Viral Shah, MD

Why Glucose Alone Isn't Enough: The Future of Ketone Monitoring in Diabetes

Clinicians broadly understand the importance of ketone monitoring, yet structured action plans remain inconsistently implemented in practice. At the 2026 

Scientific Sessions of the American Diabetes Association

, Viral Shah, MD, Indiana University, led an evidence synthesis session and presented a 5-step clinical framework designed to close the gap between awareness and actionable bedside guidance, while outlining how continuous ketone monitoring will reshape automated insulin delivery (AID) algorithm design.¹

The session builds on a broader ADA consensus effort to move ketone monitoring from a reactive diabetic ketoacidosis (DKA) response tool to a proactive, structured component of diabetes management, with implications for both clinical algorithms and next-generation device development.

Ketone Action Plan and Threshold-Based Home Management

Shah outlined a 5-step clinical decision framework developed by the ADA Evidence Synthesis team to give clinicians a practical implementation structure. The steps address:

Identifying which patients should measure ketones

Specifying the testing modality (capillary, continuous, or urine)

Determining whether home management is appropriate

Executing a structured home treatment protocol to prevent DKA progression.

Ketone thresholds were assigned evidence-based designations. Levels < 0.6 mmol/L are considered normal. The range of 0.6 to 1.5 mmol/L represents an elevated but lower-urgency zone requiring increased monitoring. Levels from 1.5 to 3.0 mmol/L are concerning and warrant active intervention to prevent further rise. Values exceeding 3.0 mmol/L indicate progression toward DKA.

Shah emphasized the majority of elevated ketone episodes are manageable at home when patients are properly educated and empowered, and the consensus document lays out specific home management principles aimed at reducing hospitalizations by intervening before the yellow-to-red transition occurs.¹

Glucose-Ketone Dissociation and AID System Integration

Shah addressed a significant shift in the field's mechanistic understanding: the assumption glucose must rise before ketones does not hold across all patients. A recent publication in 

 demonstrated 3 distinct dissociation patterns among insulin-treated individuals with diabetes: ketones rising before glucose, simultaneous rises, and glucose preceding ketones.¹ This means a patient can develop clinically significant ketosis at glucose levels of 150 to 200 mg/dL, well below the thresholds historically associated with DKA risk.

Shah noted the euglycemic DKA entity, recognized in SGLT2 inhibitor use and pregnancy, represents one end of this spectrum, but dissociation occurs more broadly than those contexts alone.

"It's not that someone has to have a blood sugar of 300 to develop ketosis," he said. The implication for practice is direct: glucose monitoring alone provides an incomplete metabolic picture, and ketone data should be considered a parallel vital marker rather than a downstream indicator.

Regarding device integration, Shah noted pump manufacturers have already announced partnerships with Abbott in anticipation of US continuous ketone monitor availability, with the stated goal of incorporating real-time ketone data into AID algorithms.¹ Specific applications include refining insulin suspension logic to prevent prolonged interruptions capable of driving ketone accumulation.

He said the algorithmic details will largely remain proprietary, but expressed confidence the field is moving toward individualized insulin delivery informed by both glucose and ketone inputs in real time.

Editors’ note: Shah reports relevant disclosures with Sanofi, Novo Nordisk, Lilly, Dexcom, Insulet, Tandem Diabetes Care, Medtronic, Sequel Med Tech, Abbott Diabetes, Roche, Biomea Fusion, and T1D Scout.

Shah V. ADA evidence synthesis on ketone monitoring and treatment. Presented at: American Diabetes Association 2026 Scientific Sessions; June 6, 2026; New Orleans, LA.

American Diabetes Association. Standards of care in diabetes. 

https://professional.diabetes.org/standards-of-care

Videos

Shah explains proactive ketone monitoring, home DKA prevention strategies, and the future of continuous ketone monitoring.

From Awareness to Action: Structured Ketone Monitoring in Diabetes Care, With Viral Shah, MD

Is Continuous Ketone Monitoring Future of Diabetes Care?

Scientific Sessions of the American Diabetes Association (ADA)

 addressed evolving standards for ketone monitoring in diabetes, emphasizing earlier identification of elevated ketone levels as a primary strategy for diabetic ketoacidosis (DKA) prevention across both 

Viral Shah, MD, Indiana University, presented the session "ADA Evidence Synthesis on Ketone Monitoring and Treatment" in New Orleans, Louisiana.

The session arrives as dual glucose-ketone continuous monitoring technology has received CE mark approval in Europe, with Abbott's FreeStyle Libre Duo among the first such devices, raising expectations for eventual US availability and prompting renewed clinical guidance on monitoring thresholds, education requirements, and patient stratification.

Ketone Monitoring Recommendations and Patient Stratification

The ADA consensus establishes universal diabetes education on ketones as a minimum standard: every individual with diabetes should receive instruction at least once yearly on what ketones are, what elevated levels indicate, and how to manage them at home, with the explicit goal of reducing hospital utilization.¹

“I think we have recognized that DKA is not just the problem in type 1 diabetes. It's also common in type two diabetes,” Shah explained. “If we want to prevent the DKA, we need to think about how we can identify the ketone or the rise in the ketone at an earlier stage so that we can do an intervention and prevent it, and I think that's why here we had a session around how to identify the elevated ketone levels, why to do it early.”

He framed DKA prevention as the field's central priority, noting elevated ketones must be identified early enough to permit outpatient intervention. Beyond universal education, the consensus identifies a higher-risk subgroup for whom a written ketone monitoring plan is recommended. These individuals require a documented protocol specifying when to check ketones, how to check them, and what actions to take when levels are elevated.

The guidance is designed to bridge the gap until continuous ketone monitoring becomes widely available in the US market. Shah noted once dual glucose-ketone devices reach US patients, the monitoring question will be partially resolved by default, as ketone data will be available alongside glucose in real time.

Blood Versus Urine Ketone Testing, Barriers to Capillary Monitoring

Shah addressed why blood ketone testing has not displaced urine testing in routine care despite its known advantages. Urine ketones measure acetoacetate rather than beta-hydroxybutyrate, the primary ketone elevated in DKA, and appear later in the clinical course.¹

Beta-hydroxybutyrate rises first; acetoacetate appears in urine hours afterward, creating a diagnostic lag. The measurement discordance also complicates treatment monitoring: as beta-hydroxybutyrate is successfully converted to acetoacetate during treatment, urine ketone readings can paradoxically increase, potentially misleading patients managing ketosis at home into believing their condition is worsening rather than improving.

Capillary blood ketone testing avoids this problem but faces 3 distinct barriers: cost, access, and education. Test strips can run between $1 and $4 each and expire quickly, making the investment difficult to justify for patients who have never experienced DKA.

"People think, 'I never had a DKA before, why would I buy a machine going to cost me a few hundred dollars and I'm not going to use it?'" Shah said. He acknowledged urine testing will remain a practical necessity in resource-limited settings globally, while continuing to advocate for broader capillary access where feasible.

The convergence of continuous ketone monitoring technology and updated clinical consensus positions the field for a meaningful shift in how ketone elevation is detected and managed. Availability of dual glucose-ketone monitoring in the US will represent a significant inflection point, particularly for the type 1 population and for type 2 patients at elevated DKA risk.¹

Abbott. Abbott secures CE Mark for world's first dual glucose-ketone sensing technology for people with diabetes. May 27, 2026. Accessed June 6, 2026. 

https://www.prnewswire.com/news-releases/abbott-secures-ce-mark-for-worlds-first-dual-glucose-ketone-sensing-technology-for-people-with-diabetes-302782795.html

Viral Shah, MD, outlines the case for earlier ketone detection across diabetes types, the limitations of urine testing, and what CKM technology may change in clinical practice.

Ketone Monitoring in Diabetes: Making The Case For When and How to Test

Diabetes Dialogue: Technology, Therapeutics, & Real-World Perspectives!

Diabetes Dialogue: Expanding GLP-1 Usage Into Type 1 Diabetes With Viral Shah, MD

In this episode of Diabetes Dialogue, recorded on-site at the American Association of Clinical Endocrinology (AACE) Annual Meeting 2026 in Las Vegas, Nevada, cohosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, welcome Viral Shah, MD, professor of endocrinology at Indiana University, for a discussion centered on the evolving role of GLP-1 receptor agonists and broader diabetes classification in type 1 diabetes care. Shah challenges the traditional distinction between type 1 and type 2 diabetes, emphasizing that type 2 diabetes lacks a definitive diagnostic test and is instead a diagnosis of exclusion based on phenotypic characteristics. He explains that patients with type 1 diabetes can also exhibit features of type 2 diabetes, making these categories non–mutually exclusive and supporting the rationale for dual diagnoses when clinically appropriate.

The group explores how this framework informs the use of GLP-1 receptor agonists in type 1 diabetes, particularly for patients with obesity, cardiovascular disease, heart failure, or chronic kidney disease. Shah notes that while obesity provides a clear indication for GLP-1 therapy, he is also comfortable using these agents in patients with lower BMI when cardiovascular or renal protection is the primary goal, with careful attention to dose adjustment and avoidance of excessive weight loss or muscle mass reduction. He adds that SGLT2 inhibitors may be preferable in some leaner patients, particularly when renal indications predominate, and highlights recent clarification that SGLT2 inhibitor use for CKD in type 1 diabetes is not considered off-label when prescribed for kidney protection rather than glycemic control.

The conversation then shifts to Shah’s broader view that type 1 and type 2 diabetes differ more in pathophysiology than in long-term disease course. He argues that both conditions share progressive beta cell dysfunction and overlapping complication risks, suggesting the field should move away from rigid separation and toward a more unified understanding of diabetes progression.

This perspective leads into a discussion of “prediabetes,” a term Shah critiques as outdated and insufficient. He reviews its historical origins as a label for intermediate hyperglycemia and argues that it has unintentionally minimized urgency by framing the condition as merely a risk factor rather than part of the disease continuum. Citing evidence of significantly elevated cardiovascular, kidney, and mortality risk in people with prediabetes, he advocates for staging type 2 diabetes similarly to type 1 diabetes, rather than maintaining an artificial threshold between “no disease” and diabetes. He notes that while therapies such as metformin, semaglutide, and tirzepatide have demonstrated benefit in delaying progression, regulatory limitations persist because prediabetes is not formally recognized as a disease state.

The episode concludes with a discussion of autoantibody screening in adults labeled with prediabetes. Shah supports broader antibody testing, particularly in younger adults, to identify individuals with early-stage type 1 diabetes who may otherwise be misclassified and present later with DKA. He emphasizes that accessible antibody testing and therapies such as teplizumab make earlier identification increasingly meaningful, while also acknowledging the importance of patient preference and individualized decision-making. Across the discussion, Shah calls for greater flexibility in diabetes classification, earlier intervention across the disease spectrum, and a more proactive approach to preventing complications rather than waiting for traditional diagnostic thresholds to be crossed.

Editors’ Note: Isaacs reports disclosures with Dexcom, Abbott, Lilly, Novo Nordisk, Medtronic, Insulet, and others. Bellini reports disclosures with Abbott Diabetes Care, MannKind, Povention Bio, and others. Shah reports disclosures with Sanofi, Novo Nordisk, Lilly, Dexcom, Insulet, Tandem Diabetes Care, and others.

Shah V. Beyond Type 2: Evaluating GLP-1 Use in Type 1 Diabetes and Obesity. Presented at the American Association of Clinical Endocrinology Annual Meeting 2026 in Las Vegas, NV. April 22-24, 2026.

Podcasts

Viral Shah, MD, joins the show to break down his AACE 2026 presentation on the benefits of using GLP-1 RAs in patients with T1D.

Beyond Insulin: GLP-1 Receptor Agonists in Type 1 Diabetes

 has centered almost exclusively on insulin delivery. Even as automated insulin delivery (AID) technology has advanced, a substantial proportion of patients fail to achieve time in range > 70%, driven in part by rising rates of 

, which increase insulin resistance and total daily insulin requirements. Insulin alone also does not address 

, which in T1D is 6 to 8 times greater than in people without diabetes.

These limitations have fueled interest in adjunctive pharmacotherapy, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RAs). Accumulating data from observational studies and randomized controlled trials point to clinically meaningful improvements in HbA1c, time in range, and weight in T1D patients, without a demonstrated increase in severe hypoglycemia risk. Regulatory trials are now underway, raising the prospect of a formal T1D indication.

At the American Association of Clinical Endocrinology (AACE) 2026 Annual Meeting, Viral Shah, MD, a professor of medicine in the division of endocrinology & metabolism and director of Diabetes Clinical Research at the IU Center for Diabetes and Metabolic diseases at Indiana University, led a session on this topic, drawing on data from the ADJUST-T1D trial, which evaluated semaglutide in people with T1D, alongside other observational and controlled studies.

Across these data sources, HbA1c reductions ranged from approximately 0.4% to 1.0%, translating to time in range improvements of roughly 5% to 10% depending on baseline glycemic status. Weight loss outcomes appeared comparable to those observed in type 2 trials, though Shah noted that head-to-head comparisons have not been conducted.

He emphasized that the clinical benefit of GLP-1 RAs in T1D is inseparable from appropriate insulin titration. Initiating semaglutide at 0.25 mg or tirzepatide at 2.5 mg typically necessitates a 20% to 30% insulin reduction, but the appropriate degree of down-titration depends on baseline HbA1c and time in range.

Patients with an HbA1c of 8.5% to 9% may not require immediate insulin reduction, as the GLP-1 RA effect is needed to bring glycemia down. Conversely, patients already near target require proactive down-titration to avoid hypoglycemia. Shah recommended follow-up within 1 to 2 weeks of initiation and monthly thereafter to monitor and adjust.

Regarding safety, available data have not shown an increased rate of diabetic ketoacidosis (DKA) with GLP-1 RAs in T1D, though Shah noted that longer-duration trials will be needed to definitively characterize this risk. Gastrointestinal tolerability generally mirrors what is seen in type 2 populations, with one important distinction: patients with T1D appear to tolerate lower maximum doses, and clinicians should calibrate titration accordingly using established GI mitigation strategies.

Shah closed with a direct challenge to industry stakeholders, arguing that obesity in T1D deserves the same clinical priority it receives in type 2, and that the field has been too slow to generate the large-scale regulatory evidence needed to make these therapies available to T1D patients.

“Through your platform, I want to say that all industry, I want them not to ignore type 1 space and do something more so that we can utilize those drugs safely in people with type 1 diabetes as well,” Shah concluded

 The emergence of obesity in type 1 diabetes. 

https://doi.org/10.1038/s41366-023-01429-8

Shah VN, Akturk HK, Kruger D, et al. Semaglutide in Adults with Type 1 Diabetes and Obesity. NEJM. doi:10.1056/EVIDoa2500173

Shah VN. Beyond Type 2: Evaluating GLP-1 Use in Type 1 Diabetes and Obesity. Presented at the American Association of Clinical Endocrinology (AACE) Annual Meeting 2026 in Las Vegas, Nevada, April 22-24, 2026.

Shah discusses the potential of GLP-1 receptor agonists as adjunctive therapy in type 1 diabetes, from glycemic control to cardiometabolic risk.

Viral Shah, MD

Articles