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Hyperosmolar hyperglycemic syndrome (HHS)

Most PWD have been warned over and over again of the signs and symptoms of Diabetic Ketoacidosis (DKA); nausea, vomiting, abdominal pain, thirst, frequency, and of course, ketones! Hyperosmolar Hyperglycemic Syndrome (HHS), another acute complication of diabetes is much less talked about, but equally as dangerous. Though DKA and HHS are different in their pathogenesis, the basic cause is similar; low circulating insulin or insulin resistance coupled with an increase in counterregulatory hormones (epinephrine, catecholamines, cortisol, growth hormone).


The above pathophysiology causes an increase in ketone bodies through the breakdown of triglycerides (lipolysis). In this metabolic state, ketones instead of glucose can be used by the body’s cells for energy; the basic principle of the ketogenic diet. The subsequent lipolysis results in weight loss in both PWD and people without diabetes. Though people without diabetes consistently make enough insulin to maintain glucose homeostasis, this is not the case in PWD. High circulating ketone bodies can therefore result in a state of metabolic acidosis, known as DKA.


Unlike in DKA, PWD who develop HHS have enough insulin circulating to prevent lipolysis and the production of ketones, but not enough insulin to prevent hyperglycemia and severe volume depletion. Most patients who develop HHS have undiagnosed type 2 diabetes or have type 2 diabetes and develop infections, begin steroid medications, or stop taking their medications for one reason or another.


Unlike in DKA, which usually develops within 24 hrs, HHS develops over a longer period of time. In HHS, hyperglycemia results in dehydration and a high blood osmolality. This can cause the person to become stuporous or comatose. Most people with HHS are admitted to the hospital with blood glucose levels over 600mg/dL, but with little to no urine or blood ketones!


DKA and HHS are treated similarly in the hospital setting; hydration, insulin, electrolyte management, and management and diagnosis of the precipitating cause. I had a newly diagnosed T2DM present with HHS recently...don’t worry. They are a-okay!


FYI this picture has nothing to do with HHS, but i’ve been reminiscing about the last time I had all my friends and family together. Missing my dad this holiday season! I’m looking forward to a time when I can safely be with my parents again.



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