DKA vs HHS: What Are The Differences?

If you have diabetes, you probably have heard of these two terms: DKA and HHS. 

Your doctors, nurses, dietitian, or diabetic educator must have warned you about these two conditions, and you should be extra careful not to let your diabetes go into these stages. 

They are the most severe emergencies that can happen when your blood glucose level exceeds a certain threshold and puts you into a hyperglycemic crisis.

This is no joke, and DKA and HHS can cost lives.

In 2018, the CDC estimated that 11.3%, or 37.3 million people in the United States, have diabetes mellitus. 

In just a year, diabetes mellitus contributes to 17 million emergency department visits and 8.25 million hospital admissions. 

Among all reasons for hospital admission in people with diabetes, hyperglycemic crisis (DKA and HHS) is the strongest indicator (85.5%) to warrant admission, likely due to its severe and potentially lethal damage to our body. 

This article will navigate everything you need to know about DKA vs HHS.  

What is diabetic ketoacidosis (DKA)?

Diabetic ketoacidosis (DKA) is an abnormal biochemical triad of high blood sugar (hyperglycemia), high ketone, and an acidic body state (metabolic acidosis).

Based on the American Diabetes Association’s criteria, the diagnosis of DKA can be made when all three parameters below are fulfilled:

  • Blood glucose level is more than 250 mg/dL,
  • Arterial blood pH is less than 7.3, and
  • Blood ketone level is more than 3.0 mmol/L, or urine ketone is 2+ and above

In order to understand how DKA happens, we need to know these two terms: glucose and insulin. 

Glucose is the principal source of energy for all cell functions, while insulin is a hormone produced by the pancreatic β-cells, which acts by driving glucose from our bloodstream into cells. 

In people with diabetes, the insulin level is low. Therefore, glucose cannot enter the cells and stays in the bloodstream. 

This causes a high blood glucose level (hyperglycemia) while the cells are starved. In order to counteract cell starvation, our body starts to burn fat tissues to produce energy. 

Ketone, as a side product of lipid breakdown, accumulates in the blood (ketonemia) and is excreted in the urine (ketonuria). 

Ketone is an acidic substance. Therefore, in DKA, the blood will turn acidic (metabolic acidosis), followed by an altered concentration of mineral ions, manifested by a huge difference in amount between positively-charged and negatively-charged ions in our body (high anion gap).

Since people with type 1 diabetes cannot produce insulin on their own, they are more susceptible to DKA than those with type 2 diabetes, who still have some insulin in their bodies.

What is HHS?

Similar to DKA, hyperosmolar hyperglycemic state (HHS) is another extreme complication of uncontrolled diabetes

While there is an absolute or near total absence of insulin in DKA, people with HHS still have a low level of insulin that is sufficient to stop the body from breaking down fat tissues. Therefore, there is no ketone production in HHS, and the blood pH remains neutral. 

However, because of its insidious development, people may only realize they have HHS in a much later stage, with a sky-high glucose level compared to DKA. 

The excess glucose is passed into the urine, which causes the person to pee more frequently. 

Dehydration makes the person’s blood more concentrated, which explains the high plasma osmolality in HHS.

According to the American Diabetes Association’s HHS guideline, a person can be diagnosed with HHS when:

  • Blood glucose level is more than 600 mg/dL
  • Plasma osmolality is less than 320 mmol/kg

HHS is more prevalent in people with type 2 diabetes.

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Warning signs

Both DKA and HHS are life-threatening conditions. Pay attention to these warning signs even if you are not diagnosed with diabetes.

8.5 million, equivalent to 23.0% of diabetic adults in the United States, are unaware of their diabetes, as reported by the CDC. 

Early symptoms of DKA and HHS include the following:

  • Thirst or a very dry mouth (polydipsia)
  • Increased urination frequency (polyuria)
  • High blood glucose level
  • Presence of blood or urine ketone

As the condition deteriorates, you may develop these symptoms:

  • Feeling extremely tired (lethargy)
  • Signs of dehydration, such as dry oral mucosa, sunken eyes, poor skin turgor, fast heartbeats (tachycardia), low blood pressure (hypotension), and shock in severe cases 
  • Nausea and vomiting
  • Abdominal pain
  • Fast or difficulty in breathing (Kussmaul breathing)
  • Fruity-smelling breath (acetone breath), like the scent of a nail polish remover 
  • Difficulty in paying attention
  • Confusion

If treatment is not given promptly, you can fall into unconsciousness. This critical state is known as diabetic coma, which can soon lead to death.


Despite having the same cause (high blood glucose) and symptoms, DKA and HHS are different. Here, we will compare the similarities and differences between HHS vs DKA.    


  1. Both are severe emergency conditions precipitated by uncontrolled diabetes. 
  2. Both are common causes of hospital admissions among people with diabetes. 
  3. If not treated promptly, both can cause severe damage to our bodies and cause death.
  4. Both can occur in people with type 1 or 2 diabetes.
  5. Both have similar signs and symptoms. 
  6. They are both characterized by insulin deficiency.


  1. DKA (8.9%) is more common than HHS (1%) for people with diabetes to visit emergency departments in the United States.
  2. DKA (8%) has a higher diabetic-related hospitalization rate than HHS (0.97%)
  3. The mortality rate is much lower in DKA (less than 1%) vs 10-20% in HHS.
  4. DKA is more common in younger people (less than 65 years), whereas HHS is more likely to occur in the elderly (65 years and above).
  5. DKA is more prevalent among people with type 1 diabetes, whereas people with type 2 diabetes are more likely to have HHS. 
  6. In DKA, there is a total absence of insulin, whereas patients with HHS still have a low insulin level.
  7. DKA has a faster onset of symptoms, usually a few hours after the precipitating factors. In contrast, HHS can develop silently and slowly over days to weeks.
  8. Dehydration is usually more severe in HHS (9L total water loss) than in DKA (6L total water loss). Therefore, HHS patients can have a higher risk of cardiovascular collapse.
  9. Symptoms of ketosis and acidosis, including acetone breath, Kussmaul respiration, nausea, vomiting, and abdominal pain, occur primarily in DKA. Meanwhile, neurological symptoms, such as lethargy, mental status changes, seizures, and coma, are distinctive features of HHS. 
  10. DKA resolves faster than HHS.

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Can you have DKA and HHS at the same time?

Yes, it is possible for someone to have DKA and HHS simultaneously. In 2020, a team of researchers in the United States conducted a study on patients admitted due to hyperglycaemic crisis for the first time. 

Of 1,211 patients, 27% fulfilled both criteria of DKA and HHS. Patients with overlapping DKA and HHS were also found to have a higher mortality rate (8%) compared to isolated HHS (5%) and DKA (3%).

Causes of DKA vs HHS

The two most common causes of DKA or HHS are infection and insufficient insulin regime.

Infections are stressful events for our bodies. Our body produces more stress hormones (cortisol and adrenaline) as a physiological response. 

These hormones work against the effect of insulin. As a result, blood glucose level rises, leading to DKA or HHS. 

Other possible causes of insulin omission among younger diabetes patients include fear of weight gain and low blood sugar (hypoglycemia), rebellious attitude, the stress of chronic disease, and eating disorders. 

Mechanical problems when administering medications, such as faulty insulin pens and blocked insulin pumps, can also lead to inadequate insulin treatment.

On top of the causes mentioned above, other precipitating factors include:

  • Stroke and other cerebrovascular diseases
  • Blood clots in the lung (pulmonary embolism)
  • Pancreas inflammation (pancreatitis)
  • Heart attack (myocardial infarction)
  • Alcohol abuse
  • Trauma
  • Medications that affect glucose metabolism, such as corticosteroids, thiazide diuretics, sympathomimetic agents, and second-generation antipsychotic drugs 
  • Illicit drugs use, such as cocaine


DKA and HHS are life-threatening emergencies. If you develop any suspicious symptoms, contact your healthcare provider or go to the hospital immediately. You will be treated on the spot in the emergency department and then likely admitted to the ward. 

Treatment protocols for DKA and HHS are usually similar, which include:

Fluid resuscitation

Patients with DKA and HHS are severely dehydrated. The first step of therapy is usually giving fluids to prevent further blood pressure drop and, in severe cases, a full-blown shock. 

Massive amounts of fluids will be transfused into your blood vessels to replace the fluid deficit, usually completed within 12 to 24 hours. 

Insulin therapy

It is usually directly transfused into your blood vessel (intravenously) during acute DKA or HHS. As the blood glucose level gradually returns to normal, you may be allowed to switch back to your usual subcutaneous insulin injection.

Electrolyte replacement

Minerals lost during DKA or HHS, such as potassium and bicarbonate, will also be given intravenously. 

Treatment for the underlying cause

Your doctor will try to find and treat the underlying disease or cause that precipitates the occurrence of DKA or HHS.

Usually, you will need around 2 to 3 days of hospital stay after developing a DKA or HHS. During admission, you will be closely monitored for any dangerous complications, such as swelling of the brain (cerebral edema), kidney injuries, and lung problems. 

Before leaving the hospital, your doctor will likely recheck and discuss your diabetes medications with you. 

Talk to your team of healthcare providers specializing in diabetes care, including diabetes nurses, educators, and dietitians. Learn how you can better control your diabetes and what you can do to avoid the recurrence of DKA or HHS.

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Lifestyle changes

The best way to protect yourself from the severe impact of DKA or HHS is to keep your diabetes under optimal control. 

Here are some tips on lifestyle changes that help manage your diabetes.


According to the American Heart Association, exercise for at least 30 minutes a day on most days of the week, besides having a 5 to 10% weight loss, can significantly reduce diabetes risk

Even better, your risk will continue to decrease as you lose more weight. Meanwhile, the World Health Organization recommended 150 to 300 minutes of moderately-intensity aerobic exercise (such as brisk walking) or 75 to 150 minutes of vigorous-intensity aerobic (such as jogging) every week. 

Eating healthy diets

Diet is an essential component of your diabetes control. Please make sure you: 

  • Eat healthy food with appropriate portions or sizes.
  • Limit your intake of sweets, added sugars, fatty and processed meats, sodium, cholesterol, and trans and saturated fat.
  • Replace refined carbohydrates with whole grains.
  • Eat more vegetables and other fiber-rich food.
  • Keep a food and blood sugar logbook. Write down when and what you eat, and check your blood glucose level at 1 to 1.5 hours afterward. This way, you can check your body’s response to a particular food and prevent unaware hyperglycemia episodes.
  • Reduce alcohol intake. Women should not take more than one drink a day and two drinks a day for men.

Quitting smoking

If you have diabetes, smoking can worsen your health condition. Besides raising the blood glucose level, smoking can exacerbate the nerve and kidney damage caused by diabetes. 

Smokers also have a higher (three times) risk of premature deaths related to cardiovascular diseases.

Managing stress

Just like physical stress (such as infection), psychological stress may cause your blood sugar control to go haywire, especially if you are unaware of the stress you are going through. 

Try to utilize stress management techniques, such as mindfulness and deep breathing exercise

Following a reduced stress level, the risk of developing diabetes-related complications can be reduced. 

Which is more dangerous, DKA or HHS?

Over the years, multiple studies have been conducted on DKA and HHS, and results have pointed to a similar conclusion: HHS is more fatal than DKA

Although more people can now be saved from dying from DKA or HHS, we still see a striking 20% death toll in HHS, while less than 1% of people are killed due to DKA. Therefore, we can conclude that HHS is more dangerous than DKA.  


This article compared the differences and similarities between DKA vs HHS. In summary, DKA and HHS are both hyperglycemic emergencies that can cause serious complications. Prevention is always better than cure. 

Protect yourself from DKA or HHS by monitoring your blood sugar regularly and complying with your treatment plan. Consult your healthcare providers if you have difficulties controlling your blood sugar.

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  2. Holt, R. I. G., DeVries, J. H., Hess-Fischl, A., Hirsch, I. B., Kirkman, M. S., Klupa, T., Ludwig, B., Nørgaard, K., Pettus, J., Renard, E., Skyler, J. S., Snoek, F. J., Weinstock, R. S., & Peters, A. L. (2021). The Management of Type 1 Diabetes in Adults. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes care, 44(11), 2589–2625. 
  3. Centers for Disease Control and Prevention. (2021). Diabetic Ketoacidosis
  4. Centers for Disease Control and Prevention. (2021). National Diabetes Statistics Report.
  5. Gosmanov, A. R., Gosmanova, E. O., & Kitabchi, A. E. (2021). Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. In K. R. Feingold (Eds.) et. al., Endotext., Inc. 
  6. Pasquel, F. J., Tsegka, K., Wang, H., Cardona, S., Galindo, R. J., Fayfman, M., Davis, G., Vellanki, P., Migdal, A., Gujral, U., Narayan, K. M. V., & Umpierrez, G. E. (2020). Clinical Outcomes in Patients With Isolated or Combined Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State: A Retrospective, Hospital-Based Cohort Study. Diabetes care, 43(2), 349–357. 
  7. Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009). Hyperglycemic crises in adult patients with diabetes. Diabetes care, 32(7), 1335–1343. 
  8. Pasquel, F. J., & Umpierrez, G. E. (2014). Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes care, 37(11), 3124–3131. 
  9. World Health Organization. (2022). Physical activity.
  10. American Heart Association. (2021). Living Healthy with Diabetes.

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