Global consensus and update on hyperglycaemic crises

Type 1 diabetes

By Mardi Chapman

1 Jul 2024

A consensus report on hyperglycaemic crises in adults with diabetes has provided a significant update on the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS).

The report, which updates a 2009 ADA document, is endorsed by the American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), American Association of Clinical Endocrinology (AACE), Joint British Diabetes Societies for Inpatient Care (JBDS), and Diabetes Technology Society (DTS).

Setting the scene at the ADA Scientific Sessions, Assistant Professor Georgia Davis, from the Emory Global Diabetes Research Center in Atlanta, said there had been a rise in the rate of hyperglycaemic emergencies in adults with both type 1 and type 2 diabetes in the early 2000s.

More recently, COVID-19 had increased the rate of DKA in newly-diagnosed diabetes compared to the pre-epidemic period.

Assistant Professor Davis said infection was still one of the most common precipitating factors for DKA worldwide, followed closely by insulin omission.

“We also need to mention the use of SGLT2 inhibitors and the risk of DKA, particularly euglycaemic DKA … increased by over threefold for patients with type 1 diabetes … and at least twofold in type 2 diabetes.”

She said the 30-day DKA readmission rate was about 20% and while mortality has reduced in DKA, it has remained high in HHS and seems to be plateauing overall.

Diagnostic criteria

Professor Ketan Dhatariya, from the Elsie Bertram Diabetes Centre in Norwich, UK, told the meeting there had been some changes in the definition of DKA and HHS. In particular:

  • the threshold for hyperglycaemia in DKA has been lowered from ≥250 to ≥200 mg/dl (13.9 to 11.1 mmol/L)
  • a prior history of diabetes has been added to the criteria for DKA to account for euglycemic DKA, which is now more common due to SGLT2 inhibitor use
  • measurement of beta-hydroxybutyrate in blood, ideally at the bedside, was strongly recommended over urine testing for ketones
  • total serum osmolarity was included along with lowering of effective serum osmolality to >300 mOsm/kg, in one of four essential criteria for HHS.

“There is an overlap epidemiologically, with a third of people having both DKA and HHS, but if you have both, you treat them as DKA because that kills people more quickly than HHS.”


Associate Professor Rodolpho Galindo, from the University of Miami and Director of the Comprehensive Diabetes Center of UHealth, told the meeting the three pillars of therapy were IV fluids, insulin and potassium.

Bicarbonate and phosphate were now relegated to sidenotes given their routine administration was not recommended as part of the treatment pathways for DKA or HHS.

Regarding fluid resuscitation, Associate Professor Galindo said the fluid choice should be determined by local availability, cost and resources.

“There is some evidence that balanced crystalloid solutions may result in faster DKA resolution, shorter length of stay in the hospital, and also less hyperchloraemic metabolic acidosis,” he said.

The consensus report recommended any fluid deficit is ideally corrected in the first 24–48 hours.

For insulin therapy, the recommendations are to use subcutaneous or IV insulin in mild DKA, IV insulin in moderate or severe DKA, and in HSS.

The consensus also includes advice on the transition to maintenance insulin therapy, criteria for the resolution of DKA and HSS and mitigation of potential complications.


Professor David Klonoff, Medical Director of the Dorothy L. and James E. Frank Diabetes Research Institute of Mills-Peninsula Medical Center in San Mateo, California, told the meeting that prevention of frequent readmissions with DKA required consideration of patient factors, social determinants of health and diabetes technology.

He said suboptimal glucose control was a risk factor for readmission in DKA.

“These are people who weren’t in good control before they came into the hospital, and these are the people that are most likely to come back. These people can benefit from diabetes education,” he said.

“HHS often is a completely different disease. It’s not necessarily precipitated by failing to take insulin, but it’s usually a severe version of a comorbidity associated with dehydration. So there’s a variety of diagnoses that can lead to HHS.”

He said patients need a comprehensive assessment and interdisciplinary collaboration.

“You want to identify a precipitating factor such as an acute illness or omission of insulin, you want to review techniques for insulin injection, also blood glucose testing, their insulin pump settings, test for ketones, and assess insulin effectiveness. Have they been keeping the insulin where it’s supposed to be, either at room temperature ideally, but definitely not too hot, and how’s the expiration date?”

“One of the reasons why people can be readmitted is they have cognitive impairment.”

He noted a recent US study [link here] found cognitive impairment increased the risk of DKA readmission by 35% however appropriate postdischarge care decreased the risk of readmission by 27%.

Professor Klonoff also said the use of diabetes technology – text messaging, CGM, smart insulin pens and continuous ketone monitoring – have also been shown effective in reducing readmissions.

The consensus report has been published in Diabetes Care [link here] and Diabetologia [link here].

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