Diabetic Hyperosmolar Syndrome

Diabetes mellitus, or diabetes, is a disease that is, unfortunately, becoming more well-known.

The incidence of diabetes is increasing; according to the World Health Organization (WHO), the number of people with diabetes has risen from 108 million people in 1980 to 422 million in 2014.

Diabetes presents in two different ways; type 1 diabetes and type 2 diabetes. Type 1 diabetes is an autoimmune disease where the pancreas loses its ability to produce the hormone insulin, which helps lower blood sugar to keep it in a healthy range.

People with type 1 diabetes are known as “insulin-dependent” because they must inject insulin to live a healthy life.

Type 2 diabetes is linked to insulin resistance and is more likely to be passed along genetically, and can also occur due to lifestyle factors.

People with type 2 diabetes don’t necessarily need to be on insulin in order to survive, unlike people with type 1 diabetes. Risk factors for type 2 diabetes include age, ethnicity, family history, and lifestyle habits such as activity level.

Maintaining healthy blood sugars is crucial for reducing risks of diabetes complications, such as kidney disease, heart disease, neuropathy, and amputations.

When blood sugar levels are consistently high, the risk of developing these complications increases. One complication of high blood sugar in people with type 2 diabetes is diabetic hyperosmolar hyperglycemic syndrome, or HHS.

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What is Diabetic hyperglycemic hyperosmolar syndrome?

Diabetic hyperglycemic hyperosmolar syndrome, or HHS, is a complication from very high blood sugars in people with type 2 diabetes.

It doesn’t occur in people with type 1 diabetes, who experience a different complication called diabetic ketoacidosis when blood sugar levels are dangerously high.

HHS is a condition of:

  • Extremely high blood sugar (glucose) level

  • Extreme lack of water (dehydration)

  • In many cases, decreased alertness or consciousness

Normally, the kidneys help to filter out extra blood glucose by increasing the amount of urine removed from the body. This is why one of the symptoms of diabetes is increased urination.

When excess urine is removed from the body, it can lead to dehydration. When the body is dehydrated, it can’t make enough urine to flush out the extra sugar.

This leads to hyperosmolality, where the blood has higher concentrations of glucose (sugar), salt, and other substances. This can cause water to be drawn away from other sources of fluid, such as the brain, which is why it can cause an altered level of consciousness.

Diabetic hyperglycemic hyperosmolar syndrome is described as nonketotic, which means that ketones aren’t produced like in the case of type 1 diabetes and diabetic ketoacidosis. This is because people with type 2 diabetes often still produce a small amount of insulin, unlike those with type 1 who are insulin deficient.

Without any insulin available, the body breaks down fat for fuel, which leads to the production of ketones as a result.

What are the symptoms of hyperglycemic hyperosmolar syndrome?

There are many symptoms to watch out for when determining if someone just has high blood sugar or hyperglycemic hyperosmolar syndrome. Signs of the hyperglycemic hyperosmolar syndrome include:

  • Blood sugar level of 600 milligrams per deciliter (mg/dL) or higher

  • Excessive thirst

  • Dry mouth

  • Increased urination

  • Warm, dry skin

  • Fever

  • Drowsiness, confusion

  • Hallucinations

  • Vision loss

  • Convulsions

  • Coma

If blood sugar levels are above 400 mg/dL and aren’t improving despite treatment or recommendations from your healthcare provider, it’s vital to seek emergency medical care right away to prevent diabetic hyperglycemic hyperosmolar syndrome.

Monitoring blood sugar levels regularly is an integral part of managing diabetes to prevent these kinds of life-threatening conditions.

Who is at risk of diabetic hyperglycemic hyperosmolar syndrome?

People with uncontrolled diabetes tend to be more at risk for hyperglycemic hyperosmolar syndrome. Other risk factors include:

  • A stressful event such as infection, heart attack, stroke, or recent surgery

  • Heart failure

  • Impaired ability to detect thirst

  • Limited access to water (especially in people with dementia or who are bedbound)

  • Older age

  • Poor kidney function

  • Poor management of diabetes, not following the treatment plan as directed

  • Stopping insulin or other medicines that lower glucose level

What happens if someone develops hyperglycemic hyperosmolar syndrome?

If untreated, diabetic hyperglycemic hyperosmolar syndrome can lead to life-threatening complications. 

  • Rhabdomyolysis, which is an increase in creatine phosphokinase levels, can injure the kidneys. Rhabdomyolysis occurs when a damaged muscle is broken down and enters the bloodstream, which is hard on the kidneys. An acute kidney injury can require hospitalization and short-term dialysis and may increase the likelihood of developing chronic kidney disease later on.

  • Cerebral edema is a very rare but fatal complication of diabetic hyperglycemic hyperosmolar syndrome. It occurs when blood sugar levels are lowered too quickly, which can cause swelling in the brain.

  • Acute respiratory distress syndrome (ARDS) is another rare but dangerous potential complication of HHS. Its mechanism isn’t quite clear but is thought to occur from the rapid correction of blood sugar levels and resulting pressure changes in the body.

  • Electrolyte abnormalities can occur during the correction of high blood sugar, usually via administering insulin. People being treated for HHS are monitored closely to avoid problems from correcting blood sugar levels too rapidly.

  • Blood clots are more likely to occur due to vascular changes from HHS. People who already have atherosclerosis (buildup of plaque in the arteries) are even more likely to develop clots. People with diabetes are already at increased risk of atherosclerosis and heart disease. Blood clots are potentially deadly as they can cause heart attack and stroke.

Diabetic hyperglycemic hyperosmolar syndrome is usually treated within a few hours. HHS is treated with:

  • Intravenous fluids to counter dehydration

  • Intravenous insulin to lower your blood sugar levels

  • Intravenous potassium, and occasionally sodium phosphate replacement to help cells function correctly

  • Treatment of any underlying cause of HHS, such as infections or chronic diseases

Serum electrolyte levels are monitored to ensure they fall back to normal ranges after treatment with insulin infusion and fluid resuscitation. A corrected serum sodium level can be used in the case of hyperglycemia since it can alter these electrolyte levels.

How can you prevent the development of hyperglycemic hyperosmolar syndrome?

  • Check blood sugar levels regularly if you have diabetes. Monitoring blood sugar levels can help identify when they are rising and can lead to prompt treatment, thereby potentially avoiding HHS.

  • Take medications as prescribed. Stopping diabetes medications can cause an unhealthy increase in blood glucose levels and lead to HHS. Always speak to your doctor about your medication regimen.

  • Limit refined carbs and added sugar. Refined carbohydrates, such as white bread and enriched pasta, tend to raise blood sugar levels. Instead of choosing white flour/enriched grains, opt for whole grains and high-fiber foods to help promote more balanced blood sugars. Foods like whole-wheat bread, oatmeal, and brown rice raise blood sugar more slowly, which reduces the spike in blood sugar that can lead to blood sugar imbalances.

  • Eat a high-fiber diet. Plant-based foods rich in fiber tend to raise blood sugar levels more slowly than low-fiber plant-based foods. Fiber is in foods such as fruits, vegetables, grains, nuts, seeds, and legumes. A high-fiber diet has been associated with a decreased risk of type 2 diabetes. Aim for 30 grams of fiber per day.

  • Drink more water. Sugary beverages are one of the leading contributors to added sugar. Soda, sweetened teas, fruit drinks and sweetened coffee all pack a lot of added sugar and often contain more than a whole day’s worth of sugar in one serving. Opting for water instead will help reduce overall added sugar intake and help prevent dehydration, which is a complication of HHS.

  • Exercise. Being physically active is a great way to help promote healthy blood sugar levels. At least 150 minutes per week of moderate physical activity, such as brisk walking, is the ideal amount. Promoting muscle mass through resistance training is also associated with improved blood sugar levels. Having an exercise routine with both cardiovascular and strength training exercises is ideal.

  • Know your risk factors. People who don’t know they have diabetes can present with diabetic hyperglycemic hyperosmolar syndrome. Knowing your diabetes risk factors can help you be more aware of your lifestyle habits and can facilitate lifestyle changes to reduce the risk of developing diabetes. Some risk factors that increase your risk of type 2 diabetes include:
  • Being age 45 or older

  • Being Black, Hispanic/Latino, Native American, Asian American, or Pacific Islander

  • Have a parent, brother or sister with diabetes

  • Being overweight

  • Being physically inactive

  • Having high blood pressure or take medicine for high blood pressure

  • Having low HDL cholesterol and/or high triglycerides

  • Having had diabetes during pregnancy (gestational diabetes)

  • Having been diagnosed with Polycystic Ovary Syndrome

  • Get screened. Having borderline diabetes (prediabetes) is a risk factor for developing type 2 diabetes. It doesn’t mean you’re destined to get diabetes, though. Healthy lifestyle changes can reverse prediabetes and return blood sugar levels back to normal. 

Screening tests usually include a fasting blood glucose test and/or a hemoglobin A1c test. A normal fasting blood sugar is below 100 mg/dL, and a normal hemoglobin A1c is below 5.7%. A fasting blood sugar indicative of prediabetes (impaired fasting glucose) is 100-125 mg/dL, and a hemoglobin A1c indicative of prediabetes is 5.7-6.4%. 

Understand how medications affect your blood sugar. Certain medications raise blood sugar and cause blood sugar problems if taken for long periods of time. The most common class of medication known to cause increased blood sugar are steroids

Practice good sleep hygiene. Lack of sleep or a disrupted circadian rhythm seems to interfere with the body’s insulin response, leading to insulin resistance and increased blood sugar levels. The National Sleep Foundation also recommends several things to improve sleep hygiene, such as:

  • Limiting daytime naps

  • Avoiding caffeine and other stimulants close to bedtime

  • Exercising during the day

  • Avoiding heavy, fatty or spicy foods close to bedtime

  • Being exposed to natural light during the day

  • Establishing a relaxing bedtime routine

  • Keeping the sleeping environment comfortable, e.g., temperature between 60-67 degrees, using white noise machines, etc.


Diabetic hyperosmolar hyperglycemic syndrome (HHS) is a condition that can occur in those with type 2 diabetes.

It can even present in people who don’t know they have diabetes. It occurs when blood glucose (sugar) levels rise to a very high level, usually greater than 600 mg/dL.

The drastic rise in blood sugar levels can cause dehydration and hyperosmolarity of the blood, meaning sugar, salt and other substances become too concentrated. The body tries to balance out this super saturation of substances by pulling water from other areas of the body, which can worsen dehydration and lead to confusion and altered mental status.

HHS is often described as nonketotic because the buildup of ketone bodies is absent. Ketone bodies are produced when there are insufficient insulin levels to break down carbohydrates for energy, so the body switches to burning fat for fuel, which produces ketones. This typically affects people with type 1 diabetes, not type 2.

HHS is treated with fluid resuscitation and insulin administration to bring blood sugar levels back to a healthy level. It usually doesn’t have long-lasting complications unless blood sugar levels are lowered too quickly, which can disrupt the body’s balance and cause complications such as cerebral edema and blood clots.

HHS is more common in people with poor control of their diabetes, underlying health conditions such as heart disease and kidney disease, infections, and who have recently undergone other stressful health events. It’s also more common in elderly patients who may not drink as much water as they should.

HHS can be prevented through good diabetes management, including monitoring blood sugars regularly, taking medications as prescribed, and implementing healthy lifestyle habits such as eating a healthy diet and being regularly physically active. Being screened for type 2 diabetes can also help prevent HHS, as many people who have no idea that they have diabetes can present with HHS.

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  1. https://www.diabetes.co.uk/diabetes-complications/hyperosmolar-hyperglycemic-nonketotic-syndrome.html
  2. Adeyinka A, Kondamudi NP. Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC, Hyperosmolar Hyperglycemic Nonketotic Syndrome) [Updated 2020 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
  3. https://care.diabetesjournals.org/content/37/11/3124
  4. Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014;37(11):3124-3131. doi:10.2337/dc14-0984
  5. http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_HHS_Adults.pdf

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