Ketone test strip use is low in adults with type 1 diabetes and is not associated with HbA1c or glucose metrics on continuous glucose monitoring

Diabetic ketoacidosis (DKA) presentations increased in Scotland between 2004 and 2018, with widening socioeconomic disparity observed over this period.1 Recent expansion in the provision of continuous subcutaneous insulin infusion (CSII)2 and continuous glucose monitoring (CGM)3 has been associated with a substantial reduction in DKA. The ADA/EASD consensus report on the management of type 1 diabetes states that ‘Adults with type 1 diabetes should be offered blood ketone testing strips’.4 However, a survey from the T1D Exchange Registry suggested 32% of respondents had no access to ketone testing (blood or urine) and only 15% checked ketone levels when glucose was persistently >16.7 mM.5 We sought to assess rates of access to capillary ketone testing within our clinic population and parameters associated with having collected a prescription for ketone test strips. We conducted a retrospective cross-sectional assessment of adults with type 1 diabetes attending Royal Infirmary of Edinburgh clinics (n = 2193). Standard practice in our centre is to make capillary ketone test strips available for all people with type 1 diabetes – this process requires an explicit prescription recommendation from the diabetes clinic to the primary care provider. Individuals with post codes outside our clinic catchment area were excluded as prescribing data were not available (final cohort size n = 2052). Clinical and demographic data were extracted from SCI Diabetes (the Scottish national diabetes register) and prescribing data (2024) were obtained from our hospital's prescribing analytics service. A snapshot of 14-days CGM data were captured in October 2025. DKA admission data across 2024 were obtained from hospital admissions coding (excluding presentations at the point of diabetes diagnosis). As a service evaluation of routinely collected data, this project did not require ethical approval. Results are presented as median [IQR]. Wilcoxon rank-sum test was used to compare continuous data. Categorical data were compared by χ2 test. p values 13.9 mmol/L had collected ketone test strips. These data show that only 35% of people with type 1 diabetes collected ketone test strip prescriptions and, given that UK prescriptions typically contain 10 strips, those collecting only one or two prescriptions per year would not have sufficient supplies to check ketones in accordance with national sick-day guidance. Although prior DKA is associated with collecting ketone test strips, 39% of those with DKA had not collected a single prescription and those at highest risk of DKA (e.g. high HbA1c and greater socioeconomic deprivation6) were no more likely to have obtained test strips. The evidence base for capillary ketone testing is limited; a small study suggested a reduction in hospital admissions in children and young adults when compared to urine testing.7 Very few people with type 1 diabetes have regular experience in assessing and acting upon their ketone levels, yet the advent of continuous ketone monitoring is imminent.8 This is also true of health care professionals and recently published guidance on capillary ketone monitoring is based on expert opinion rather than robust evidence.9 Continuous ketone monitoring will result in far greater access to ketone levels and the hope is this will build upon improvements in DKA reduction already observed with CGM and CSII. However, substantial challenges may arise from this additional information such as greater anxiety, increased contacts with diabetes specialist nurses and increased emergency department attendances. There is an urgent need for evidence-based guidance to support clinicians and people with diabetes in dealing with constant access to ketone data. The authors have nothing to report. Fraser W. Gibb has received speaker fees from Abbott, Dexcom and Insulet. Anna R. Dover has received speaker fees from Abbott. Janet I. Barclay has received advisory board fees from Abbott.