People with diabetes must monitor their blood sugar and ketone levels to prevent complications. In some cases, people may experience euglycemic diabetic ketoacidosis. This refers to when a person has high ketone levels but normal blood sugars.

Glucose is the body’s primary source of energy. When people consume carbohydrates, they release glucose, raising blood sugar levels. However, if glucose is not available, the body can break down fats in the bloodstream, producing chemicals called ketones, and use these for fuel instead.

Insulin is a hormone responsible for allowing glucose in the blood to enter cells. This provides them with the energy to function.

People living with diabetes may not make enough insulin, or their cells may be resistant to insulin. In this scenario, blood sugar can become high, as the cells are unable to use it. As a result, a person may experience a severe complication called diabetic ketoacidosis (DKA).

However, in some cases, blood sugar levels may remain in a normal range, but people still have high ketone levels.

In this article, we look at what can cause high ketone levels with normal blood sugar.

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High ketones with normal blood sugar may arise due to euglycemic diabetic ketoacidosis (EDKA). This term refers to an uncommon complication of diabetes that can cause symptoms such as dehydration and, rarely, coma or death.

According to research, DKA usually manifests with a high blood glucose of more than 250 milligrams per deciliter (mg/dL), but EDKA is ketoacidosis associated with a blood glucose level of less than 250 mg/dL.

Experts advise that EDKA is an uncommon diabetic complication associated with several risk factors, such as fasting, surgery, and pregnancy.

They also explain that it may develop when someone uses sodium-glucose cotransporter 2 (SGLT2) inhibitors. SGLT2 inhibitors are a newer type of oral diabetes medication that includes:

  • canagliflozin
  • dapagliflozin
  • empagliflozin
  • ertugliflozin

Doctors may also prescribe SGLT2 inhibitors for heart failure in patients with or without diabetes. SGLT2 inhibitors can help lower blood sugar by preventing the kidneys from reabsorbing glucose in the body. Experts explain that the drugs increase urinary glucose loss, which may result in severe dehydration and ketosis.

The Food and Drug Administration (FDA) has approved SGLT2 inhibitors for people with type 2 diabetes but not type 1. The FDA does not recommend that people with type 1 diabetes use SGLT2 inhibitors because the risk of ketone-associated effects can be as high as 9%.

EDKA may be more common in individuals with diabetes that use SGLT2 inhibitors and have lower body mass index and decreased glycogen stores. Additionally, other factors that may trigger EDKA episodes include:

  • surgery
  • infection
  • trauma
  • major illness
  • reduced food intake
  • persistent vomiting
  • gastroparesis
  • dehydration
  • reduced insulin dosages

Some researchers have estimated that SGLT2 inhibitors increase the risk of DKA in T2D patients by sevenfold.

The American Diabetes Association (ADA) advises that DKA is a serious condition that can lead to a diabetic coma or even death. DKA may happen to anyone with diabetes, though it is rarer in people with type 2 diabetes.

People with diabetes may develop DKA when there is an overload of ketones in their blood, making it more acidic.

According to the National Health Service (NHS) in the United Kingdom, a ketone blood test reading of 3 millimoles per liter (mmol/L) or above means that someone has a very high risk of DKA and should get medical help immediately.

Additionally, lower readings of 0.6 to 1.5 mmol/L mean a person is at a slightly increased risk of DKA and should test again in 2 hours.

The ADA advises that with DKA, early symptoms may include:

  • frequent urination
  • thirst or dry mouth
  • high blood glucose
  • high ketone levels

Then, other symptoms appear, including:

  • persistent tiredness
  • dry or flushed skin
  • nausea, vomiting, or abdominal pain
  • difficulty breathing
  • a fruity odor on the breath
  • difficulty paying attention or confusion

Experts advise that EDKA symptoms vary from person to person and may be similar to DKA. However, blood glucose levels in EDKA appear normal. People with EDKA may present with the following:

  • nausea
  • vomiting
  • shortness of breath
  • generalized malaise
  • lethargy
  • loss of appetite
  • fatigue
  • abdominal pain

The ADA recommends testing for ketones with a simple urine test strip. They suggest testing for ketones when blood glucose exceeds 240 mg/dL. In addition, when someone is ill, such as with the flu or a cold, they should test for ketones every 4–6 hours.

People can ask a healthcare professional about ketone urine test strips.

People should contact their doctor if a urine test shows high levels of ketones or if they have any signs or symptoms of DKA or EDKA.

However, experts note that insulin-using individuals often do not recognize their symptoms as DKA because serum glucose levels are not high. As such, it is important for a person to regularly test ketone levels when they experience symptoms such as nausea, vomiting, and fatigue.

It is possible for a person to have high levels of ketones and normal blood sugar levels. This may be due to SGLT2 inhibitors causing euglycemic diabetic ketoacidosis.

It is advisable for people living with diabetes to monitor their blood sugar and ketone levels and look out for signs or symptoms that could indicate DKA or EDKA. If a urine test shows high levels of ketones, it is advisable to contact a doctor.