We know that chronic high blood glucose can have serious long-term health consequences, but what happens when blood glucose rises extremely high in a short time? Hyperglycaemia can become an immediate, potentially fatal emergency. Here is what you need to know!

We divide hyperglycaemic emergencies into two forms: Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic State (HHS). Their common element is an extremely high blood glucose level, and they differ in the presence of ketones. Ketones are an alternative source of energy for the body when it cannot use energy from sugar due to a lack of insulin. Both DKA and HHS usually occur in insulin-dependent people due to missed insulin injections, stress or infection.

1. Diabetic K etoacidosis: Keto – ketones, acidosis – acidification of the blood

DKA is characterised by very high blood glucose levels, usually 350 – 600 mg/dl, and high levels of ketones in blood and urine. Common symptoms are heavy breathing, diarrhea, vomiting, confusion and possibly unconsciousness. DKA typically affects people with type 1 diabetes, where a complete lack of insulin leads to high ketone production. Because ketones are dangerous in large amounts, the body tries to get rid of its toxic compounds (acetone) by exhaling them via the lungs – resulting in a fruity breath reminiscent of nail polish remover or alcohol. This is why people with DKA are often mistaken for passed-out drunks at night. Without immediate medical treatment, DKA can lead to severe dehydration, loss of consciousness or death.

2. Hyperosmolar Hyperglycaemic State

Hyperosmolar means that there is too much sugar (and other molecules) in the blood and not enough water to dilute it. In HHS we see extremely high levels of glucose, usually over 1000 mg/dl (55 mmol/L), but no ketones. HHS develops slowly over several days and occurs typically in people with type 2 diabetes, often older people. The first symptoms are often extreme thirst and dehydration, frequent urination and nausea. Warning signs of progression include confusion, loss of vision and eventually unconsciousness or coma.

Hyperglycemic Emergencies – Drunk or Diabetes?

As the brain is dependent on glucose for function, the first symptom of any disruption in glucose metabolism is often confusion or some change in mental status. When medical students ask, “Which patient should we do a glucose test on in the emergency room?“ A common response is: “Any funny patient!“ – referring to signs of confusion or odd behaviour when glucose metabolism has gone out of balance.

By looking out for these warning signs (confused, dehydrated, unconscious) in our environment, we can recognise hyperglycemic emergencies earlier and facilitate prompt, professional medical attention – and prevent dire consequences.

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1. Cardiovascular mortality

Managing diabetes is a daily struggle but is poses even greater risks and challenges for women. Generally, diabetes roughly doubles the risk for cardiovascular mortality, for women it is even a three-fold risk-increase. They are likely to have earlier heart attacks and are more likely to die from it.1 Due to differences in acute symptoms, women often don’t get the right treatment for severe cardiac events: While men may present with excruciating chest pain, women often display less obvious symptoms like neck- and abdominal pain, insomnia, and shortness of breath.

2. Reproductive health

Women with diabetes also face additional challenges related to their reproductive health. Conditions such as Polycystic Ovary Syndrome (PCOS), hormonal imbalances, impaired fertility, aggravation of menopausal symptoms and urinary tract infections (UTIs) occur all too frequently and can be a significant limitation in daily life.

3. Mental burden

Besides physical problems, the mental burden of diabetes weighs heavy. Stigma around weight and lifestyle in diabetes is highly prevalent and affects women more often than men. In gestational diabetes, women may experience stigma in the form of discrimination from health personnel, guilt and shame. While weight and lifestyle are important risk factors, gestational diabetes also occurs in metabolically healthy women, and these feelings of blame can be a heavy burden during this time.

4. Being criticised

Women also are more likely to feel criticized for their dietary choices and body weight, both in the media and personally. The recommendation to “just move more and eat better “, or questions such as „are you really allowed to eat that?“, can take on special significance in women. The constant preoccupation with food, weighing it, reading labels, rating its nutritional value, and classifying it into “good” and “bad” can be a major contributor to an unhealthy relationship with food. In female adolescents, eating disorders and weight dysphoria are particularly common and even more so in females with type 1 diabetes.

5. Sex disparities

It begins early on: a recent published systematic review showed that girls with T1D have higher BMIs, worse glycemic control, need higher insulin doses, more hospitalisations, and a lower quality of life, compared to their male counterparts.

So, what is needed to improve women’s health care in diabetes? One step is raising awareness and fostering understanding. But more than understanding, women and girls with diabetes need special attention from their physicians to their unique concerns: their physical symptoms, their mental health, and secure access to a tight support-network from various fields of health care.

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Keteepe-Arachi T, Sharma S. Cardiovascular Disease in Women: Understanding Symptoms and Risk Factors. Eur Cardiol. 2017 Aug;12(1):10-13. doi: 10.15420/ecr.2016:32:1. PMID: 30416543; PMCID: PMC6206467.

Davidsen E, Maindal HT, Rod MH, Olesen K, Byrne M, Damm P, Nielsen KK. The stigma associated with gestational diabetes mellitus: A scoping review. EClinicalMedicine. 2022 Aug 11;52:101614. doi: 10.1016/j.eclinm.2022.101614. PMID: 35990581; PMCID: PMC9386490.

Striegel-Moore RH, Rosselli F, Perrin N, DeBar L, Wilson GT, May A, Kraemer HC. Gender difference in the prevalence of eating disorder symptoms. Int J Eat Disord. 2009 Jul;42(5):471-4. doi: 10.1002/eat.20625. PMID: 19107833; PMCID: PMC2696560.

de Vries, Silvia & Verheugt, Carianne & Mul, Dick & Nieuwdorp, Max & Sas, Theo. (2023). Do sex differences in paediatric type 1 diabetes care exist? A systematic review. Diabetologia. 66. 10.1007/s00125-022-05866-4.