Our agreed meters for people with type 1 diabetes for blood ketone and glucose testing are: 
Glucomen Areo on 0800 243 667 
Caresens Dual on 08008 815 423

Both companies are happy for clinicians or patients to contact them and they will send the meter and leaflets on how to use a ketone meter directly to the patient. Both meters test blood glucose and ketones and strips for both would need to be added to repeat. The companies make a loss if they issue meters purely for ketone tests. Patients can continue to use their current lancet device with any meter.
We would suggest every practice has a working ketone meter with blood ketone strips available for use in the following circumstances:
Uses of these meters:
1.    To give to every person with type 1 diabetes so they can test blood ketones when unwell. Please issue a copy of the TREND sick day rules from the Sick Day Rules page.
2.    Unwell person with type 1 diabetes seen in the GP practice. 
3.    New patient with diabetes who has osmotic symptoms (thirst, urinary frequency etc) as raised ketones would indicate type 1 diabetes and need for admission.
4.    Person with type 2 diabetes on an SGLT2i eg empagliflozin needs a blood ketone check if they present unwell in any way to exclude DKA even if their blood glucose is normal.
5.    Person coded as having type 2 who has a rising blood glucose or surprisingly quickly rising HbA1c, especially if in the first year after diagnosis or losing weight or relatively low BMI or a strong family history of diabetes. They could have a more "slow burn" type 1 or an unusual type of diabetes. Raised ketones would alert you to the need for urgent advice. 

How to use the meter

The meters are used in exactly the same way as testing a finger prick blood glucose with a drop of blood. The only difference is a blood ketone strip needs to be inserted into the machine.

Interpretation of Blood Ketone Results

• Less than 0.6 mmol/L is normal. 
• 0.6 to 1.5 mmol/L – person is at risk of developing DKA so test again after 2 hours if at home or arrange review with safety netting in primary care. Ensure a person with type 1 diabetes has access to and understands sick day rules.
• 1.6 to 2.9 mmol/L- person is at at risk of DKA and should contact their diabetes team as soon as possible, or health care professional can seek advice on their behalf.  They will need to follow the sick day rules.
• 3 mmol/L or higher- person is at high risk of DKA:
If Ketones > 3.0, but well, and able to eat and drink, follow sick day rules - contact the advice line immediately, aim to manage at home
If ketones > 3.0 and ill, especially abdominal pain / vomiting- needs admission
If ketones > 3.0 and if in doubt /unsure of sick day rules / can't access advice- needs admission

• Aged 18 to 65 years (inclusive).
• Diagnosed with Type 2 diabetes within the last 6 years.
• BMI ≥ 27kg/m² in people from White ethnic groups (adjusted to ≥ 25kg/m² in people from Black, Asian and other ethnic groups).
  o BMI obtained from self-measured weight is acceptable for referral. If this cannot be obtained, a clinic-measured value within the last 12 months may be used, provided there is no concern that weight may have reduced since last measured such that the individual would not be eligible for the T2DR programme at present.
• HbA1c measurement taken within the last 12 months, in line with the following:
  • If on diabetes medication (HbA1c result reflects the effect of glucose-lowering medications), HbA1c 43-87mmol/mol.
  • If not on diabetes medication (HbA1c result does not reflect the effect of glucose-lowering medications), HbA1c 48-87mmol/mol.
  • If there is any concern that HbA1c may have changed since last measured, such that repeat testing may indicate that the individual would not be eligible for the T2DR programme at present, HbA1c should be rechecked before referral is considered.
• Must have attended for monitoring and diabetes review when last offered, including retinal screening, and commit to continue.
  attending annual reviews, even if remission is achieved (no need to wait for retinal screening to take place if newly diagnosed).
• Does not meet any exclusion criteria (see below).

• Has been on the NHS T2DR Programme (or NHS LCD Programme) in the last 12 months, unless referred but did not start TDR
• Current insulin user
• Pregnant or planning to become pregnant within the next 6 months
• Currently breastfeeding
• Has at least one of the following significant co-morbidities;
  • active cancer.
  • heart attack or stroke in last 6 months.
  • severe heart failure (defined as New York Heart Association grade 3 or 4).
  • severe renal impairment (most recent eGFR less than 30mls/min/1.73m2).
  • active liver disease other than non-alcoholic fatty liver disease (i.e. NAFLD is not an exclusion).
  • active substance use disorder.
  • active eating disorder.
  • porphyria.
  • known proliferative retinopathy that has not been treated (no need to wait for retinal screening before referral if newly 
    diagnosed).
• Previously had bariatric surgery.
• Health professional assessment that the person is unable to understand or meet the demands or monitoring requirements of the 
  programme.

• Checked eligibility and made sure no exclusions apply
• Checked list of medications currently prescribed / taken (including those from other providers such as hospitals) and identified:
  • Glucose-lowering medications.
  • BP-lowering medications (including those not specifically used to treat blood pressure, e.g. furosemide or tamsulosin).
  • Medications which may need to be adjusted due to changes in body weight or diet
    • if in doubt, discuss with a clinical pharmacist colleague.
    • only refer if safe, robust processes to manage adjustment and review in line with dietary / weight changes.
• Agreed medication adjustments for 1st day of TDR – must be specified in writing to the provider (incl. if no changes are needed.
  • recommended adjustments for glucose-lowering and BP-lowering medications are described in this slide pack.
  • use your clinical judgement – if in doubt, discuss with the T2DR service provider.
  • patients will not be able to start TDR unless they confirm to the provider that they are stopping / not taking sulfonylureas, meglitinides or SGLT2 inhibitors.
• Confirmed with the patient that they will continue attending reviews / monitoring, regardless of whether remission is achieved.
• Confirmation that patient will notify the GP practice of any unexpected or concerning symptoms which are considered urgent.
• Confirmed with the patient that they will notify the GP practice if they disengage or drop out before programme end. This is particularly important if any medications have been adjusted / stopped on the 1st day of TDR (as may need to be restarted).
• Counselled the patient appropriately and obtained valid, informed consent to refer.

Please email completed forms to scwcsu.derbyshiret2dr@nhs.net.