Managing hyperglycaemic emergencies: an illustrative case and review of recent British guidelines
Editor – In the paper ‘Managing hyperglycaemic emergencies: an illustrative case and review of recent British guidelines’ (Clin Med April 2013 pp160–2) the authors have discussed the difficulties of differential diagnosis between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
In this discussion, they have omitted an important event: the Nobel Prize of 1977 which went to Rosalyn Yallow for the development of new methods of biochemical analysis, enabling also to measure concentration of insulin in human plasma.
Already in 1981, the monograph Diabetic coma: ketoacidotic and hyperosmolar1 states the names of 12 authors who reported insulin in plasma of patients with DKA. Thus, the statement ‘. . . in DKA, the lack of insulin . . .’ is not correct.
On the other hand, lack of plasmatic insulin has been reported in patients with HHS,2 for example, and even in diabetic outpatients on regular control without subjective complaints.3 Thus, also the end of the statement on p160 ‘. . . in HHS, residual beta cell function is sufficient to prevent lipolysis . . .’ is incorrect.
It is very useful to discuss difficulties in the differential diagnosis of DKA and HHS; however, this discussion would be more exact and more reliable if concrete numerical values of concentration of plasmatic insulin were included.
- © 2013 Royal College of Physicians
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