The Differences Between Hyperosmolar Hyperglycaemic State (HHS) and Diabetic Ketoacidosis (DKA)

Happy new year. We are starting this year outlining the crucial differences between complications of Diabetes

Hyperosmolar Hyperglycemic State (HHS) is a serious complication that mainly affects people with Type 2 diabetes¹. It occurs when blood glucose levels are extremely high for a prolonged period, leading to severe dehydration and confusion¹.

The primary difference between HHS and Diabetic Ketoacidosis (DKA), another diabetes complication, lies in the presence of ketones and blood acidity. DKA, which most commonly affects people with Type 1 diabetes, occurs when the body doesn't have enough insulin and starts breaking down fat for energy, releasing ketones into the bloodstream¹. These ketones cause the blood to become acidic, which can be life-threatening¹.

On the other hand, HHS also involves a lack of insulin, but the person usually still produces enough insulin to prevent the production of ketones¹. Therefore, HHS does not involve ketones and blood acidity¹. Additionally, there's usually an underlying condition, such as an infection, that's also contributing to the high blood sugar¹.

Here are some key differences between DKA and HHS¹:




People affected

Most commonly affects people with Type 1 diabetes

Most commonly affects people with Type 2 diabetes

Time to develop

Develops quickly — often within 24 hours

Develops more slowly — usually within days to weeks

Blood sugar level

Usually above 250 mg/dL

Higher than 600 mg/dL

Urine or blood ketones


Trace or none

Blood pH level

7.3 or lower

Higher than 7.3

Mortality rate

About 1% to 8%

About 10% to 20%

It's important to note that both DKA and HHS are serious, life-threatening conditions that require immediate medical attention¹.

(1) Hyperosmolar Hyperglycemic State (HHS): Treatment - Cleveland Clinic.
(2) HHS diabetes: Symptoms, diagnosis, treatment, and more - Medical News Today.
(3) Hyperosmolar Hyperglycaemic State (HHS) | Diabetes UK.
(4) Complications | Background information | Diabetes - type 2 | CKS - NICE.

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