II. Pathophysiology
- See Ketoacidosis
-
Fasting or starvation results in an inadequate Glucose supply for metabolic need
- Similar to Alcoholic Ketoacidosis (also related to inadequate Glucose)
- Ketone Bodies from Triglyceride metabolism (acetyl-CoA via ketogenic pathway) in the absence of Glucose
III. Differential Diagnosis
- See Ketoacidosis
- Alcoholic Ketoacidosis
- Euglycemic Ketoacidosis
- Low-Carbohydrate Diet (<40-50 g/day)
- May results in mild Ketosis
IV. Labs: Ketone Detection
- See Ketoacidosis
- Serum Beta-Hydroxybutyrate
- Primary metabolite of Ketone Bodies in most Ketoacidosis (includes Diabetic Ketoacidosis, Alcoholic Ketoacidosis)
-
Urine Ketones
- Nitroprusside reaction detects acetone and Acetoacetate, but not Serum Beta-Hydroxybutyrate
- May be near normal despite significant Ketoacidosis (due to Beta-Hydroxybutyrate)
- Positive in Isoproteronol Poisoning (primarily due to acetone)
V. Labs: General Labs
-
Metabolic Acidosis with Anion Gap
- Absent only in Isoproteronol Poisoning (since acetone is not a charged partical)
- Metabolic panel (chemistry panel)
- Venous Blood Gas
- Serum Osmolal Gap
- Increased in Alcoholic Ketoacidosis and in Toxic Alcohol ingestions (e.g. Methanol, ethylene gylcol, propyl Alcohol)
VI. Management
- Differentiate from Diabetic Ketoacidosis, Euglycemic Ketoacidosis (SGLT2 Inhibitors), Alcoholic Ketoacidosis
- Insulin is not typically indicated in Starvation Ketoacidosis and Alcoholic Ketoacidosis
- Dextrose in crystalloid (NS, LR)
- Dextrose is critical in clearing Ketone Bodies
- In Alcoholic Ketoacidosis, Thiamine 100 mg is given prior to dextrose
-
Electrolytes
- Monitor and replace Serum Potassium, Serum Magnesium, Serum Phosphorus
VII. References
- Mehta and Emmett in Sterns and Traub (2019) UpToDate, Fasting Ketosis and Alcoholic Ketoacidosis, accessed 7/19/2019