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Bell, MD, FACP — By Jenna Fletcher on August 30, 2022Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are two serious complications of diabetes that are potentially life threatening. Although both conditions cause a dangerous rise in sugar levels, there are important differences between the two. DKA is usually associated with type 1 diabetes, whereas people with type 2 diabetes are at risk of HHS. Both conditions occur as a result of an insulin deficiency that causes hyperglycemia. This article reviews the differences and similarities between DKA and HHS. Overview Share on Pinterestdragana991/Getty ImagesDKA and HHS have some similar features. They both result from an issue with insulin that causes an unsafe rise in blood sugar levels. DKA is typically an issue for people living with type 1 diabetes, although people living with type 2 diabetes can also develop the condition. It occurs when the body lacks enough insulin to convert sugar into energy. As a result of this deficiency, the liver starts to break down fats for energy instead of sugar. As part of this process, it creates chemicals called ketones. The number of ketones can rapidly become too high, creating a potentially dangerous situation for the person. HHS typically occurs in people living with type 2 diabetes. Unlike in DKA, the pancreas continues to create insulin. However, the peripheral tissue is highly resistant to this hormone, causing an unsafe buildup in blood sugar levels. Both conditions can be life threatening if a person does not receive immediate care. Learn more Learn more about diabetic emergencies. What to do in diabetic emergenciesHow do you recover from a diabetic coma?What to know about diabetic shock Comparison table The table below shows the causes, symptoms, and treatment of DKA and HHS. It also compares the mortality rates.ConditionPrimarily affectsPossible causesTreatment optionsMortality rateSymptomsDKApeople with type 1 diabetes• illness • missing an insulin dose• cardiac event• heavy alcohol use• injury IV delivery of:• fluids • insulin• electrolytes • medications for illnessup to 2%• fruity-smelling breath • high ketone levels in urine• symptoms present within a few hoursHHSpeople with type 2 diabetes• illness• cardiac eventIV delivery of:• fluids• insulin• electrolytes• medications for illnessup to 20%• fast heart rate• neurological symptoms such as confusion• symptoms present over days or weeks Symptoms DKA and HHS can present with similar symptoms. The early stages of both conditions cause:excessive thirstfrequent urinationhigh blood sugar levels DKA The symptoms of DKA can worsen quickly if a person does not get treatment. They can include:dry skin and mouthfruity smelling breathflushed facefast, heavy breathingexcessive tirednessheadachesmuscle stiffness or achesstomach painnausea and vomiting HHS HHS can present very similarly to DKA, meaning that doctors must take care to distinguish between the two syndromes. The symptoms of HHS can include:malaise, or a general feeling of illnessfatigueweaknessdehydration, which can involve dryness of the mouth, eyes, or lips One distinguishing characteristic is that HHS can cause neurological signs and symptoms, which may include:comadrowsinessloss of visionhallucinationsconfusion Finally, HHS can also present with symptoms related to its cause. Sometimes, a person may develop HHS following an infection or a cardiac event, such as a heart attack or stroke. If an infection causes HHS, a person might also experience:tachycardia, or a fast heart rate general weaknessabnormally rapid breathingfever If a cardiac event causes HHS, a person might also experience:heart palpitationsheadacheschest pain and tightness DKA vs HHS DKA and HHS can present similarly, as many of their symptoms overlap. However, one key difference is the presence of neurological symptoms. HHS can cause a person to experience hallucinations, confusion, drowsiness, loss of vision, or a coma. Both conditions cause an unsafe level of blood sugar. However, DKA is associated with high levels of ketones in the blood, whereas HHS is not. Both conditions may result from similar factors, such as:medication useillnesscardiac events However, DKA can occur due to a missed insulin dose, heavy alcohol use, or a physical injury. Although both conditions can lead to diabetic coma and death, the mortality rate of HHS is 10 times higher than that of DKA. However, a person can survive either condition with proper treatment. Causes The causes of both DKA and HHS are similar. Both may occur due to:illnessa cardiac event, such as a heart attack or strokeissues with diabetes medications, such as missing a dose or taking too much or too littlethe use of certain other medications, such as diuretics However, the most common causes are different. For HHS, the most common cause is an infection, which accounts for at least 50% of all cases. The two most common causes of DKA are missing a dose of insulin and an acute illness. Other possible causes include an injury, such as a car accident, and alcohol or drug use. Treatments The treatments for DKA and HHS are similar. Doctors will typically recommend the use of an IV line to deliver:electrolytesfluidsinsulinmedications to treat any underlying conditions, such as antibiotics for bacterial infections A doctor may discuss ongoing diabetes management with the person, including any necessary changes to their diet and exercise regimen. They may also adjust the person’s medications. Prevention A person can take steps at home to help prevent the development of either DKA or HHS. These include:monitoring blood glucose levels frequently, particularly when sicktaking medications on time and according to the prescriptionkeeping blood glucose levels within a target rangediscussing adjustments to medication or insulin based on dietary or exercise-related changes When to see a doctor DKA and HHS are emergencies that require immediate medical attention. A person living with diabetes should seek emergency care if they develop symptoms of either condition. It is also advisable for a person to test their blood sugar levels if they start to have early warning signs of hyperglycemia, such as extreme thirst or frequent urination. Frequently asked questions Below are the answers to common questions about DKA and HHS. Which is worse out of DKA and HHS Both DKA and HHS can be life threatening and require prompt treatment. However, HHS has a fatality rate that is about 10 times that of DKA. What is the difference between HONK and HHS HONK stands for hyperglycemic hyperosmolar non-ketotic coma, which is how the medical community previously referred to HHS. Non-ketotic hyperglycemic coma and hyperosmolar hyperglycemic non-ketotic syndrome are two other former names for the condition. Summary DKA and HHS are two complications of diabetes that have similar symptoms, causes, and treatments. Both conditions result from high blood glucose levels and require insulin to help treat them. DKA typically affects people living with type 1 diabetes, whereas HHS usually occurs in people living with type 2 diabetes. HHS tends to be more dangerous than DKA, but both conditions can be deadly if a person does not receive treatment. Prompt medical attention is necessary in both cases. A person should seek emergency medical care if they develop symptoms that could indicate HHS or DKA. Last medically reviewed on August 30, 2022DiabetesType 1Type 2Emergency Medicine 3 sourcescollapsedMedical News Today has strict sourcing guidelines and draws only from peer-reviewed studies, academic research institutions, and medical journals and associations. We avoid using tertiary references. We link primary sources — including studies, scientific references, and statistics — within each article and also list them in the resources section at the bottom of our articles. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.Adeyinka, A., et al. (2022). Hyperosmolar hyperglycemic syndrome. https://www.ncbi.nlm.nih.gov/books/NBK482142/Diabetes & DKA (ketoacidosis). (n.d.). https://www.diabetes.org/diabetes/dka-ketoacidosis-ketonesDiabetic ketoacidosis. (2021). https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.htmlFEEDBACK:Medically reviewed by Angela M. Bell, MD, FACP — By Jenna Fletcher on August 30, 2022 Latest newsWhat sets 'SuperAgers' apart? Their unusually large neuronsOmega-3 may provide a brain boost for people in midlifeSeasonal affective disorder (SAD): How to beat it this fall and winterCDC: Monkeypox in the US 'unlikely to be eliminated in the near future'Why are more women prone to Alzheimer's? New clues arise Related CoverageWhat is the relationship between DKA and ABG? What are DKA and ABG, and what is their relationship? 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