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Hyperosmolar Hyperglycemic State Medication

  • Author: Robin R Hemphill, MD, MPH; Chief Editor: George T Griffing, MD  more...
 
Updated: Aug 03, 2016
 

Medication Summary

Aggressive rehydration with intravenous (IV) fluids, including 0.9% isotonic saline, is indicated in every patient with hyperosmolar hyperglycemic state (HHS). Insulin therapy and repletion of electrolytes (especially potassium) are the other cornerstones of management. Antipyretics, antiemetics, and antibiotics are added when appropriate to control fever and vomiting and to treat an underlying infection if one is suspected.

Frequent monitoring of electrolyte concentrations is indicated when patients are treated with IV fluids. Volume overload is the only other potential problem associated with IV fluid replacement; therefore, regular assessment of the hydration state is indicated.

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Antidiabetics, Insulins

Class Summary

Although many patients with hyperosmolar hyperglycemic state (HHS) respond to fluids alone, intravenous (IV) insulin in dosages similar to those used in diabetic ketoacidosis (DKA) can facilitate correction of hyperglycemia. Insulin used without concomitant vigorous fluid replacement increases the risk of shock.

Regular insulin (Humulin R, Novolin R)

 

Regular insulin has a rapid onset of action (within 0.5-1 hours), and a short duration of action (4-6 hours). Peak effects occur within 2-4 hours. Insulin is used to reduce blood glucose levels and decrease ketogenesis. Some authors favor lower bolus and infusion dosages, with the rationale that fluids are the cornerstone of therapy and that HHS is more a disorder of insulin resistance than it is one of insulin deficiency. Furthermore, lowering serum glucose and serum osmolarity overly rapidly can result in complications.

Insulin aspart (NovoLog)

 

Insulin aspart has a rapid onset of action (5-15 minutes) and a short duration of action (3-5 hours). Peak effects occurs within 30-90 minutes.

Insulin glulisine (Apidra)

 

Insulin glulisine has a rapid onset of action (5-15 minutes) and a short duration of action (3-5 hours).

Insulin lispro (Humalog)

 

Insulin lispro has a rapid onset of action (5-15 minutes) and a short duration of action (4 hours).

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Alkalizing agents

Class Summary

No evidence is found that sodium bicarbonate provides any benefit to patients with HHS. It may be considered if a patient has significant acidosis (pH < 7.0), particularly if inotropic agents are required to maintain blood pressure.

Sodium bicarbonate (NaHCO3)

 

Sodium bicarbonate neutralizes hydrogen ions and raises urinary and blood pH.

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Electrolytes Supplements, Parenteral

Class Summary

Electrolytes are given to replenish electrolyte supplies depleted by the presence of a high blood glucose level.

Potassium chloride (Klor-Con, K-Tab, Micro-K)

 

In virtually all cases of HHS, supplemental potassium is necessary because the serum level drops secondary to insulin therapy and correction of metabolic acidosis. Do not start IV potassium until the initial serum level is ascertained, as the initial level may be high related to hemoconcentration. Administer it cautiously, with attention to proper dosing and concentration. If the patient can tolerate oral medications or has a gastric tube in place, potassium chloride can be given orally in doses of up to 60 mEq, with dosing based on frequently obtained laboratory values.

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Contributor Information and Disclosures
Author

Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Joseph Michael Gonzalez-Campoy, MD, PhD, FACE Medical Director and CEO, Minnesota Center for Obesity, Metabolism, and Endocrinology

Joseph Michael Gonzalez-Campoy, MD, PhD, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists, Association of Clinical Researchers and Educators (ACRE), and Minnesota Medical Association

Disclosure: Nothing to disclose.

George T Griffing, MD Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, InternationalSocietyfor Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Lewis S Nelson, MD, FACEP, FAACT, FACMT Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Attending Physician, Department of Emergency Medicine, Bellevue Hospital Center, New York University Medical Center and New York Harbor Healthcare System

Lewis S Nelson, MD, FACEP, FAACT, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

David S Schade, MD Chief, Division of Endocrinology and Metabolism, Professor, Department of Internal Medicine, University of New Mexico School of Medicine and Health Sciences Center

David S Schade, MD is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, New Mexico Medical Society, New York Academy of Sciences, and Society for Experimental Biology and Medicine

Disclosure: Nothing to disclose.

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society

Disclosure: Nothing to disclose.

Paulina B Sergot, MD Staff Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center

Paulina B Sergot, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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