There has not been a significant update on the management of Diabetes Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Syndrome since 2009. To remedy this, eight international diabetes organizations met to determine a consensus statement reflecting best practices that can be applied worldwide and in various settings. Researchers unveiled an updated consensus statement on hyperglycemic crises at the 2023 EASD Conference in Hamburg, Germany, in October 2023. However, the actual consensus statement has yet to be available online, but the authors shared some highlights through interviews and statements.

Rates of DKA and HHS on the Rise

From 2014 to 2018, emergency department visits among adults with diabetes increased by 21%, according to the CDC’s National Diabetes Statistics report. However, many rural healthcare facilities and providers may not be familiar with best practices when it comes to treating hyperglycemic crises. Patients may be discharged on ineffective insulin regimens or may continue taking their SGLT-2 Inhibitors, which can contribute to increased mortality. With the distribution of these new guidelines, the goal is to standardize and improve diagnosis, treatment, and follow-up.

Changing the Glucose Cutoff for DKA diagnosis 

With the emergence of euglycemic ketoacidosis secondary to mainly SGLT-2 Inhibitor use and other factors, the new hyperglycemia cutoff is now lowered to 200 mg/dL from the previous 250 mg/dL. However, the glucose cutoff has been removed entirely for people with a history of diabetes.

Assessing for DKA

The new guideline strongly recommends using beta-hydroxybutyrate via point-of-care tests or laboratory measurements with a low cutoff equal to or greater than 3.0 mmol/L. Alternatively, a urine ketone strip value of 2+ or greater can be used. The urine ketone test is beneficial for rural settings who may not have access to beta-hydroxybutyrate testing,

Less focus on anion gap.

Metabolic acidosis is now defined as a pH < 7.3 and a bicarbonate concentration < 18 mmol/L. Also, the anion gap has been removed from the primary definition, but the document will say that it can still be used in settings where ketone testing is unavailable.

Assessing for HHS

The glucose cutoff of 600 mg/dL or greater for HHS will stay the same. But now, the effective serum osmolality has been lowered from more than 320 to more than 300 mOsml/L to account for the effect of dehydration, along with alternative criteria of total serum osmolality of more than 320 mOsm/L. The same two changes as with DKA for both ketones and acidosis have also been included for HHS.

Different treatment strategies

In the statement, DKA is still classified as mild, moderate, or severe. All levels can be treated with IV insulin, fluids, and electrolyte replacement therapy. However, mild DKA can be treated with subcutaneous insulin therapy replacement, which may decrease the need for extended hospitalization.

Making the right diagnosis

Half of new-onset type 1 diabetes occurs in adults who are often misdiagnosed as type 2 diabetes, putting them at risk for DKA.

Transition to discharge. 
Mortality increases for those with multiple episodes of DKA and HHS. There is a need for careful follow-up and post-discharge monitoring and assistance.

Many times, social determinants of health are a driver of recurrent hyperglycemic crises. 

Addressing risk factors and providing resources for ongoing care must be included in the treatment plan.

We will discuss other updates in more detail in our upcoming webinar on Hyperglycemic Crisis – DKA and HHS New Guidelines.

More research needed

There are still gaps in the best treatment approaches, and more research is needed. This new unified international definition and treatment plan allows more effective comparisons and further research on best practices for diabetes hyperglycemic crisis.

The aim is to get the word out to community hospitals, primary care providers, and ED providers to increase familiarity with identifying and effectively treating DKA and HHS.

From EASD Interview posted on October 27, 2023 and Medscape article

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Join us for our upcoming Hyperglycemic Crises, DKA & HHS Standards webinar

Airs live on December 12th, 2023, at 11:30 am PT

Topics:

• Discuss the common causes of hyperglycemic crises.
• List the differences & similarities between DKA and HHS and treatment strategies.
• Describe the causes & treatment of hyperglycemic crises.

This course discusses common causes of hyperglycemia crises. Topics include hyperglycemia secondary to medications & insulin deprivation. The differences & similarities between Diabetes Ketoacidosis and hyperosmolar Hyperglycemic Syndrome are also covered. Treatment strategies for all situations are included.

Can’t make it live? No worries. We will send post the recorded version to the Online University within 24 hours of the broadcast

Instructor: Beverly Thomassian RN, MPH, CDCES, has been Board Certified in Advanced Diabetes Management for over 20 years. She is an Associate Clinical Professor at UCSF, a working educator, and a nationally recognized diabetes expert. She has a Master’s Degree in Public Health from UCLA, with a focus on behavioral health and education.

All hours earned count toward your CDCES Accreditation Information

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