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

From the Guidelines

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

Key Components of Treatment

• Aggressive fluid replacement with normal saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour, then adjusted based on hemodynamic status
• Insulin therapy with regular insulin 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
• Electrolyte replacement, particularly potassium, phosphate, and magnesium, as levels will drop with insulin therapy
• Identification and treatment of underlying causes such as infection, medication non-compliance, or acute illness

Monitoring and Adjustments

• Close monitoring of vital signs, mental status, fluid balance, electrolytes, and glucose levels is essential throughout treatment
• Adjustments to insulin therapy and fluid replacement should be made based on patient response and laboratory results
• Transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia, as supported by recent studies 1

Importance of Prompt Treatment

• HHS carries a higher mortality rate than diabetic ketoacidosis due to the extreme dehydration and hyperosmolarity, making prompt and aggressive treatment necessary to prevent complications like thrombosis, rhabdomyolysis, and cerebral edema
• The use of bicarbonate in patients with DKA or HHS is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1

From the Research

Treatment Overview

The treatment for Hyperosmolar Hyperglycemic State (HHS) involves a multi-step approach to address the underlying causes and manage the symptoms. The primary goals of treatment are to:

• Improve clinical status and replace fluid losses
• Gradually decline osmolality to minimize the risk of neurological complications
• Achieve a blood glucose level between 10-15 mmol/L in the first 24 hours
• Prevent hypoglycemia, hypokalaemia, and other complications

Treatment Strategies

The following treatment strategies are recommended:

• Fluid replacement: Intravenous (IV) 0.9% sodium chloride to restore circulating volume, with caution in elderly patients 2, 3, 4
• Insulin therapy: Fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement, unless there is ketonaemia 2, 3
• Glucose infusion: 5% or 10% glucose infusion should be started once glucose <14 mmol/L 2
• Potassium replacement: According to potassium levels 2, 5, 4
• Monitoring: Intensive monitoring of the patient and laboratory values, especially glucose, sodium, and potassium levels 2, 3, 6, 4

Resolution Criteria

The resolution of HHS is determined by the following criteria:

• Osmolality <300 mOsm/kg
• Hypovolaemia corrected (urine output ≥0.5 ml/kg/h)
• Cognitive status returned to pre-morbid state
• Blood glucose <15 mmol/L 2

Precipitating Causes

Underlying precipitants must be identified and treated simultaneously with correction of the metabolic abnormalities 2, 5, 4