potentially life-threatening.

“I do not necessarily know if healthcare professionals in primary care would know how to interpret or treat a positive ketone result,” said Katie.

DKA is a rare side effect of SGLT2 inhibitors and there is no official guidance published around type 2 diabetes and ketone monitoring. However, some confusion among healthcare professionals may stem from MHRA drug safety alerts, which highlight the importance of ketone testing only in hospital settings for people temporarily interrupting treatment because of major surgical procedures or acute serious medical illnesses.

These UK alerts were issued following an in-depth review by the European Medicines Agency (EMA).

As part of its recommendations, the EMA stressed that: “Patients taking these medicines should be aware of the symptoms of diabetic ketoacidosis, including rapid weight loss, nausea or vomiting, stomach pain, excessive thirst, fast and deep breathing, confusion, unusual sleepiness or tiredness, a sweet smell to the breath, a sweet or metallic taste in the mouth or a different odour to urine or sweat.

“Patients should contact a doctor or the nearest hospital straightaway if they have any of these symptoms.”

Katie commented: “It is about knowing what DKA is and the symptoms associated rather than seeking a ketone monitor.”

The ‘Commissioning recommendations following the second national assessment of blood glucose and ketone meters, testing strips and lancets’ were last updated in June 2025.

This guidance ensures that all healthcare professionals are recommending the same blood glucose and ketone meters, testing strips and lancets to people with diabetes.

Professor Partha Kar, Consultant Diabetologist, Portsmouth, said: “For people with type 2 diabetes taking SGLT2’s, diabetic ketoacidosis is classified as a rare occurrence, aligning with the NICE NG28 guidelines and MHRA notifications that ketone monitoring is not required.

“Money saved through inappropriate prescribing of blood ketone strips to people with type 2 diabetes, could therefore be utilised to support new technologies and treatments for all people living with diabetes.”

To access the recommendations, click here.