Treatment of Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS): Novel Advances in the Management of Hyperglycemic Crises (UK Versus USA)

Abstract

Purpose of ReviewDiabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the UK and USA. This review delineates the differences in diagnosis and treatment between the two countries.Recent FindingsLarge-scale studies to determine optimal management of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation.SummaryThere is considerable overlap but important differences between the UK and USA guidelines for the management of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol.

Empagliflozin as adjunct to insulin in Japanese participants with type 1 diabetes: Results of a 4‐week, double‐blind, randomized, placebo‐controlled phase 2 trial

“…Empagliflozin increased levels of serum ketone bodies in Japanese participants with T1DM in this study, as was previously observed in non‐Japanese and Japanese participants with T2DM receiving empagliflozin. Mean serum BHB levels after 4 weeks of empagliflozin treatment were generally <0.5 mmol/L, with the highest individual BHB level at approximately 0.8 mmol/L, below the levels of total ketone bodies seen with physiological ketosis, such as prolonged fasting or exercise (1‐2 mmol/L), and well below levels seen in DKA (>3 mmol/L) . Importantly, special attention was paid to prevention of DKA during the study, including adoption of measures such as avoiding marked reduction in insulin dose.…”

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

“…1763 Patients presenting with mild diabetic ketoacidosis who are alert and able to tolerate oral fluids may be able to receive treatment in the emergency department, potentially with oral fluids and subcutaneous insulin, and without need for hospital admission 64. Patients presenting with more severe degrees of metabolic derangement need to be admitted to a hospital unit with trained personnel and resources for intensive monitoring and administration of intravenous fluids, potassium, and insulin.…”

“…The ADA and the Joint British Diabetes Societies for Inpatient Care have both published guidelines for management of diabetic ketoacidosis, but these guidelines have several differences. These differences are primarily due to lack of published evidence to guide treatment in many areas 63. Despite this, the ADA guideline has been widely distributed, is used internationally, and has been cited more than 600 times 63.…”

“…These differences are primarily due to lack of published evidence to guide treatment in many areas 63. Despite this, the ADA guideline has been widely distributed, is used internationally, and has been cited more than 600 times 63. In addition, a survey of 118 UK clinical diabetes teams found that the UK guideline has been adopted by more than 90% of those surveyed 1065…”

“…Although not specifically designated as a guideline, it has been used for this purpose with several more recent reviews and commentaries that outline both the strengths and weaknesses of this widely followed report, as well as areas that are in need of revision or future study 7106063. The most recent 2019 ADA clinical practice recommendations for management of diabetic ketoacidosis include several updates to the 2009 consensus statement, as pointed out in table 1 and table 2 6.…”