What are your thoughts on trending beta-hydroxybutyrate once a diagnosis of DKA is already established?

Beta-hydroxybutyrate (BOHB) ≥3.0 mmol/L is highly sensitive and specific for diagnosing DKA and can be measured through serum or point-of-care testing. However, its role in monitoring treatment response and determining resolution remains debated. The American Diabetes Association recommends continuing insulin until “ketonemia is controlled,” but does not specify thresholds. In contrast, other guidelines (e.g., ISPAD, JBDS; Kilpatrick et al., PMID 35050366) suggest serial BOHB measurements every 2 hours, aiming for a ≥0.5 mmol/L/h decrease until <1.0 mmol/L. Some protocols define DKA resolution as BOHB <0.6 mmol/L with venous pH ≥7.3 or bicarbonate ≥18 mmol/L, while cautioning against reliance on the anion gap or urinary ketones due to physi...