BHB is the best indicator of DKA

  • BHB is 1 of 3 sources of ketone bodies.
  • Its relative proportion in the blood (78%) is greater than the other 2 ketone bodies, acetoacetate (20%) and acetone (2%).
  • As diabetic ketoacidosis (DKA) is treated, serum BHB decreases more consistently than acetoacetate which is converted to BHB and does not change as rapidly.1
  • The BHB/acetoacetate ratio is typically between 3:1 and 7:1 in severe ketotic states.2
  • The American Diabetic Association (ADA) recommends the use of blood ketone testing, based on the measurement of BHB, rather than urine ketone testing, for the diagnosis and monitoring of DKA.3

BHB Results are Quantitative

Quantitative results

Provides physicians with meaningful quantitative results to better differentiate metabolic acidosis and helps in monitoring therapy.

Expected Values

Normal levels are expected to be less than 0.6 mmol/L. Results between 0.6 and 1.5 mmol/L may require medical assistance. Results higher than 1.5 mmol/L indicate the patient may be at risk of DKA4.

Earlier resolution during insulin therapy

BHB levels have been shown to decrease long before acetoacetate & acetone levels, thus providing a better predictor of DKA resolution.

Can be useful in differential diagnosis of HHS in type 2 diabetes

BHB values are crucial because Hyperglycemic Hyperosmolar Syndrome (HHS) presents without significant ketoacidosis5

1 Mae Sheikh-Ali, MD; John M. Miles, MD et al. Can Serum-Hydroxybutyrate Be Used To Diagnose Diabetic Ketoacidosis? Diabetes Care, Volume 31, Number 4, April 2008.

2 Vassault A, Bonnefont JP, Specola N, et al: Lactate, pyruvate, and ketone bodies. In Techniques in Diagnostic Human Biochemical Genetics – A Laboratory Manual. Edited by F Hommes. New York, Wiley-Liss, 1991.

3 American Diabetes Association. Standards of Medical Care in Diabetes – 2013.

4 Luciplus™Ref. No. 3100 β-Ketone Test Strip Instructions for Use, References 1 – 6, (accessed September 20, 2018).

5 Diabetes Care 2013; 36 (Suppl 1): s11 – s66.Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatric Diabetes, 2014 15 (Suppl. 20) : 154-179.

6 American Diabetes Association, DKA (Ketosis) and Ketones,
complications/ketoacidosis-dka.html, (accessed September 20, 2018).