“The number of patients with hyperglycaemic crises has increased worldwide,” says Guillermo E. Umpierrez, lead author of a new consensus report that was simultaneously published in Diabetologia and Diabetes Care. In both type 1 and type 2 diabetes, there has been a significant increase in cases of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS).
In order to provide up-to-date knowledge on the management of hyperglycaemic crises, the European Association for the Study of Diabetes (EASD) – together with the American Diabetes Association (ADA), the Joint British Diabetes Societies for Inpatient Care ((JBDS-IP), the American Association of Clinical Endocrinology (AACE) and the Diabetes Technology Society (DTS) – convened a panel of experts to update the 2009 ADA consensus statement on hyperglycaemic crises in adults with diabetes. In their collaborative effort, the societies cover a broad range of topics from epidemiology, pathophysiology and clinical presentation to prevention, diagnosis, treatment and future areas of research.
Hyperglycaemic crises on the rise
“DKA and HHS are the most serious, acute and life-threatening hyperglycaemic emergencies in people with type 1 and type 2 diabetes,” the consensus authors agree. The global increase in hospitalisations underscores the need for updated guidelines that include recently published data. This urgency is further emphasised by the rising DKA and HHS cases during the COVID-19 pandemic and the evidence regarding an increased risk of DKA associated with SGLT2 inhibitors.
While exact numbers are elusive, recent data suggest that rates of hyperglycaemic crisis range from 44.5 to 82.6 per 1,000 person-years in type 1 diabetes and up to 3.2 per 1000 person-years in type 2 diabetes – the latter being a much lower rate but accounting for most of the admissions. The new guidelines aim to provide healthcare professionals, researchers and people with diabetes with the latest data and recommendations.
Lower glucose threshold to diagnose DKA
The most significant changes to the 2009 ADA consensus include updated diagnostic criteria: The plasma glucose threshold for hyperglycaemia as a criterion for DKA has been lowered from > 13.9 mmol/l or 250 mg/dl to ≥11.1 mmol/l or 200 mg/dl, or even a history of diabetes alone, regardless of glucose levels. This accounts for a wide range of clinical presentations, including euglycaemic DKA.
In addition to hyperglycaemia or diabetes, the diagnosis of DKA is based on the presence of elevated ketones and metabolic acidosis. “All three components must be present to make this diagnosis,” the guidelines state, while “HHS is characterised by severe hyperglycaemia, hyperosmolality, and dehydration in the absence of significant ketosis or acidosis.” This is due to residual insulin secretion in HHS, but not in DKA.
Both DKA and HHS can occur in any type of diabetes and at any age. Typically, DKA is more frequent in younger people with type 1 diabetes, while HHS is more common in older people with type 2 diabetes. Both emergencies are often the result of infections (mainly urinary tract infections and pneumonia) or non-adherence to insulin therapy.
Switching to subcutaneous insulin
For the treatment of DKA, the guidelines recommend the use of either subcutaneous (SC or intravenous (IV insulin, depending on the severity. “Patients with uncomplicated, mild or moderate DKA may be treated with SC rapid-acting insulin analogues,“ the guidelines state, recommending administration every 1–2 hours as an alternative to IV infusion of short-acting insulin. However, this is not the case for severe and complicated DKA or for HHS, where fixed rate IV insulin infusions remain the state of the art. General points to consider during the transition to SC insulin include the risk of hypoglycaemia, nutritional intake, IV dextrose infusion and insulin use (see figure 1 for detailed recommendations).
After 15 years: EASD and other societies present updated recommendations on how to manage hyperglycaemic crises in adults
A new consensus report offers key insights from over 6,000 articles on diabetic ketoacidosis and hyperglycaemic hyperosmolar state published since the previous 2009 consensus statement. Here we summarise how the evolving knowledge impacts clinical practice..
“DKA and HHS have a similar underlying pathogenesis consisting of insulin deficiency, increased counterregulatory hormones, and loss of fluid and electrolytes,” as stated in the consensus report. Therefore, in addition to insulin therapy, treatment includes fluid replacement and replenishment of electrolytes, especially potassium, which is usually within range initially but declines within 48 hours of admission. Routine administration of bicarbonate is not recommended, but should be considered if the acidosis is severe. In any case, the underlying cause(s) should be identified and treated accordingly, and all measures should be accompanied by stringent monitoring. “Appropriate treatment has reduced mortality owing to DKA to < 1 %; however, mortality has remained five- to tenfold higher in individuals with HHS,” the guidelines state, summarising the successes and remaining challenges in the management of hyperglycaemic crises. Because of the residual risk of death, patients should be admitted to intensive care in severe cases or when a critical illness is the precipitating cause.
Focus on preventing recurrence
Hyperglycaemic crises require immediate resolution, but also effective post-crisis management. The guidelines stress the importance of motivating healthcare professionals and people with diabetes to identify triggers and to prevent recurrences, which are common especially in DKA. “Hyperglycaemic crises are associated with substantial morbidity, mortality and costs,” the consensus points to the many levels at which successful prevention or management of hyperglycaemic crises could benefit both people and the healthcare system.
“Since the ADA last published consensus recommendations 15 years ago, there have been over 6,000 new publications. We’ve done a tremendous amount of work in reviewing the important information to improve the lives of people with diabetes,” says Umpierrez, who hopes that the new consensus report will provide readers with new insights into how hyperglycaemic crises develop, present and should be dealt with.
Key Points:
- The number of hospitalisations for diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) has increased worldwide.
- In the new consensus report the plasma glucose threshold for the diagnosis of hyperglycaemia in DKA has been lowered to ≥11.1 mmol/l or 200 mg/dl, considering clinical presentation.
- Depending on severity, DKA may be treated with either SC or IV insulin, with specific protocols for transitioning to SC administration. The insulin regimen in severe DKA and HHS remains fixed rate IV insulin infusion.
- The consensus report emphasises the need for healthcare professionals and people with diabetes to identify triggers and to prevent the recurrence of hyperglycaemic crises in order to reduce morbidity and mortality.
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Author: Hanna Gabriel, BA MSc. Any opinions expressed in this article are the responsibility of EASD e-Learning.
Watch out: An EASD e-Learning Module on the new consensus report on hyperglycaemic crises in adults (featuring Guillermo E. Umpierrez, Ketan Dhatariya, Gian Paolo Fadini and Shivani Misra) will be published on EASD e-Learning in early 2025