Primary prevention

In the majority of patients, hyperosmolar hyperglycemic state (HHS) evolves over several days and so frequent blood glucose monitoring may help to recognize patients at risk, especially in older patients and in those in long-term care facilities.[45]​

Many episodes could be prevented through education and effective outpatient treatment programs. Patients and family members should be educated about the following:[46]​​

  • Symptoms or blood glucose readings that should prompt the patient to contact the diabetes care team

  • The importance of insulin use during an illness, and never discontinuing insulin without contacting their healthcare provider

  • Frequent monitoring of blood sugars in patients with hyperglycemia (i.e., up to every 2-4 hours if they are ill)[47]​​

  • Blood glucose goals and the use of supplemental short- or rapid-acting insulins to correct elevated blood sugars

  • Initiation of an easily digestible, liquid carbohydrate diet when nauseated

  • Availability of antipyretics and drugs to treat infection

Diabetes technology, such as insulin pump therapy and continuous glucose monitoring, can also be used to reduce risk.[45]

All patients with diabetes, as well as patients with HIV or schizophrenia, and their caregivers should receive education about drugs that may cause or worsen hyperglycemia.[33][48]​​​​

All patients with diabetes at risk of HHS and diabetic ketoacidosis should be reviewed at each clinical encounter for history of hyperglycemic crises.[45]

The table that follows summarizes recommendations for primary prevention of hyperglycemic emergencies (including HSS) in people with diabetes, taken from the American Diabetes Association (ADA) standards of care in diabetes.[45]​

Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.

Adult with type 1 or type 2 diabetes

All

Intervention
Goal
Intervention

Diabetes self-management education and support

Advise all people with diabetes to participate in diabetes self-management education and support.

Programs may be offered in group or individual settings. Consider offering programs via telehealth and/or digital interventions as needed.

Behavioral strategies may be used to support diabetes self-management and engagement in health behaviors (e.g., taking drugs, using diabetes technologies), including:

  • Motivational interviewing

  • Patient activation

  • Goal setting and action planning

  • Problem solving

  • Tracking or self monitoring health behaviors with or without feedback from a healthcare professional

Goal

Optimal diabetes self-management, including prevention of hyperglycemia

The overall goals of diabetes self-management and support are to improve clinical outcomes, health status and wellbeing by supporting:

  • Informed decision-making

  • Self-care behaviors

  • Problem solving

  • Active collaboration with the health care team

This is recommended:

  • At diagnosis

  • Annually and/or when not meeting treatment goals

  • When complicating factors develop (e.g., medical, physical, psychosocial)

  • When transitions in life and care occur

Using insulin or other glucose-lowering medication and capable of safely using a continuous glucose monitoring (CGM) device

Intervention
Goal
Intervention

Consider CGM

Consider the use of CGM devices from the outset of diagnosis for all people whose diabetes requires insulin management.

CGM is recommended for all adults with diabetes on any type of insulin therapy.

Consider using CGM in adults with type 2 diabetes treated with glucose-lowering drugs other than insulin.

It is recommended that the choice of device is made based on the individual’s circumstances, preferences and needs.

The individual must be capable of using the device safely (either by themselves or with a caregiver).

Goal

Better glycemic control; reduced rates of diabetic complications including HHS

Consideration of continuous glucose monitoring needs is recommended at all clinical encounters (initial visit, all follow-up visits and the annual visit).

With intercurrent illness

Intervention
Goal
Intervention

Reevaluation of diabetes treatment plan

Assess any individual with diabetes experiencing acute illness for the need for more frequent monitoring of glucose.

Reevaluate diabetes treatment during intercurrent illness and make adjustments as appropriate.

Goal

Prevention of life-threatening conditions relating to hyperglycemia

With hospital admission

Intervention
Goal
Intervention

Individualized approach to glycemic management

An individualized approach to glycemic management is recommended during hospital admission, taking into account factors such as:

  • Prior home use and dose of insulin or non-insulin therapy

  • Prior HbA1c

  • Current glucose levels

  • Oral intake

  • Duration of diabetes

An insulin schedule with basal and correction components is indicated for all hospitalized individuals with type 1 diabetes, even when taking nothing by mouth, with the addition of prandial insulin when eating.

It is important that hospitals ensure that basal insulin is not omitted or delayed for people with type 1 diabetes, especially during care transitions, and that ongoing prescriber and nursing education is provided.

Corticosteroid therapy is common in hospitalized individuals, and carries a particularly high risk of hyperglycemia. It is recommended that clinicians working within a hospital setting consider corticosteroid type and duration of action when determining appropriate insulin treatments. Careful blood glucose monitoring is crucial. Daily adjustment of insulin may be required based on levels of glycemia and anticipated changes in type, doses and duration of corticosteroids.

In particular, the perioperative period is associated with an increased risk of hyperglycemia; management of glycemic treatment and glucose monitoring during this period is complex, and is typically guided by local protocols.

Goal

Maintenance of euglycemia; prevention of hyperglycemic emergencies including HHS

Older adult living in a long-term care facility

Intervention
Goal
Intervention

Consider development of a glycemia alert strategy

Care facility staff are advised to call a healthcare professional immediately when:

  • Two or more blood glucose values >250 mg/dL are observed within a 24-hour period, and are accompanied by a significant change in status.

Care facility staff are advised to call a healthcare profession as soon as possible when:

  • Glucose values are consistently >250 mg/dL (>13.9 mmol/L) within a 24-hour period

  • Glucose values are consistently >300 mg/dL (>16.7 mmol/L) over 2 consecutive days

  • Any reading is too high for the glucose monitoring device

  • The person is sick, with vomiting, symptomatic hyperglycemia, or poor oral intake

Goal

Timely adjustment of glycemic treatment; prevention of hyperglycemic emergencies including HHS

In practice, an alert strategy would include notifications for both hypoglycemia and hyperglycemia (although the former is beyond scope for this table). Hypoglycemia and symptomatic hyperglycemia must be managed immediately.

Health care professionals may adjust treatment plans by telephone, fax, or in person directly at the long-term care facility, depending on service arrangements and clinical urgency.

With alcohol use

Intervention
Goal
Intervention

Patient education on safe alcohol use

Educate people with diabetes about the risk of hyperglycemia with excessive alcohol consumption and encourage them to monitor glucose frequently after drinking any alcohol.

Goal

Avoidance of alcohol related harm, including hyperglycemia

Advise people with diabetes to follow the same guidelines as those without diabetes.

To reduce risk of alcohol-related harms, adults can choose not to drink or to drink in moderation by limiting intake to:

  • ≤2 drinks a day for men

  • ≤1 drink a day for women

(One drink is equal to a 12-oz beer, a 5-oz glass of wine, or 1.5 oz of distilled spirits).

With fasting for religious or cultural reasons

Intervention
Goal
Intervention

Patient education and support; individualized treatment plan for times of fasting

Inquire about any religious or cultural reasons for fasting for people with diabetes and provide education and support to accommodate their choice.

Use an established tool such as the International Diabetes Federation and Diabetes and Ramadan International Alliance (IDF-DAR) comprehensive prefasting risk assessment to generate a risk score for the safety of religious fasting.

Assess and optimize the treatment plan, dose and timing of medication and fasting for people with diabetes well in advance of religious fasting to mitigate against its associated risks.

Provide fasting-focused education to minimize risks; emphasize that people should increase the frequency of glucose monitoring during fasting.

Offer individualized fluid adjustment and meal advice with emphasis on higher intake of fiber and replacing added sugars with complex carbohydrates. Emphasize the importance of sustaining adequate daily fluid intake.

Consider the use of technology as a useful adjunct to risk calculation and/or nutrition planning and education.

Goal

Prevention of dehydration and hyperglycemia

With psychosocial distress or behavioral health diagnosis

Intervention
Goal
Intervention

Individualized psychosocial care; specialist referral

Reinforce diabetes self-management education and support when factors, including psychosocial challenges, arise which may complicate diabetes self-management.

When indicated, refer to behavioral health professionals or other trained health care professionals, ideally those with experience in diabetes, to increase engagement in diabetes self-management and support, and for further assessment and treatment for symptoms of:

  • Diabetes distress

  • Depression

  • Suicidality

  • Anxiety

  • Treatment-related fear of hypoglycemia

  • Disordered eating

Goal

Improved glycemic outcomes; reduced risk of hyperglycemia and HHS

Improve individual’s or family’s ability to carry out diabetes care tasks.

Better glycemic stability.

In the long-term, reduce mortality risk.

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