What is the treatment for Hyperosmolar Hyperglycemic State (HHS)?

From the Guidelines

The treatment for Hyperosmolar Hyperglycemic State (HHS) focuses on aggressive fluid replacement, insulin therapy, and addressing underlying causes, with the goal of restoring circulatory volume, resolving hyperglycemia, and correcting electrolyte imbalances, as recommended by the most recent guidelines 1.

Key Components of HHS Treatment

• Initial management requires immediate intravenous fluid resuscitation with normal saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour, then adjusted based on hemodynamic status.
• After starting fluid therapy, regular insulin should be administered as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr, titrating to achieve a glucose reduction of 50-70 mg/dL per hour, as supported by recent studies 1.
• Once blood glucose reaches 250-300 mg/dL, switch to 5% dextrose with continued insulin to prevent hypoglycemia.
• Electrolyte replacement, particularly potassium, is crucial as levels will fall with insulin therapy, and phosphate and magnesium should be monitored and replaced as needed.

Addressing Underlying Causes and Monitoring

• Underlying causes such as infection, myocardial infarction, or medication non-compliance must be identified and treated.
• Close monitoring of vital signs, mental status, fluid balance, electrolytes, and glucose levels is essential throughout treatment.
• The use of bicarbonate is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1.

Mortality and Morbidity Considerations

• HHS carries a mortality rate of 10-20%, higher than diabetic ketoacidosis, making prompt and appropriate management critical for patient survival.
• The risk of cerebral edema, a rare but potentially fatal complication, can be mitigated by gradual correction of glucose and osmolality, as well as judicious use of isotonic or hypotonic saline, depending on serum sodium and hemodynamic status 1.

From the Research

Treatment Overview

The treatment for Hyperosmolar Hyperglycemic State (HHS) involves several key components, including:

• Fluid and insulin administration to restore circulating volume and reverse dehydration 2, 3
• Monitoring of the response to treatment, including regular measurement of serum osmolality to monitor the response to treatment and aim to reduce osmolality by 3-8 mOsm/kg/h 2
• Delivery of care by a diabetes specialist team as soon as possible, with patients nursed in areas where staff are experienced in the management of HHS 2

Fluid Administration

• Intravenous (IV) 0.9% sodium chloride solution is used as the principal fluid to restore circulating volume and reverse dehydration 2, 3
• Fluid replacement alone will cause a fall in blood glucose (BG) level, and insulin should be withheld until the BG level is no longer falling with IV fluids alone (unless ketonaemic) 2
• An initial rise in sodium level is expected and is not itself an indication for hypotonic fluids 2

Insulin Administration

• Fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia 3
• Insulin therapy should be continuous, with regular monitoring of blood glucose levels and adjustment of insulin doses as needed 3, 4

Electrolyte Replacement

• Potassium replacement should be according to potassium levels, with regular monitoring to prevent hypokalemia 3, 4
• Other electrolyte abnormalities, such as hypophosphatemia and hypomagnesemia, should also be monitored and treated as needed 4

Monitoring and Prevention of Complications

• Regular monitoring of serum osmolality, blood glucose, and electrolyte levels is essential to prevent complications such as cerebral edema, seizures, and death 2, 3, 5, 4
• Prevention of hypoglycemia and hypokalemia is also crucial, with regular monitoring and adjustment of insulin and electrolyte replacement as needed 3, 4