Hyperosmolar Hyperglycemic State

Hyperosmolar Hyperglycemic State is a topic covered in the Washington Manual of Medical Therapeutics.

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General Principles

HHS is one of the most serious life-threatening complications of T2DM.1


  • HHS occurs primarily in patients with T2DM, and in 30%–40% of cases, it is the initial presentation of a patient’s diabetes.1
  • HHS is significantly less common than DKA, with an incidence of <1 case per 1000 person-years.


  • Ketoacidosis is absent because the ambient insulin level may effectively prevent lipolysis and subsequent ketogenesis while being inadequate to facilitate peripheral glucose uptake and to prevent hepatic residual gluconeogenesis and glucose output.
  • Precipitating factors for HHS include dehydration, stress, infection, stroke, noncompliance with medications, dietary indiscretion, and alcohol and cocaine abuse. Impaired glucose excretion is a contributory factor in patients with renal insufficiency or prerenal azotemia.

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