Risk Factors and Precipitating Triggers

The effective management of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) extends beyond merely treating the symptoms. A nuanced understanding of the common triggers and risk factors is pivotal for early identification, prevention, and management of these acute hyperglycemic crises. Both DKA and HHS can be precipitated by a variety of factors that generally serve to exacerbate insulin resistance or reduce effective circulating insulin levels.

Common Triggers for DKA

• Infections: Upper respiratory tract infections, urinary tract infections (UTIs), pneumonia, and skin and soft tissue infections are often implicated. Sepsis can be both a trigger and a complication.
• Poor Medication Adherence: Non-compliance, especially with insulin regimens, can quickly lead to DKA. This is particularly problematic in younger patients and those with psychiatric comorbidities.
• New-Onset Diabetes: In many cases, particularly in the pediatric population, DKA is the first presentation of diabetes.
• Other Medical Illnesses: Acute pancreatitis, myocardial infarction (MI), and cerebrovascular accidents (strokes) can precipitate DKA.
• Certain Medications: Corticosteroids, atypical antipsychotics, and certain diuretics can induce DKA by affecting carbohydrate metabolism.
• Alcohol and Drug Abuse: Binge drinking and the use of drugs like cocaine can lead to DKA. Alcohol-induced pancreatitis is also a risk factor.
• Pregnancy: Pre-existing diabetes or gestational diabetes can lead to DKA if not adequately managed.

Common Triggers for HHS

• Infections: More severe types of infections, like sepsis and certain pneumonias, are often implicated in HHS.
• Medications: Particularly diuretics, antipsychotics, and immunosuppressive medications.
• Acute Illness: MI, stroke, acute pancreatitis, and other critical illnesses can lead to HHS.
• Chronic Illnesses: Particularly end-stage renal disease and congestive heart failure, which themselves often lead to fluid and electrolyte imbalances.
• Post-operative States: Especially after major surgeries, where there is often a period of relative insulin deficiency.

Clinical Insights

• The absence of a known trigger should prompt a thorough investigation for an underlying, yet undiagnosed issue such as an occult infection or undiagnosed diabetes.
• In the hospital setting, vigilance is necessary when administering medications like corticosteroids or atypical antipsychotics that are known to affect glucose metabolism. The risk is especially heightened in ICU settings where high-dose corticosteroids may be used.
• “Euglycemic DKA” is a variant often seen with the use of SGLT2 inhibitors. These patients may not present with overt hyperglycemia but can still have severe ketoacidosis, making diagnosis challenging.

Comprehensive Table of Risk Factors and Precipitating Triggers