Hyperosmolar non-ketotic diabetic syndrome precipitated by treatment with diuretics.

Abstract

The hyperosmolar non-ketotic diabetic syndrome, first reported in 1957,' is being diagnosed with greater frequency.' Several cases have been reported of this syndrome being precipitated by treatment with diuretics, especially thiazide diuretics and frusemide.3-9 Diuretic treatment lasted from 15 days4 to 4 years" before the syndrome developed. We reviewed the case notes of a consecutive series of 11 patients with the hyperosmolar non-ketotic diabetic syndrome to find out how often diuretic treatment precipitated it. The criteria used for diagnosis were severe hyperglycaemia (blood glucose greater than 30 mmol/l (541 mg/100 ml)), absence of ketoacidosis, dehydration, variable neurological signs, including depressed sensorium or frank coma, and serum osmolarity above 340 mOsm/kg (calculated using the formula: osmolarity (mOsm/kg) 2 x (serum sodium + potassium) +blood glucose +blood urea). Case report One week before admission a woman aged 59 years was started on treatment for symptomless hypertension with Moduretic (amiloride 5 mg and hydrochlorothiazide 50 mg) two tablets daily. There was no family history of diabetes and no glycosuria. Soon after starting treatment she became tired, weak, thirsty, and had polyuria. On admission she was afebrile, drowsy,

The Impact of Hyperosmolarity on Long-Term Outcome in Patients Presenting with Severe Hyperglycemic Crisis: A Population Based Study

“…This is an important observation because both may be predisposing factors for HHS. A few case reports of HHS precipitated by diuretic use have been described [13]. Although antipsychotics and antidepressants are well known precipitators of both HHS and diabetic ketoacidosis [14], little is known about the role of benzodiazepines in these clinical entities.…”

A comparison of the effects of bumetanide (Burinex) and frusemide on carbohydrate metabolism in the elderly

“…The elderly patient is particularly vulnerable to this complication of diuretic therapy and in the series of 11 cases of the diabetic hyperosmolar syndrome reported by Fonseca & Phear 6 all patients were aged 60 or more. The present investigation was carried out in order to compare the effect of bumetanide with that of frusemide on carbohydrate metabolism in this vulnerable sub‐population of elderly patients.…”

“…The hyperosmolar non‐ketotic diabetic syndrome has been described during treatment with frusemide 9 , ethacrynic acid 10 and thiazide diuretic treatment 11 . Despite widespread use over the last 15 years, there appears to be only a single report in the literature of the hyperosmolar diabetic syndrome during treatment with bumetanide 6 . This patient received concomitant treatment with propanolol which itself has been implicated as a precipitating factor 12 .…”

“…The combination of a diabetogenic effect, together with a potent diuretic response, is potentially dangerous, with the risk of precipitating hyperosmolar diabetic coma. This is seen particularly in elderly patients, who may or may not have a history of pre‐existing diabetes, and has been described with a variety of diuretics 5 , 6 . We are aware of only one such report implicating bumetanide 6 and it has been shown in healthy volunteers that this drug may have a beneficial effect on carbohydrate metabolism 7 .…”

“…This is seen particularly in elderly patients, who may or may not have a history of pre‐existing diabetes, and has been described with a variety of diuretics 5 , 6 . We are aware of only one such report implicating bumetanide 6 and it has been shown in healthy volunteers that this drug may have a beneficial effect on carbohydrate metabolism 7 .…”