2. Hyperosmolar hyperglycemic syndrome—Hyperosmolar hyperglycemic syndrome (HHS) is diagnosed in persons with type 2 diabetes and is characterized by profound hyperglycemia and dehydration. It is associated with inadequate oral hydration, especially in elderly patients; with other illnesses; with the use of medication that elevates the blood sugar or causes dehydration, such as phenytoin, steroids, diuretics, and calcium channel blockers; and with peritoneal dialysis and hemodialysis. The diagnostic hallmarks are declining mental status and even seizures, a plasma glucose >600 mg/dL, and a calculated serum osmolality >320 mmol/L. Persons with HHS are not acidotic unless DKA is also present.
The treatment of HHS centers around aggressive rehydration and restoration of glucose and electrolyte homeostasis; the rate of correction of these variables must be monitored closely. Low-dose insulin therapy may be required.
Chronic Complications of Diabetes
Late clinical manifestations of diabetes mellitus include a number of pathologic changes that involve small and large blood vessels, cranial and peripheral nerves, the skin, and the lens of the eye. These lesions lead to hypertension, end-stage chronic kidney disease, blindness, autonomic and peripheral neuropathy, amputations of the lower extremities, myocardial infarction, and cerebrovascular accidents. These late manifestations correlate with the duration of the diabetic state subsequent to the onset of puberty and glycemic control. In type 1 diabetes, end-stage chronic kidney disease develops in up to 40% of patients, compared with less than 20% of patients with type 2 diabetes. Proliferative retinopathy ultimately develops in both types of diabetes but has a slightly higher prevalence in type 1 patients (25% after 15 years’ duration). In patients with type 1 diabetes, complications from end-stage chronic kidney disease are a major cause of death, whereas patients with type 2 diabetes are more likely to have macrovascular diseases leading to myocardial infarction and stroke as the main causes of death. Cigarette use adds significantly to the risk of both microvascular and macrovascular complications in diabetic patients.
•Glipizide•Glyburide•Glimepiride•Gliclazide1 Insulin secretagogues: Close K+ channels in betacells•increaseinsulin release Reduce circulating glucose in patients with functioning beta cells Type 2 diabetes Orallyactive•duration10–24h•Toxicity: Hypoglycemia, weight gain •Tolazamide, tolbutamide, chlorpropamide, acetohexamide: Older sulfonylureas, lower potency, greater toxicity; rarely used •ColesevelamhydrochlorideBile acid binder: Lowers glucose through unknown mechanisms Reduces glucose levels Type 2 diabetes Oral•24-hdurationofaction•Toxicity: Constipation, indigestion, flatulence 1Not available in United States.