Continuous Ketone Monitoring Captures Overt Ketosis in Type 1 Diabetes Caused by Empagliflozin, Low-Carbohydrate Diet, and Exercise

Euglycemic ketosis can occur in individuals with type 1 diabetes when multiple metabolic stressors converge; however, early recognition is challenging without dedicated ketone monitoring. We report a case of a 30-year-old woman with type 1 diabetes using automated insulin delivery and 10 mg empagliflozin who adopted a low-carbohydrate diet and increased physical activity while using continuous ketone monitoring (CKM) with a wearable ketone sensor (NCT06753994). Under these combined conditions, CKM detected persistent ketosis exceeding 1.0 mmol/L for 14 h, with a maximum concentration of 2.9 mmol/L, despite euglycemia on continuous glucose monitoring. CKM supported the timely identification of ketosis, guided appropriate carbohydrate and insulin treatment, and allowed real-time monitoring of recovery. This case illustrates how CKM can reveal clinically meaningful euglycemic ketosis and aid in early intervention, suggesting a potential role for CKM in mitigating diabetes ketoacidosis risk in individuals using sodium-glucose cotransporter-2 inhibitors or undertaking carbohydrate restriction and intense exercise.