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Managing DKA, Euglycemic DKA, And HHS: What’s New

DKA, Euglycemic DKA, and HHS are the three hyperglycemic emergencies, which if not diagnosed and managed properly, can lead to the death of the patient.

Euglycemic DKA (diabetic ketoacidosis) is one of the complications of SGLT2 Inhibitors.

It is being increasingly diagnosed since the markets have flooded with SGLT2 Inhibitors like Jardiance and Farxiga.

Euglycemic DKA, as the name suggests, is DKA in the absence of Hyperglycemia. Ketosis develops while the blood sugars are normal.

This is because Insulin is released in states of hyperglycemia and insulin secretion is suppressed when the blood glucose drops.

Patients who are on SGLT2 inhibitors have a state of relative insulin deficiency that results in ketosis.

DKA (Diabetic ketoacidosis) is a state of relative or absolute insulin deficiency. It commonly affects young kids with Type 1 Diabetes.

HHS or Hyperosmolar Hyperglycemic State commonly affects older individuals with Type 2 diabetes. It is associated with myocardial infarction, stroke, and venous thrombosis.


Diagnosing DKA, HHS, and Euglycemic DKA: Highlights of the new consensus guidelines:


Because of the increased occurrence of Euglycemic DKA, the new consensus guidelines which will soon be published, suggest a lower cut-off of blood sugars for diagnosing DKA [Ref].

The new consensus guidelines have lowered the blood sugar threshold to 200 mg/dl (11.1 mmol/L) (instead of 250 mg/dl).

Similarly, it is recommended to test Beta-Hydroxybutyrate via a point-of-care serum test or urinary ketones. The new cut-off for serum ketones is 3 mmol/L or more or 2+ urine ketones.

For metabolic acidosis, the cut-off for PH is <7.3 and the cut-off for bicarbonate is <18 (raised from the previous value of <15).

Anion gap is no longer considered important in all cases, however, in situations where ketones can not be performed, anion gap may be used.

For HHS, the blood sugar cut-off will remain the same, >600 mg/dl, however, the effective serum osmolality has been lowered from >320 mOsm/L to >300 mOsm/L.

DKA (Diabetic Ketoacidosis) is typically diagnosed when a person has:

  1. High blood glucose, usually exceeding more than 250 mg/dl (13.9 mmol/L)
  2. Metabolic Acidosis: PH <7.30 and Bicarbonate <18 mEq/L
  3. Ketonemia or ketonuria

Based on the degree of metabolic acidosis, DKA is further classified into mild, moderate, and severe DKA:

DKA Severity

pH Level

Serum Bicarbonate Level

Anion Gap

Mild DKA7.25 – 7.315-18 mEq/L> 10
Moderate DKA7.0 – 7.2410-<15 mEq/L> 12
Severe DKA< 7.0< 10 mEq/L> 12

HHS or Hyperosmolar Hyperglycemic State is diagnosed according to the ADA guidelines:

Diagnostic Features


Plasma Glucose Level600 mg/dL or greater
Effective Serum Osmolality320 mOsm/kg or greater
DehydrationProfound, up to an average of 9 L
Serum pHGreater than 7.30
Bicarbonate ConcentrationGreater than 15 mEq/L
Ketone LevelsSmall ketonuria and absent-to-low ketonemia
Consciousness AlterationSome alteration in consciousness

HHS is differentiated from DKA by the absence of severe hyperglycemia and acidosis.

The blood glucose in HHS usually exceeds 600 mg/dl and the PH is usually more than 7.30 with a Bicarbonate of more than 15 mEq/L.


Treating DKA, HHS, and Euglycemic DKA: Highlights of the new consensus guidelines:


The consensus guidelines also focused on the treatment of DKA. Here are some important points from the new consensus statement:

Bicarbonate should not be given except when the PH falls to less than 7.0

Crystalloids should be used as the preferred IV fluid and Dextrose may be added when the blood glucose falls to <250 mg/dl

In patients with Euglycemic DKA, Dextrose and Saline should be administered from the start.

Subcutaneous Insulin may be administered in patients with mild DKA (but not in moderate and severe DKA)

For patients with HHS, either insulin and fluids should be started simultaneously or a fluid bolus should be given first followed by a low-dose fixed insulin infusion.

DKA Treatment:

The primary goals of treating DKA are to correct [Ref]:

  • Hyperglycemia
  • Dehydration
  • Metabolic acidosis and Anion gap
  • Electrolyte abnormalities
  • Concurrent infection or the underlying cause.


Hyperglycemia is corrected using intravenous insulin infusion at a rate of 0.1 units/kg/hour. For a 60 kg person, this will be equal to 6 units per hour.

The rate of decline of blood glucose should be at a steady rate of 50 to 100 mg/dl/hour. If the blood glucose falls too rapidly or does not change, the dose should be adjusted accordingly in increments of 2 units/hour.

A long-acting insulin glargine, detemir, or NPH may be given once the patient is able to eat and drink.

When the glucose falls to less than 250 mg/dl, saline should be replaced with a 10% dextrose solution and the insulin should be continued

If despite 10% dextrose, the glucose falls to less than 150 mg/dl, the rate of insulin infusion should be halved. For example, 6 units per hour should be reduced to 3 units per hour.


Dehydration is corrected using 0.9% saline. However, in patients with severe hyperglycemia, it is best to administer balanced crystalloid to avoid the risks of hyperchloremic metabolic acidosis.

Fluid resuscitation depends on the degree of dehydration and the underlying comorbid conditions.

Typically a patient with DKA requires 4 to 6 litres of fluid during the first 24 hours.

It is administered as an IV bolus of 1000 ml over 30 to 60 minutes initially, followed by another bolus over 1 – 2 hours, then 2 – 4 hours, and 4 – 6 hours thereafter.

Correcting acid-base disorder in patients with DKA:

Metabolic acidosis in patients with DKA does not require any treatment if the arterial PH is more than 7.0.

In severe acidosis, when the PH falls to less than 7.0, bicarbonate infusion can be given as 100 to 150 ml of 1.4% solution over 30 minutes.

Bicarbonate may also be considered in patients who have a PH of 7.0 to 7.30 and associated kidney disease.

Over-correction should be avoided to prevent rebound metabolic alkalosis.

Electrolyte Imbalance:

Hypokalemia is common in patients who are being treated for DKA.

Potassium is added to the second IV fluid once the patient starts producing urine.

Potassium replacement should be avoided if the baseline potassium is >5.5 mEq/L.

If the potassium level is between 4.5 – 5.5 mEq/L, 10 mEq/hour of potassium should be administered.

If the potassium level is between 3 to 4.5 mEq/L, 20 mEq/hour of potassium should be given.

Potassium can be added to the maintenance fluid. 20 to 40 mEq/L may be added to the maintenance fluid once the potassium levels drop to 5.5 mEq/L.

Potassium may be given a potassium chloride or potassium phosphate. It is better to give half of the potassium as potassium chloride and the other half as potassium phosphate.

Treat concurrent infections:

Empiric 3rd generation antibiotics may be given in patients with severe DKA. Antibiotics may be changed once the culture and sensitivity report is available.


HHS Treatment:

The management of HHS is essentially the same as DKA, however, there are a few differences in the management [Ref]:

  • Patients with HHS usually require large volumes of fluid. They usually require 8 to 10 liters of fluid for volume resuscitation
  • The insulin requirement is generally less and hence, once the blood glucose falls to 300 mg/dl, the rate of insulin infusion is reduced to 0.5 units/kg/hour.
  • The target glucose should not be reduced by more than 50 mg/dl during the first hour. Patients are therefore given only IV fluids rather than insulin. In contrast, patients with DKA can be given insulin and fluids simultaneously.
  • After the first hour, the rate of glucose decline should not exceed 300 mg/dl/hour. For patients who do not achieve a decline in blood glucose of 50 to 75 mg/dl, the rate of insulin infusion may be doubled.
  • IV insulin may be continued until the patient is alert.
  • Patients should be investigated and treated for concurrent myocardial infarction, stroke, and kidney failure.
  • Prophylactic and sometimes therapeutic doses of enoxaparin may be given to prevent and treat venous thromboembolism.

Criteria for Resolution of DKA:

The following cut-offs have been recommended to label the patient as out of DKA:

Ketones<0.6 mmol/L
Glucose<200 mg/dl (11.0 mmol/L)

For HHS, in addition to improvement in cognitive functions, the following cut-offs have been recommended to declare a patient as treated:

Calculated or measured serum osmolality <300 mOsm/Kg
Blood glucose<250 mg/dl (<13.9 mmol/L)
Urine output>0.5 ml/kg/hour

Patients who are diagnosed with Euglycemic DKA should not be initiated on SGLT2 inhibitors during the hospital stay despite the resolution of DKA.


Monitoring for Complications:

Hypoglycemia is one of the common complications. It is recommended to administer dextrose-containing fluid when the blood glucose falls to less than 250 mg/dl.

Potassium should be monitored every 4 hours as hypokalemia may occur in up to half of the patients.

Acute kidney injury usually resolves with proper fluid replacement in patients with DKA and HHS. Renal functions should be monitored daily.

Follow-up in the outpatient department or via telemedicine at 2 to 4 weeks is recommended to prevent recurrence which may affect up to 22% of the patients within 30 days.

Structured education, self-monitoring of blood glucose and ketones at home, adjusting insulin doses, and finding the cause of DKA should be looked into during the follow-up visit.

An adequate amount of insulin and educational material should be given to the patient.


Hope You have learned something new. Can you answer this DKA Quiz?

  • Question of

    Blood Glucose may be normal in which of the following conditions?

    • Diabetic Ketoacidosis
    • Hyperosmolar Hyperglycemic State
    • Euglycemic Ketoacidosis
  • Question of

    What is the cut-off of blood sugars for diagnosing DKA as per the latest guidelines?

    • 300 mg/dl
    • 250 mg/dl
    • 200 mg/dl
  • Question of

    What is the cut-off of bicarbonate to diagnose DKA as per the latest guidelines?

    • 15 mEq/L
    • 18 mEq/L
    • 20 mEq/L
  • Question of

    What is the cut-off blood sugars to diagnose HHS as per the latest guidelines?

    • 800 mg/dl
    • 600 mg/dl
    • 400 mg/dl
  • Question of

    What is the cut-off plasma osmolaltiy to diagnose HHS as per the latest guidelines?

    • 320 mOsm/Kg
    • 310 mOsm/Kg
    • 300 mOsm/kg
  • Question of

    Can you give subcutaneous insulin in patients with mild DKA?

    • Yes
    • No
  • Question of

    Which of the following medications can cause Euglycemic DKA?

    • Januvia (Sitagliptin)
    • Ozempic (Semaglutide)
    • Mounjaro (Tirzepatide)
    • Farxiga (dapagliflozin)
  • Question of

    Which of the following medications can be given safely to a patient who has been treated for Euglycemic DKA?

    • Jardiance (Empagliflozin)
    • Farxiga (Dapagliflozin)
    • Steglatro (Ertugliflozin)
    • Galvus (Vildagliptin)
    • Invokana (Canagliflozin)
  • Question of

    Which of the following ketone can give a false-positive result after the resolution of DKA?

    • Beta-hydroxybutyrate
    • Acetone
    • Acetoacetate
  • Question of

    Which of the following diagnosis is usually missed?

    • DKA
    • HHS
    • Euglycemic DKA

What do you think?

Written by Dr. Ahmed

I am Dr. Ahmed (MBBS; FCPS Medicine), an Internist and a practicing physician. I am in the medical field for over fifteen years working in one of the busiest hospitals and writing medical posts for over 5 years.

I love my family, my profession, my blog, nature, hiking, and simple life. Read more about me, my family, and my qualifications

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