COVID-19: A Higher Risk of DKA and Diabetic Hyperosmolar Syndrome?

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If you have diabetes, you may be concerned about your risk of getting COVID-19. The CDC (Centers for Disease Control and Prevention) states that people with type 2 diabetes, as well as people with other underlying medical conditions, including chronic kidney disease, cancer, COPD and obesity, are at increased risk for severe illness from COVID-19. Other health authorities believe that people with type 1 diabetes are also at risk of severe COVID-19 

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Diabetic ketoacidosis (DKA) and diabetic hyperglycemic hyperosmolar syndrome (HHS) are two serious, potentially life-threatening conditions that can occur in people with diabetes. There is concern in the medical community that people diagnosed with COVID-19 are at higher risk of developing either DKA or diabetic hyperosmolar syndrome. Let’s take a look at these two conditions and how they are linked to COVID-19. 


DKA is a very serious complication of diabetes that, if left untreated, can lead to diabetic coma or even death. DKA occurs when the body doesn’t have enough insulin to move glucose from the bloodstream into cells to be used for energy. Without enough glucose, the body looks elsewhere for a source of fuel. That source is fat. More specifically, in the absence of adequate glucose, the liver begins to burn fat to supply energy. The process of burning fat produces acidic substances called ketones. Ketones begin to buildup in the bloodstream, making the blood acidic.  

The presence of ketones leads to an imbalance in electrolytes such as potassium, sodium and chloride. Meanwhile, glucose levels continue to climb because of a lack of insulin. In an effort to help rid the body of some of this glucose, the kidneys filter some of this glucose and excrete it in the urine.  

DKA symptoms

DKA symptoms can develop very quickly, even within 24 hours. Typical symptoms of DKA can include: 

  • Decreased alertness 
  • Deep, rapid breathing 
  • Dehydration 
  • Dry skin and mouth 
  • Frequent urination 
  • Excessive thirst 
  • Flushed face 
  • Fruity-smell breath 
  • Headache 
  • Muscle stiffness or aches 
  • Nausea and vomiting 
  • Stomach pain 
  • Shortness of breath 
  • Weakness or fatigue 
  • Confusion 

Other signs of DKA include high blood sugar levels and high levels of ketones in the urine. Ketone levels can also be measured with a special meter that checks the blood for a type of ketone called beta-hydroxybutyrate, one of the main types of ketones. 

DKA is most likely to occur in people with type 1 diabetes. In fact, DKA is often the first indicator that a person has type 1 diabetes. DKA is less likely to happen in people with type 2 diabetes, although it can occur.  

Because DKA is so serious, if you have type 1 diabetes, always check your urine for ketones if your blood sugar is over 250 mg/dl two times in a row, especially if you’re sick. Call your healthcare provider right away if you have moderate or high levels of ketones in your urine. If you have symptoms of DKA, seek emergency medical help. 

DKA causes

The causes of DKA are: 

  • A lack of insulin due to missing insulin doses or not taking enough insulin 
  • Illness or infection, such as COVID-19 
  • Heart attack 
  • Alcohol or drug abuse 
  • Some medicines, such as corticosteroids and certain diuretics 
  • Physical or emotional trauma 

The goals of DKA treatment are to correct the high blood sugar with insulin, replace the loss of electrolytes, and replace fluid losses from urination and vomiting. The other part of treatment is to determine the cause of DKA and provide treatment, such as antibiotics for a urinary tract infection, for example. 

Sometimes, certain complications can occur during DKA treatment, such as low blood sugar; low potassium levels, which can affect the action of the heart, muscles and nerves; and swelling in the brain (called cerebral edema). However, treating DKA is crucial in order to prevent serious illness and death. 

COVID-19 and DKA

Now that you’ve had an overview of DKA, what might strike you is the fact that illness is a key trigger for DKA. If you have type 1 diabetes and you have COVID-19, you are at risk of developing DKA, in other words.  

Infection and illness are thought to precipitate DKA by causing an inflammatory state. Inflammation causes a release of several hormones (glucagon, cortisol, catecholamines and growth hormone) that lead to hyperglycemia. There is also some evidence suggesting that the coronavirus may damage pancreatic islet cells that further lead to hyperglycemia and ketosis. An important finding among COVID-19 patients is that “severe disease is accompanied by high levels of inflammatory markers, which are also elevated in the setting of DKA independent of accompanying illness,” say the authors of  a study published in the August 2020 issue of Journal of Clinical Endocrinology & Metabolism. One of these markers, called IL-6, has been found to be elevated in DKA and is thought to be a driver of ketosis. But, as the authors write, more research is needed.  

Diabetic hyperglycemic hyperosmolar syndrome 

Diabetic hyperglycemia hyperosmolar syndrome is a condition caused by extremely high blood sugar levels and occurs primarily in people with type 2 diabetes, although it can also occur in people who have not been diagnosed with diabetes.  

Other names for this condition are diabetic hyperosmolar syndrome, hyperglycemic hyperosmolar nonketotic coma (HHNK) and nonketotic hyperosmolar syndrome (NKHS). 

According to the Cleveland Clinic’s website, HHS is most likely to affect people with type 2 diabetes who: 

  • Are older (in their 60s or 70s) 
  • Are African American, Native American or Hispanic 
  • Have other health issues, such as infection, illness or a heart condition 

HHS can occur when blood sugars are too high for a long period of time. The body tries to get rid of some of this extra sugar by excreting it into the urine, which causes the need to urinate frequently. If you don’t drink enough fluid or you continue to eat foods that contain carbohydrate, you can become very dehydrated, and the kidneys are unable to get rid of extra sugar. As a result, blood sugar levels can become very high, sometimes more than 10 times the usual amount.  

At the same time, dehydration causes the blood to become more concentrated, called hyperosmolarity. Sodium, glucose and other substances build up in the bloodstream, and this pulls water from the body’s organs, including the brain.  

Hyperglycemic hyperosmolar syndrome symptoms

Symptoms of HHS include: 

  • Blood sugar of 600 mg/dl or higher 
  • Increased thirst and urination 
  • Weakness 
  • Nausea 
  • Weight loss 
  • Dry mouth 
  • Fever 
  • Drowsiness 
  • Confusion 
  • Hallucinations 
  • Vision loss 

These symptoms may develop over days or weeks. Left untreated, seizures, coma or death may result. Other complications include shock, blood clots, brain swelling and lactic acidosis. 

HHS causes

Factors that can lead to HHS are: 

  • Infection or illness, such as COVID-19, pneumonia or a urinary tract infection 
  • Heart attack or stroke 
  • Recent surgery 
  • Impaired thirst 
  • Limited access to water 
  • Older age 
  • Poor kidney function 
  • Uncontrolled diabetes 
  • Some medicines, such as corticosteroids and certain diuretics 

HHS and DKA are similar in that they both stem from an insulin deficiency. Unlike DKA, though, the production of ketones in HHS is very rare; that’s because the beta cells in the pancreas still produce some insulin. However, if you take a diabetes medicine called an SGLT-2 inhibitor (e.g., Invokana, Farxiga, Steglatro or Jardiance), there is a risk of DKA. Talk with your provider about checking for ketones if you take any of these medicines. 

If you have HHS symptoms, you need to go to the emergency room or call 911 right away. Treatment will include IV fluids to reverse dehydration, insulin to lower blood sugar levels, and electrolyte replacement, if needed. The doctor will aim to treat any underlying infections or conditions that caused the HHS. Side effects of HHS treatment may include hypoglycemia, swelling of the arms and legs, and weight gain.  

It’s estimated that between 5% to 20% of people with HHS will die, usually due to the underlying cause. The prognosis is worse for elderly people and people who are in a coma or who have hypotension (low blood pressure). Prevention of HHS is vital, as is knowing the early signs and symptoms of this condition.  

COVID-19 and HHS

As with DKA, the presence of coronavirus can cause a release of hormones, especially glucagon and cortisol that lead to high blood sugar levels. Researchers have also discovered that coronavirus leads to higher amounts of cytokines in people with diabetes. Cytokines are proteins that play a role in the inflammatory process. It’s thought that a COVID-19 infection is linked with triggering HHS due to this severe inflammatory response and resulting “cytokine storm, even in people with well-controlled type 2 diabetes. 


Both DKA and HHS are extremely serious conditions that can have dire consequences if not treatedFortunately, there are ways to prevent both of these conditions: 

  • Know the signs and symptoms of DKA or HHS. 
  • Take your diabetes medicines (including insulin) as prescribed, especially when you are ill. 
  • Check your blood sugar levels often when you are sick. If your levels are running above 240 mg/dl for two or more readings, contact your healthcare provider to discuss next steps. 
  • Even if you have COVID-19 and don’t have symptoms, it’s important to be diligent with taking your diabetes medicines and checking your blood sugars regularly. 
  • If you have type 1 diabetes, check for ketones when you are sick or under stress. If you have type 2 diabetes and take insulin, talk with your diabetes educator or provider to find out if you should check for ketones. 
  • Drink plenty of sugar-free fluids. 
  • Do your best to follow your usual eating plan; if you are unable to eat, alternate drinking sugar-free beverages with those that contain sugar, such as ginger ale or apple juice. 
  • Wear or carry a form of medical identification. 
  • Stay up to date with your vaccinations. 
  • Tell a family member or friend about the signs and symptoms of DKA or HHS so that they can help recognize them and get you emergency medical help, if needed. 

Want to learn more about coronavirus and diabetes? Read “Coronavirus and Diabetes: A COVID-19 Update,” “Healthy Eating During Hard Times” and “COVID-19: Staying Safe at Work.”


Amy Campbell, MS, RD, LDN, CDCES

Amy Campbell, MS, RD, LDN, CDCES

Amy Campbell, MS, RD, LDN, CDCES on social media

A Registered Dietitian and Certified Diabetes Educator at Good Measures, LLC, where she is a CDE manager for a virtual diabetes program. Campbell is the author of Staying Healthy with Diabetes: Nutrition & Meal Planning, a co-author of 16 Myths of a Diabetic Diet, and has written for  publications including Diabetes Self-Management, Diabetes Spectrum, Clinical Diabetes, the Diabetes Research & Wellness Foundation’s newsletter,, and

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