Blood β-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: a systematic review

Diabet Med. 2013 Jul;30(7):818-24. doi: 10.1111/dme.12136.


Aim: Diabetic ketoacidosis is a life-threatening complication of Type 1 diabetes. Blood β-hydroxybutyrate testing is now widely available as an alternative to urine acetoacetate testing for detecting ketosis. The aim of this study was to review the effectiveness of capillary or serum β-hydroxybutyrate compared with urine acetoacetate testing in prevention and management of diabetic ketoacidosis.

Methods: MEDLINE, EMBASE, EBM Reviews, The Cochrane Library and CINAHL (until April 2012, no language restrictions, studies in humans) were searched for experimental and observational studies comparing the effectiveness of blood β-hydroxybutyrate and urine acetoacetate testing. Outcomes examined were prevention of diabetic ketoacidosis, time to recovery from diabetic ketoacidosis, healthcare costs and patient or caregiver satisfaction. Additional sources included reference lists, conference proceedings and contact with experts in the field.

Results: Four studies (two randomized controlled trials and two cohort studies) met eligibility criteria, including 299 participants across 11 centres. Risk of bias was low to moderate. Blood ketone testing compared with urine testing was associated with reduced frequency of hospitalization (one study), reduced time to recovery from diabetic ketoacidosis (three studies), cost benefits (one study) and greater satisfaction (one study, intervention group only). No study assessed prevention of diabetic ketoacidosis. Meta-analysis could not be performed because of heterogeneity in study design and published data.

Conclusions: There is evidence suggesting that blood β-hydroxybutyrate testing is more effective than urine acetoacetate testing in reducing emergency department assessment, hospitalization and time to recovery from diabetic ketoacidosis, as well as potentially lowering healthcare expenditure. Further research in both young people and adults is needed.

Publication types

  • Comparative Study
  • Review
  • Systematic Review

MeSH terms

  • 3-Hydroxybutyric Acid / blood*
  • Acetoacetates / urine*
  • Critical Care / economics
  • Crown-Rump Length
  • Diabetes Mellitus, Type 1 / complications*
  • Diabetic Ketoacidosis / economics
  • Diabetic Ketoacidosis / prevention & control*
  • Diabetic Ketoacidosis / therapy*
  • Health Expenditures
  • Hospitalization / economics
  • Humans
  • Randomized Controlled Trials as Topic


  • Acetoacetates
  • acetoacetic acid
  • 3-Hydroxybutyric Acid