Anticoagulation in hyperosmolar hyperglycaemic state: a case report and review of the literature

Introduction Hyperosmolar hyperglycaemic state (HHS) is one of two serious metabolic derangements that occur in people with diabetes mellitus. The first cases of HHS were described by von Frerichs and Dreschfeld in the 1880s with an ‘unusual diabetic coma’. It is a serious, life-threatening, but fortunately rare emergency that, although less common than its counterpart, diabetic ketoacidosis (DKA), has around a 10 times higher mortality rate, up to 15–20%.1 HHS accounts for around 1% of hospital admissions in people with diabetes, typically in the elderly. Increasing prevalence of obesity has additionally increased the incidence of HHS in the paediatric population. Prognosis is worse when associated with increasing comorbidities, age and significant electrolyte abnormalities.2 It is well known that diabetes can affect the clotting pathway, resulting in endothelial dysfunction, eventually enhancing the activation of procoagulant factors, predisposing towards thrombosis. This process is further amplified in both hyperosmolarity and DKA.3 Several case reports highlight the significant mortality and morbidity that can be associated with venous thromboembolism (VTE) and its complications in people with hyperosmolarity including fatality from massive pulmonary embolism.1 Patients having major orthopaedic surgery tend to receive extended VTE prophylaxis and demonstrate significant reduction in VTE with this therapy. Given the paucity of evidence for prophylactic versus therapeutic anticoagulation in HHS, we looked at the evidence surrounding orthopaedic surgery where there has been considerable research. Direct oral anticoagulants are now being used for VTE prophylaxis in orthopaedic patients and may have a role in acutely unwell medical patients with a low risk of bleeding.4 The evidence regarding the potential benefit of prolonged anticoagulation in HHS remains unclear.5 We performed a literature review to look at the evidence.