A review of capillary β-hydroxybutyrate cut-off levels for the exclusion and identification of diabetic ketoacidosis

Nghiep Tran; Steven James; Ben Nash; Frank Gao; Scott Bennetts; David O'Neal; Michele Gaca; Loren Sher; Elif I Ekinci

doi:10.1111/jdi.70317

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A review of capillary β-hydroxybutyrate cut-off levels for the exclusion and identification of diabetic ketoacidosis

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A review of capillary β-hydroxybutyrate cut-off levels for the exclusion and identification of diabetic ketoacidosis

Nghiep Tran, Steven James, Ben Nash, Frank Gao, Scott Bennetts, David O'Neal, Michele Gaca, Loren Sher and Elif I Ekinci

Journal of Diabetes Investigation, Vol.Advanced access

23-Apr-2026

DOI: https://doi.org/10.1111/jdi.70317

PMID: 42023700

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Abstract

Type 2 diabetes

Type 1 diabetes

Diabetic ketoacidosis

Aims/Introduction Diabetic ketoacidosis (DKA) is an acute, life-threatening emergency that can arise as a complication of diabetes mellitus. We sought to examine the literature regarding capillary β-OHB testing levels that can inform cut-offs and help clinicians to safely and effectively exclude or identify DKA. Materials and Methods For this narrative review with a systematic approach, MEDLINE, Embase, and Emcare databases were searched for primary studies. Included studies described capillary β-OHB levels in relation to suspected DKA, for populations aged ≥16 years. Exclusion criteria were non-English language, animal studies or case reports, and/or exclusive focus on serum β-OHB. Results Of the 1,177 records identified, 11 studies met the criteria for data extraction. To exclude DKA in patients with hyperglycemia, capillary β-OHB cut-off values of <1.0 mmol/L and <1.5 mmol/L were most recommended. A capillary β-OHB level >3.0 mmol/L exhibited high sensitivity and specificity in detecting DKA and may be used in identifying cases of DKA. Conclusions Capillary testing can reliably detect β-OHB levels within the DKA diagnostic threshold. While a capillary β-OHB threshold of <1.5 mmol/L may help clinicians exclude DKA, a capillary β-OHB level >3.0 mmol/L showed high sensitivity and specificity in detecting DKA. Future studies are needed to validate proposed cut-offs and examine the utility of capillary β-OHB testing in prehospital settings.

Details

Title: A review of capillary β-hydroxybutyrate cut-off levels for the exclusion and identification of diabetic ketoacidosis
Authors: Nghiep Tran - The University of Melbourne
Steven James - University of the Sunshine Coast
Ben Nash - Northern Health
Frank Gao - The University of Melbourne
Scott Bennetts - Ambulance Victoria
David O'Neal - Baker Heart and Diabetes Institute
Michele Gaca - The University of Melbourne
Loren Sher - The University of Melbourne
Elif I Ekinci - University of the Sunshine Coast
Publication details: Journal of Diabetes Investigation, Vol.Advanced access
Publisher: John Wiley & Sons, Inc.
DOI: 10.1111/jdi.70317
ISSN: 2040-1124
PMID: 42023700
Copyright note: © 2026 The Author(s). Journal of Diabetes Investigation published by Asian Association for the Study of Diabetes (AASD) and John Wiley & Sons Australia, Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Data Availability: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Organisation Unit: School of Health - Nursing
Language: English
Record Identifier: 991226930002621
Output Type: Journal article

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