Societies offer guidance on treatment of hyperglycemic crises

An updated consensus statement on hyperglycemic crises in patients with diabetes was jointly released by a number of medical organizations.

The American Diabetes Association (ADA), European Association for the Study of Diabetes, Joint British Diabetes Societies for Inpatient Care, American Association of Clinical Endocrinology, and Diabetes Technology Society collaborated to review the ADA's most recent statement on the subject, last updated in 2009, and to provide up-to-date knowledge about the epidemiology, pathophysiology, and clinical presentation of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS), as well as recommendations for treatment. The statement was published on June 22 by Diabetes Care and Diabetologia.

The statement provides diagnostic criteria for both DKA (glucose ≥200 mg/dL [11.1 mmol/L] or prior history of diabetes; beta-hydroxybutyrate concentration ≥3.0 mmol/L or urine ketone strip 2+ or greater; and pH <7.3 and/or bicarbonate concentration <18 mmol/L) and HHS (plasma glucose ≥600 mg/dL [33.3 mmol/L]; calculated effective serum osmolality >300 mOsm/kg or total serum osmolality >320 mOsm/kg; beta-hydroxybutyrate concentration <3.0 mmol/L or urine ketone strip less than 2+; and pH ≥7.3 and bicarbonate concentration ≥15 mmol/L). It also reviews the differing presentations of these two conditions, and provides a framework for categorizing DKA as mild, moderate, or severe and choosing a level of care accordingly.

The statement offers recommendations on treatment options, including fluids, insulin (initial and the transition to maintenance therapy), potassium, bicarbonate, and phosphate. It provides criteria for when DKA and HHS are resolved, guidance on potential complications of treatment, and considerations for special populations, including frail older adults, pregnant patients, and patients taking sodium-glucose co-transporter-2 inhibitors, requiring dialysis, or being treated for COVID-19 infection. Finally, the statement addresses prevention of DKA and HHS, recommending continuous glucose monitors be offered to all patients hospitalized with DKA on discharge, and outlines areas for future research.