Acute complications of diabetes: hyperosmolar hyperglycemic state

Classification

According to severity, hyperglycemia is divided into:

• Light
  – up to 8.2 mmol/l.
• Moderate –
  from 8.3 to 11 mmol/l.
• Severe –
  over 11 mmol/l.

This numerical division is considered very conditional, since it is not the level of glycemia that is of greater importance, but the rate of increase. Based on their nature, hyperglycemia is classified into physiological (stress, carbohydrate intake) and pathological hyperglycemia. According to the origin of hyperglycemia, there are:

• Hormonally determined.
  An increase in sugar is caused by various endocrine pathologies (diabetes, hypercortisolism, etc.).
• Central genesis.
  An increase in glucose levels occurs in diseases of the central nervous system and brain injuries.
• Nutritionally determined.
  Hyperglycemia develops as a result of rare hereditary constitutional and metabolic disorders.

Causes of high blood sugar

High blood sugar may be associated with certain diseases:

• diabetes mellitus and other endocrine pathologies;
• liver diseases;
• dysfunction of the pancreas;
• severe infectious diseases;
• obesity.

Diabetes mellitus is considered the most common cause of hyperglycemia, which is long-lasting and negatively affects almost all internal organs and systems of the body.

Factors that contribute to hyperglycemia that are not associated with pathologies of the body are also identified:

• overeating, predominance of simple carbohydrates in the diet;
• stress;
• severe premenstrual syndrome in women;
• alcohol abuse;
• hereditary predisposition.

Causes of hyperglycemia

Physiological conditions

A short-term increase in blood sugar can be observed during pregnancy, when eating carbohydrate-containing food on the eve of a biochemical analysis. Under stress, hyperglycemia occurs due to the activation of the sympatho-adrenal and hypothalamic-pituitary-adrenal systems and the production of contrainsular hormones. In these conditions, hyperglycemia is transient (reversible) and does not require any intervention.

Diabetes

Diabetes mellitus (DM) is the leading cause of high blood glucose levels. The pathogenetic mechanisms for the development of hyperglycemia are somewhat different in different types of diabetes. Type 1 diabetes is characterized by a decrease in insulin production by the beta cells of the islets of Langerhans of the pancreas (absolute insulin deficiency), which leads to impaired utilization of glucose as an energy substrate by peripheral tissues (fat, muscle) and, accordingly, its retention in the blood.

In type 2 diabetes, on the contrary, due to long-term hyperinsulinemia, insulin resistance occurs (increased insulin sensitivity threshold) due to a decrease in the number of insulin receptors on the surfaces of muscle and fat tissue cells (relative insulin deficiency). Gestational diabetes mellitus (GDM) is caused by a decrease in insulin clearance, as well as the action of fetoplacental hormones (placental lactogen, progesterone).

• Type 1 diabetes.
  The spasmodic nature of hyperglycemia is typical. A sharp increase in blood sugar levels can occur at the time of clinical manifestation of the disease, and, most often, when insulin dosages are not observed or insulin injections are missed. Lifelong insulin therapy is required to maintain glucose within normal limits.
• Type 2 diabetes.
  It is characterized by a slow and steady increase in glucose concentration, which is why it can reach very high values ​​(30-40 mmol/l). The level of glycemia decreases under the influence of diet and the use of glucose-lowering drugs. Normalization of body weight and bariatric surgery can reduce or completely eliminate the need for treatment.
• GSD.
  With gestational diabetes, blood sugar gradually increases in the II-III trimesters of pregnancy. Specific treatment is carried out before labor or surgical delivery. In the postpartum period, spontaneous remission is often observed, but hyperglycemia may persist with the transition to type 2 diabetes mellitus.

Hyperglycemia

Other endocrine disorders

In addition to diabetes mellitus, other diseases of the endocrine system can lead to hyperglycemia. This mainly concerns endocrinopathies, accompanied by increased production of counter-insular hormones, i.e. hormones that increase glucose concentration by influencing various stages of carbohydrate metabolism:

• Thyrotoxicosis.
  In diffuse toxic goiter or toxic adenoma, thyroid hormones activate glycogenolysis, gluconeogenesis, and stimulate the absorption of glucose in the intestine. Hyperglycemia is moderate and resolves after normalization of thyroid hormone levels.
• Hypercorticism.
  Glucocorticosteroids (cortisol) enhance gluconeogenesis and suppress the breakdown of glucose. With Cushing's disease/syndrome, so-called “steroid diabetes” often develops.
• Pheochromocytoma.
  Catecholamines (adrenaline, norepinephrine) stimulate the breakdown of glycogen in the liver. Hyperglycemia occurs paroxysmally, the glucose level increases sharply at the time of sympathoadrenal crisis. During the interictal period, glycemia remains within normal limits.
• Acromegaly.
  Growth hormone produced by a pituitary tumor somatotropinoma, in addition to the direct hyperglycemic effect, suppresses the utilization of glucose by peripheral tissues, i.e. forms insulin resistance. Therefore, hyperglycemia in acromegaly is of a special nature. Unlike other endocrinopathies, in which impaired glucose tolerance often occurs, acromegaly quite often leads to the development of type 2 diabetes.
• Glucagonoma.
  Glucagon, as the main antagonist of insulin, stimulates the formation of glucose from amino acids in the liver. Hyperglycemia is mild. In most cases, changes in diet are enough to normalize blood sugar.

Other reasons

• Convulsive states.
• Organic lesions of the central nervous system:
  encephalitis, brain tumors, hemorrhages in the fourth ventricle.
• Liver failure.
• Severe diseases of the pancreas
  : pancreatic necrosis, cystic fibrosis.
• Taking medications:
  thiazide diuretics, glucocorticosteroids, beta-adrenergic blockers.
• Severe somatic disorders:
  sepsis, extensive burns.
• Autoimmune polyglandular syndromes:
  Schmidt's syndrome.
• Rare hereditary syndromes
  : Sipe-Lawrence lipodystrophy, Prader-Willi syndrome, Wiedemann-Beckwith syndrome.
• HIV infection.

Irkutsk City Clinical Hospital No. 9

Memo for the patient:

What to do to prevent the development of hyperglycemia and diabetes.

Facts about hyperglycemia and diabetes:

• There is a new case of diabetes every 20 minutes in the United States, and every forty minutes in Europe.
• Currently, the prevalence of overt diabetes mellitus among the population of economically developed countries reaches 4-7%. However, mass surveys have shown that there are twice as many patients with latent forms of diabetes.
• In individuals whose body weight exceeds the norm by 20%, diabetes mellitus is detected 10 times more often than in the population. Among people with severe obesity, the incidence of diabetes increases 30 times. The combination of several risk factors has been shown to increase the likelihood of developing clinical diabetes mellitus by approximately 29 times.
• The mortality rate among patients with diabetes mellitus who have suffered a myocardial infarction is 1.5 - 2.5 times higher than in persons without carbohydrate metabolism disorders.

Hyperglycemia (high blood sugar) occurs when blood sugar levels rise above normal. This occurs when the pancreas does not produce enough insulin or it does not work as well as it should. Then glucose, the main source of energy, is not absorbed by the cells, the cells begin to “starve”, and weakness develops; blood sugar, on the contrary, rises and draws water from the cells - thirst appears; Due to metabolic disorders, small and large vessels of the brain, heart, kidneys and other organs are quickly affected, and immunity is impaired.

Check if you have any signs of diabetes?

• strong thirst;
• drowsiness;
• blurred vision;
• frequent urination;
• irritability;
• itching (especially in the perineal area);
• dry skin, pustules and boils;
• increased appetite;
• sticky urine.

If blood glucose levels are too high, diabetes develops. In 95% of cases, this is type 2 diabetes, which occurs more often in people over 40 years of age who lead an unhealthy lifestyle. Look, maybe you also have risk factors for this dangerous disease?

• age over 45 years;
• diabetes mellitus in relatives;
• excess body weight;
• low physical activity;
• accidentally detected elevated glucose levels during examination;
• increased blood sugar during pregnancy and the birth of a large fetus;
• high blood pressure, above 140/90 mmHg;
• changes in cholesterol metabolism (low high-density lipoprotein levels ≤ 0.9 mmol/l and/or triglyceride levels ≥ 2.82 mmol/l);
• polycystic ovary syndrome;
• suffered strokes, heart attacks.

If something has alerted you, then the only way to check whether you have diabetes or not is to do a blood test: determine your glucose level on an empty stomach and/or 2 hours after taking 75 grams of glucose. The frequency of examination depends on the risk group you fall into.

Capillary blood glucose level

You can also check your risk of developing prediabetes or type 2 diabetes in the next 10 years using the following questionnaire:

• Age: up to 45 years (0 points), 45-54 years (2 points), 55-64 years (3 points), over 65 years (4 points).
• Body mass index - height (m) divided by body weight (kg) squared, for example, with a height of 165 cm and a weight of 73 kg, the index is 73: (1.65 m X 1.65) = 26.8 = 27 kg /m2: below 25 kg/m2 (0 points), 25-30 kg/m2 (1 point), more than 30 kg/m2 (3 points).
• Waist circumference - measured under the ribs at the level of the navel. Men: less than 94 cm (0 points), 94-102 cm (3 points), more than 102 cm (4 points). Women: less than 80 cm (0 points), 80-88 cm (3 points), more than 88 cm (4 points).
• How often do you eat vegetables, fruits or berries? Every day (0 points), not every day (1 point);
• Do you exercise regularly? Do you exercise 30 minutes every day or 3 hours during the week? Yes (0 points), no (2 points);
• Have you ever taken medications regularly to lower your blood pressure? No (0 points), yes (2 points).
• Have you ever had your blood sugar level higher than normal (during preventive examinations, during illness or pregnancy)? No (0 points), yes (5 points).
• Did your relatives have type 1 or type 2 diabetes? No (0 points), yes: grandparent, aunt/uncle, cousins ​​(3 points), parents, brother/sister or own child (5 points).

TOTAL POINTS__________________________

Your risk of developing type 2 diabetes over 10 years is:

• If you score less than 12 points, you are in good health and should maintain a healthy lifestyle.
• If you score 12-14 points, you may have prediabetes. You should ask your doctor about lifestyle changes.
• If you score 15-20 points, you may have prediabetes or type 2 diabetes. It is advisable for you to check your blood sugar levels. You may need to change your lifestyle and may need medication to control your blood sugar levels.
• If you score more than 20, you most likely have type 2 diabetes. You should regularly check your blood sugar levels with a glucometer. You need to change your lifestyle and need medications to control your blood sugar levels.

Diabetes prevention should start in the kitchen.

About 80% of patients with type 2 diabetes are overweight, which weakens the effect of insulin. Therefore, the primary task in this situation is to reduce weight (not to the full norm, but 5-10% below the original) and maintain it at this level through continued dieting. This diet should be tasty, varied, not cause a feeling of hunger, but contain fewer calories than the patient consumed before; for this you just need to follow some rules:

These products should be sharply limited:

a) Severely increases blood sugar:

• Sugar, honey, dried fruits, fruit juices, confectionery, sweets, jam, lemonades (“Fanta”, “Pepsi”, etc.), natural kvass.
• Semolina porridge, mashed potatoes, heavily boiled porridge.

b) Contain a lot of calories:

• Butter, vegetable oil (especially in salads, vinaigrettes and when heating food), sour cream, mayonnaise, butter substitutes (Rama, etc.).
• Lard, sausages and sausages, sausages and pates, smoked meats, fatty meat, fatty fish, meat by-products (liver, liver), chicken legs, poultry skin.
• Fatty (“yellow” and processed) cheeses, cream, fatty cottage cheese.
• Nuts and seeds, pies and pies.

The consumption of these products should be halved:

• Bread (black or white), cereals (rice, buckwheat, oatmeal, etc.).
• Potatoes, pasta, corn and soy products, crackers, crackers (unsweetened), etc.
• Fruits: distribute throughout the day.
• Candies, waffles, etc.: as an “infrequent treat” (once a week).
• Acceptable in moderation: lean meat, fish, cottage cheese.

Increase consumption:

• Vegetables (but without added fat) in the form of vegetable side dishes : cabbage, cauliflower, carrots, beets, turnips, radishes, cucumbers, tomatoes, greens.
• Drinks without sugar: mineral water, tea).

Diagnostics

Hyperglycemia is primarily detected during a preventive or targeted laboratory blood test for sugar. However, patients who have a portable glucose meter may independently detect a regular increase in glucose in the morning on an empty stomach. In this case, you should immediately visit a general practitioner or endocrinologist. In the future, to clarify the nature of the pathological process, the following can be done:

• Study of carbohydrate metabolism.
  A patient with hyperglycemia undergoes a urine test for sugar, an oral glucose tolerance test, and daily monitoring of the glycemic profile. Together with glucose tests, determination of the level of glycated hemoglobin, blood insulin, and the HOMA index (insulin resistance) is often additionally prescribed.
• Hormonal studies.
  If a pathology of the endocrine system is suspected, a blood test is performed for thyroid hormones (TSH, free T4, T3), insulin-like growth factor-1, and measurement of the level of metanephrines in daily urine. If the patient has clinical signs of hypercortisolism, measure the concentration of cortisol in saliva, as well as in plasma after performing small and large dexamethasone tests.
• Ultrasound.
  In the case of hyperglycemia of pancreatogenic origin, an ultrasound of the abdominal organs reveals a decrease in the echogenic density of the pancreas, its swelling, blurred contours, the presence of cysts, etc. In hyperthyroidism, an ultrasound of the thyroid gland shows a decrease in the echogenicity of the parenchyma, the presence of nodules.
• CT.
  With laboratory confirmation of hyperproduction of hormones of the adrenal cortex, a CT scan of the adrenal glands is performed to look for a tumor formation - corticosteroma.
• MRI.
  In acromegaly and Itsenko-Cushing's disease, an MRI of the brain reveals a benign tumor of the pituitary gland - an adenoma.

Since long-term hyperglycemia itself has an adverse effect on the entire human body, if it is detected, especially after repeated blood sugar measurements, an examination is prescribed to assess the condition of the target organs, which includes:

• study of total cholesterol and lipid profile;
• blood pressure measurement;
• taking an electrocardiogram;
• determination of the level of creatinine, urea in the blood serum, total protein, albumin-creatinine ratio in the urine; if necessary, the glomerular filtration rate is calculated;
• fundus examination.

Insulin therapy is the leading method of treating diabetes mellitus

Principles of treatment

If you have high blood sugar, you will need treatment to avoid life-threatening conditions. The complex of therapeutic measures includes:

• adherence to the principles of proper nutrition;
• regular monitoring of blood sugar levels - for this you can purchase a special device for home use - a glucometer. It is recommended to carry out the test several times a day. Urgent consultation with an endocrinologist is required if sugar levels increase repeatedly over a short period;
• regular physical activity;
• weight normalization;
• regular monitoring of blood pressure and cholesterol levels;
• taking medications to reduce blood glucose concentrations (insulin secretagogues, alpha-glucosiade inhibitors, etc.).

Treatment tactics are always selected individually depending on the reasons that led to the increase in blood sugar.

Correction

Conservative therapy

After receiving tests that exceed the reference glucose values, you should consult a doctor. A short-term increase in glycemia due to physiological factors does not require treatment. In case of drug-induced hyperglycemia, it is necessary to discontinue the causative drug, as well as consult the specialist who prescribed this drug to replace it.

In some cases, to normalize glycemia, competent treatment of the underlying disease (prescription of thyreostatic drugs, steroidogenesis inhibitors, somatostatin analogues) is sufficient. The following measures are used to treat patients with pathological hyperglycemia, especially caused by diabetes mellitus:

• Diet.
  Following a low-carbohydrate diet is one of the main conditions for successful correction of hyperglycemia. First of all, easily digestible carbohydrates are limited - chocolate, pastries, cakes. Preference is given to whole grain products (buckwheat, oatmeal).
• Physical exercise.
  Thanks to regular performance of various physical exercises, increased utilization of glucose by muscles occurs, which allows for a decrease in glycemia.
• Insulin therapy.
  Insulin injections are indicated for all patients with type 1 diabetes and pregnant women with gestational diabetes. Insulin is also prescribed for decompensation of type 2 diabetes. The effectiveness of therapy is the achievement of target levels of glycated hemoglobin (HbA1c).
• Antihyperglycemic agents.
  For type II diabetes, as well as hyperglycemia caused by other endocrinopathies, the drugs of choice are hypoglycemic drugs - biguanides (metformin), sulfonylurea derivatives (glibenclamide), DPP-4 inhibitors (vildagliptin).

Surgery

In some cases, when hyperglycemia cannot be corrected by conservative methods (for example, in patients with morbid obesity and type II diabetes), bariatric surgery is resorted to - gastric bypass, resection, gastric banding. For the successful treatment of many endocrinopathies, surgery is required - thyroidectomy for thyrotoxicosis, transnasal adenomectomy for acromegaly, bilateral adrenalectomy for Cushing's syndrome.

Forecast

Pathological hyperglycemia is an extremely unfavorable prognostic factor. High glucose levels can cause acute life-threatening conditions - hyperosmolar hyperglycemic and lactic acidotic coma. Hyperglycemia inhibits the phagocytic activity of leukocytes, resulting in increased susceptibility to infectious diseases.

Long-term hyperglycemia due to glycosylation of lipoproteins and endothelium of vascular walls rapidly accelerates the progression of atherosclerosis. Subsequently, this can lead to the early development of cardiovascular accidents (acute myocardial infarction, stroke), as well as chronic renal failure, loss of vision, and gangrene of the extremities.