Hyperosmolar hyperglycemic state (HHS) is a serious metabolic condition that can occur in patients with type 2 diabetes. It is a life-threatening condition resulting out of very high blood sugar levels (often greater than 40mmol/l.) HHS was originally known as hyperosmolar hyperglycemic nonketotic coma. The name was later changed as coma was seen in less than 20% of cases of this disorder.
What is Hyperosmolar Hyperglycemic State?
HHS is a complication of type 2 diabetes characterized by severe dehydration and an increase in osmolarity (relative concentration of soluble compounds in the blood.) HHS can result from high blood sugar (often greater than 40mmol/l.) It can develop over a course of a few weeks due to a combination of illness (often an infection) and dehydration. One of the potential causes of this condition is stopping blood sugar lowering medication due to difficulty in swallowing and nausea (often symptoms of an infection.) However, the condition can occur despite regular medication. The hormones produced in the body during an illness that contribute to the rise in blood sugar.
Symptoms of Hyperosmolar Hyperglycemic State
- Frequent urination
- Excessive thirst
- Dryness of skin
- Drowsiness and later, loss of consciousness
According to the American Diabetes Association, diagnostic features of HHS include:
- Plasma glucose level of 600 mg/dL or greater
- Effective serum osmolality (measure of the concentration of a solution; normal ranges are between 278 and 300 mOsm/kg) of 320 mOsm/kg or greater
- Severe dehydration, up to an average of 9L (this is the average loss of fluids from the body)
- Serum pH (measure of acidity or alkalinity, with figures less than 7 denoting acidity and higher denoting alkalinity) greater than 7.30
- Bicarbonate concentration greater than 15 mEq/L (normal ranges are between 23 and 29 mEq/L)
- Small ketonuria (ketone bodies in urine) and low to absent ketonemia (ketone bodies in blood)
- Some alteration in consciousness
What Causes Hyperosmolar Hyperglycemic State?
In HHS, there is a reduction in the levels of circulating insulin that eventually lead to high blood sugar. This reduction in insulin is caused by an increase of counterregulatory hormones that the body produces in response to an illness. Counterregulatory hormones like cortisol and adrenaline work to decrease the levels and activity of circulating insulin.
A stress response to an infection (especially pneumonia or a urinary tract infection) causes the body to produce counterregulatory hormones that tend to increase blood glucose levels. In addition to infection, stress responses can also occur in conditions like:
- Silent MI (myocardial infarction or heart attack)
- Pulmonary embolism (a condition in which one or more arteries in your lungs get blocked by a blood clot)
- Intracranial hemorrhage (bleeding in the brain)
- Acute pancreatitis (inflammation of the pancreas)
HHS is often seen in elderly and chronically ill patients. These patients often have a decreased perception of thirst and do not have easy access to water. In general, any illness or condition that causes dehydration and a reduced activity of insulin increases the risk of HHS. Patients who have an underlying kidney or heart disease (congestive heart failure) are at a risk of HHS. Drugs and substances that raise blood glucose levels, inhibit insulin or cause dehydration can also increase the risk of HHS. These include alcohol, cocaine, anti-diabetic medications, antihypertensives (drugs to lower high blood pressure), beta blockers, corticosteroids, statins, diuretics, etc.
How is Hyperosmolar Hyperglycemic State Treated?
HHS is a hospital emergency and is treated by correcting the underlying fluid imbalance. This is usually done by infusing fluids through an intravenous drip. Since there is a loss of between 8 to 12 liters during HHS, the infusion has to be done slowly over a period of 24 hours. Initial rates of IV are kept at 1 liter per hour for a few hours or till the condition is stabilized. The rates of infusion are lowered thereafter, so as not to rehydrate the patient too quickly. Rapid rehydration may lead to other complications like electrolyte (like sodium, potassium and chloride) imbalance or fluid accumulation (edema) in the brain.
People with HHS usually have dangerously low potassium levels. Replacement of electrolytes, especially potassium, is done through an IV drip. Insulin is also given to the patient to reduce blood sugar levels. Insulin also acts to push potassium into cells. Potassium levels need to be sufficiently high else hypokalemia (very low potassium levels) may occur. Insulin infusion needs to start only after the body has sufficient potassium levels.
If left untreated, hyperosmolar hyperglycemic state can result in seizures, heart attack, stroke, coma, and death.
How to Prevent Hyperosmolar Hyperglycemic State?
Regular control and management of your diabetes can help you in preventing HHS. Also, being aware of situations that can put you at a risk of a hyperosmolar hyperglycemic state can also help. You need to know the symptoms of high blood sugar and you should regularly monitor your blood sugar levels. The frequency of testing for HHS should be increased when you are sick.
When you have an infection, you should keep yourself hydrated by drinking non-alcoholic, caffeine-free beverages regularly. You should continue with your diabetes management plan by getting a healthy diet. Since pneumonia can put you at risk of HHS, ask your doctor about pneumococcal vaccines and get yourself vaccinated.
Hyperosmolar hyperglycemic state is a rare metabolic health risk of type 2 diabetes. It is a condition that is completely preventable and also treatable if the symptoms are recognized early and treatment begins immediately.
Type 2 diabetes is fully reversible. A Functional Medicine approach helps you in looking at this chronic condition from a holistic perspective to help reverse it through dietary and lifestyle changes.