Hyperglycemic crises in adults with diabetes: a consensus report
Open accessAbstract
The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.
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A BHB level of 3.0 mmol/L is necessary but not sufficient for the diagnosis of diabetic ketoacidosis, which also requires evidence of acidosis.
“A BHB level of 3.0 mmol/L is necessary but not sufficient for the diagnosis of diabetic ketoacidosis, which also requires evidence of acidosis.7”
From Time to Moderate and Severe Hyperglycemia and Ketonemia Following an Insulin Pump Occlusion (2024) · cites this paper as [7]
The Diagnostic Criteria discussion (page unavailable) requires elevated ketones and metabolic acidosis, and the ketone-testing discussion identifies β-hydroxybutyrate ≥3.0 mmol/L as a useful diagnostic threshold. But the report also allows ketones to be assessed by other methods, so it does not say that a measured BHB level of 3.0 mmol/L is necessary in every case. It additionally requires hyperglycemia or a history of diabetes. (LLM, conf=0.85)
Experimental — accuracy not yet measuredRisk factors for DKA in individuals with type 1 or type 2 diabetes treated with SGLT inhibitors include very-low-carbohydrate diets, prolonged fasting, dehydration, excessive alcohol intake, and other common precipitating factors.
“Risk factors for DKA in individuals with either type 1 or type 2 diabetes treated with SGLT inhibitors include very-low-carbohydrate diets, prolonged fasting, dehydration, excessive alcohol intake, and other common precipitating factors (84,236).”
From 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2025 (2025) · cites this paper as [236]
The Risk Factors section lists very-low-carbohydrate diets, prolonged fasting, dehydration, excessive alcohol intake, and typical precipitating factors for people with T2D taking SGLT2 inhibitors. It also reports increased DKA risk with SGLT2 inhibitors in T1D, but does not attribute that specific list of risk factors to people with T1D. (LLM, conf=0.88)
Experimental — accuracy not yet measuredDiabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) are serious, acute, and life-threatening hyperglycemic emergencies.
“Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) are serious, acute, and life-threatening hyperglycemic emergencies (162).”
From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [162]
Occasionally, people with type 2 diabetes may present with DKA, particularly members of certain racial, ethnic, and ancestral groups (e.g., African American and Hispanic/Latino adults), who may present with ketosis-prone type 2 diabetes.
“Occasionally, people with type 2 diabetes may present with DKA (37), particularly members of certain racial, ethnic, and ancestral groups (e.g., African American and Hispanic/Latino adults), who may present with ketosisprone type 2 diabetes (30).”
From 2. Diagnosis and classification of diabetes: standards of care in diabetes-2025 (2025) · cites this paper as [30]
Individuals with type 1 diabetes and insulin-deficient type 2 diabetes are at increased risk for DKA with SGLT inhibitor therapy.
“Individuals with type 1 diabetes (84,236) and insulin-deficient type 2 diabetes are at increased risk for DKA with SGLT inhibitor therapy.”
From 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2025 (2025) · cites this paper as [236]
There is considerable variability in the presentation of DKA and HHS.
“There is considerable variability in the presentation of DKA and HHS”
From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [165]
The higher mortality rates in low- and middle-income countries may be due to delayed diagnosis and treatment.
“potentially because of delayed diagnosis and treatment (165).”
From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [165]
Approximately 10% of people experiencing DKA present with euglycemic DKA (plasma glucose <200 mg/dL); therefore, DKA diagnosis requires either the presence of hyperglycemia or prior history of diabetes.
“Importantly, approximately 10% of people experiencing DKA present with euglycemic DKA (plasma glucose <200 mg/dL [<11.1 mmol/L]); therefore, DKA diagnosis requires either the presence of hyperglycemia or prior history of diabetes (165).”
From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [165]
DKA and HHS are serious, acute, and life-threatening hyperglycemic emergencies in individuals with diabetes that incur substantial morbidity, mortality, and costs.
“DKA and the hyperglycemic hyperosmolar state (HHS) are serious, acute, and lifethreatening hyperglycemic emergencies in individuals with diabetes (165) that incur substantial morbidity, mortality, and costs (166).”
From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [165]
Mortality rates for hyperglycemic crises in low- and middle-income countries are much higher than those in developed countries.
“Mortality rates reported in low-and middle-income countries are much higher than those in developed countries”
From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [165]
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Significant Published Articles in 2024 for Pharmacy Nutrition Support Practice
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Cîndrea, A. C., Marza, A. M., Borita, A. M., Armega-Anghelescu, A., & Mederle, O. A. (2025) · Reports — Medical Cases Images and Videos · doi:10.3390/reports8020095 · Cited by 1 · see citing works
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Qiang, J. K., Kiss, A., Yu, W., Amaral, A. C. K.-B., Shelton, D., Notario, L., & Halperin, I. J. (2025) · Canadian Journal of Diabetes · doi:10.1016/j.jcjd.2025.10.173 · Cited by 1 · see citing works
- Authors
- Umpierrez, G. E., Davis, G. M., ElSayed, N. A., Fadini, G. P., Galindo, R. J., Hirsch, I. B., Klonoff, D. C., McCoy, R. G., Misra, S., Gabbay, R. A., Bannuru, R. R., & Dhatariya, K. K.
- Affiliations
- Emory University (US)
- American Diabetes Association (US)
- University of Padua (IT)
- University of Miami (US)
- University of Washington (US)
- 8Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA
- University of Maryland, Baltimore (US)
- Imperial College Healthcare NHS Trust (GB)
- University of East Anglia (GB)
- Corresponding author
- Umpierrez, Guillermo E.
- ORCID
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2024-06-22
- Volume
- 47
- Issue
- 8
- Pages
- 1257-1275
- ISSN
- 0149-5992 (ISSN-L)
- 1935-5548
- PMC
- PMC11272983
- OpenAlex
- W4399923484
- Cited by
- 278
- References
- 185
- Citations by year
- 2026: 129 · 2025: 131 · 2024: 18
- FWCI
- 91.07
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Diabetes Care (publishedVersion)
- PubMed Central (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed (publishedVersion)
- Padua Research Archive (University of Padova) (submittedVersion)
- Funders
- NIH
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hyperglycemia and glycemic control in critically ill and hospitalized patients
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Keywords
- diabetic ketoacidosis, hyperosmolar hyperglycemic state, adults with diabetes, pathophysiology, clinical features, diagnosis, treatment, prevention, clinical guidelines
- MeSH terms
- Adult, Diabetes Mellitus, Humans, Hyperglycemia, Hyperglycemic Hyperosmolar Nonketotic Coma, Diabetic Ketoacidosis
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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