What are the presentations of Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic Nonketotic (HONK) syndrome, and Hypoglycemia?

From the Guidelines

Diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS or HONK), and hypoglycemia are critical complications of diabetes that require prompt recognition and management, with presentations ranging from mild hyperglycemia and acidosis to severe hyperglycemia, dehydration, and coma 1.

Presentations of DKA, HHS/HONK, and Hypoglycemia

• DKA is characterized by hyperglycemia (blood glucose >250 mg/dL), ketosis, and metabolic acidosis (pH <7.3 or bicarbonate <15 mEq/L) 1.
• HHS/HONK presents with severe hyperglycemia (>600 mg/dL) without significant ketosis or acidosis, and is more common in older adults with type 2 diabetes 1.
• Hypoglycemia (blood glucose <70 mg/dL) can occur in any diabetic patient, especially those on insulin or sulfonylureas, with symptoms including sweating, tremors, and confusion 1.

Management and Treatment

• Management of DKA and HHS/HONK involves restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis, with individualization of treatment based on careful clinical and laboratory assessment 1.
• Treatment of DKA and HHS/HONK should focus on fluid resuscitation, insulin therapy, and electrolyte replacement, with careful monitoring of electrolytes and osmolality 1.
• Immediate treatment of hypoglycemia involves administering 15-20g of fast-acting carbohydrates orally if the patient is conscious, or 1mg glucagon IM/SC if unconscious 1.

Prevention and Education

• Addressing the underlying cause of DKA, HHS/HONK, and hypoglycemia, such as infection or medication non-compliance, is crucial for prevention 1.
• Regular blood glucose monitoring, patient education on recognizing symptoms, and adjusting diabetes management plans are essential for prevention and management of these complications 1.

From the FDA Drug Label

Hypoglycemia (too little glucose in the blood) is one of the most frequent adverse events experienced by insulin users. Symptoms of mild to moderate hypoglycemia may occur suddenly and can include: sweating drowsiness dizziness sleep disturbances palpitation anxiety tremor blurred vision hunger slurred speech restlessness depressed mood tingling in the hands, feet, lips, or tongue irritability lightheadedness abnormal behavior inability to concentrate unsteady movement headache personality changes Signs of severe hypoglycemia can include: disorientation seizures unconsciousness death Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. Hyperglycemia, diabetic ketoacidosis, or hyperosmolar coma may develop if the patient takes less Humulin R U-100 than needed to control blood glucose levels Early signs of diabetic ketoacidosis include glycosuria and ketonuria Polydipsia, polyuria, loss of appetite, fatigue, dry skin, abdominal pain, nausea and vomiting and compensatory tachypnea come on gradually, usually over a period of some hours or days, in conjunction with hyperglycemia and ketonemia.

The presentations of:

• Hypoglycemia include symptoms such as sweating, drowsiness, dizziness, and irritability, and signs of severe hypoglycemia include disorientation, seizures, unconsciousness, and death.
• Diabetic Ketoacidosis (DKA) include a drowsy feeling, flushed face, thirst, loss of appetite, fruity odor on the breath, glycosuria, ketonuria, polydipsia, polyuria, loss of appetite, fatigue, dry skin, abdominal pain, nausea, vomiting, and compensatory tachypnea.
• Hyperosmolar Hyperglycemic Nonketotic (HONK) syndrome is mentioned as hyperosmolar coma, which may result from severe sustained hyperglycemia. 2 2

From the Research

Presentations of Diabetic Emergencies

The presentations of Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic Nonketotic (HONK) syndrome, and Hypoglycemia are as follows:

• Diabetic Ketoacidosis (DKA): characterized by insulin deficiency and ketoacidosis, with prominent features of the clinical presentation including hyperglycemia, ketosis, and acidosis 3, 4, 5
• Hyperosmolar Hyperglycemic Nonketotic (HONK) syndrome: characterized by severe hyperglycemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of ketoacids 6, 4, 5
• Hypoglycemia: a limiting factor for achieving ambitious glucose targets, representing a severe and potentially life-threatening complication of diabetes mellitus that requires prompt diagnostics and treatment 7

Clinical Features

The clinical features of these disorders include:

• DKA: hyperglycemia, ketosis, and acidosis, with patients usually presenting with a prolonged phase of osmotic diuresis leading to severe depletion of both the intracellular and extracellular fluid volumes 3, 4
• HONK syndrome: severe hyperglycemia, hyperosmolarity, and dehydration, with patients usually presenting with a prolonged phase of osmotic diuresis leading to severe depletion of both the intracellular and extracellular fluid volumes 6, 4
• Hypoglycemia: severe and potentially life-threatening complication of diabetes mellitus, requiring prompt diagnostics and treatment 7

Treatment

The treatment regimens for these disorders include:

• DKA: aggressive administration of intravenous fluids with appropriate replacement of electrolytes, followed by administration of insulin, usually via an intravenous insulin infusion 3, 4, 5
• HONK syndrome: restoration of the intravascular volume to assure adequate perfusion of vital organs, administration of hypotonic fluids, and replacement of potassium and other electrolytes 6, 4
• Hypoglycemia: prompt diagnostics and treatment, with the goal of restoring normal blood glucose levels 7