Hyperosmolar hyperglycemic state (HHS) most commonly affects elderly people. Like DKA, HHS starts with hyperglycemia and insulin deficiency. As in DKA, people with HHS urinate frequently and become dehydrated. However, unlike in DKA, HHS impairs the ability of the kidneys to filter glucose from the bloodstream, so the hyperglycemia worsens.
Individuals developing HHS don’t experience the same buildup of ketones in the blood as do those with DKA. Diabetes experts believe that this is probably because most people with HHS have Type 2 rather than Type 1 diabetes, so they probably have enough insulin secretion left to prevent the breakdown of fats. Even so, because of the extreme dehydration, HHS can be life-threatening and even more difficult to treat than DKA.
Either of these conditions can occur in anyone with diabetes, whether he has Type 1 or Type 2 diabetes. However, DKA more commonly affects people with Type 1 diabetes and HHS more commonly affects those with Type 2. Both DKA and HHS may be triggered by insulin deficiency or by any major stress to the body, which can cause the counterregulatory hormones to surge and elevate blood glucose levels.
The most common trigger for a hyperglycemic crisis is an infection, such as strep throat, pneumonia, an infected foot ulcer, an intestinal virus, or a urinary tract infection. Other triggers include stroke, heart attack, trauma, alcohol abuse, certain drugs (such as corticosteroids and certain blood pressure medicines), and the skipping or lowering of one’s insulin dose.
In rare instances, mechanical problems with insulin pumps, such as blocking or kinking of the tubing, can stop insulin delivery and result in extreme hyperglycemia. People who use the rapid-acting insulin analog lispro (brand name Humalog), aspart (NovoLog), or glulisine (Apidra) in an insulin pump need to be particularly alert to pump malfunctions. Since lispro, aspart, and glulisine stop working more quickly than Regular insulin does, hyperglycemia can occur more quickly.
DKA and HHS can be prevented by keeping hyperglycemia from happening in the first place. Prevention involves carrying out all parts of your diabetes regimen, monitoring your blood glucose level regularly, and learning to adjust your insulin dose properly, if you use insulin.
Because infection is a common trigger, it’s important to be aware of signs of infection (such as high blood glucose) and to seek treatment promptly. In addition, when you’re sick, it’s important to take your usual doses of insulin or diabetes pills, monitor your blood glucose frequently, and test your urine for ketones. (For more specifics, see “Sick-Day Management.”)
It’s also important to be aware of symptoms of hyperglycemia, which include thirst, increased appetite, frequent urination, weight loss, and dehydration, since both DKA and HHS typically start with hyperglycemia. These symptoms may be present for several days before either condition develops. Signs of dehydration include dryness of the mouth, cracked lips, sunken eyes, weight loss, and flushed, dry skin. As the situation worsens, vomiting, weakness, confusion, and coma may occur. People with DKA may experience abdominal pain and a “fruity” odor on the breath, due to the presence of ketones.
Children and adolescents. DKA is the most common diabetes-related cause of hospitalization and death in children with diabetes. Unfortunately, hospitalization for DKA is often the way a child is first diagnosed with diabetes. To prevent DKA in children and adolescents, parents need to find a balance between giving children responsibility for their diabetes care and taking a supportive and active role in helping them maintain good monitoring and medicine habits. (Although some children are mature for their age, responsibility and good judgment are not hallmarks of childhood and adolescence.) Parents should also anticipate when high levels of blood glucose may occur, such as when a child is sick, and be ready to take a more active role in such situations to avoid problems.