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In addition to occurring in previously undiagnosed patients, ketosis may occur if insulin therapy is interrupted. This is another good reason why insulin therapy should never be stopped in type 1 DM. If no insulin is available, most tissues will switch to fat metabolism as they are unable to metabolise carbohydrates. It is this fat metabolism by the mitochondria, mostly in the liver, which generates the ketone bodies. Increased levels of acetone are formed in ketosis and accumulate in the blood. Acetone is a volatile substance and some of it is blown off in the expired air from the lungs. This causes the breath to smell of acetone; a smell usually described as being like ‘pear drops’. Like most smells, once you have experienced it the first time you will immediately recognise it again.