What are the recommended insulin management protocols for patients with HHS in a primary care setting?

Recommended insulin management protocols for patients with hyperosmolar hyperglycaemic state (HHS) in a primary care setting:

• HHS is a medical emergency that requires urgent hospital management; primary care should focus on rapid referral rather than initiating complex insulin protocols.
• In hospital, insulin is administered intravenously by infusion to manage hyperglycaemia effectively, as per diabetic ketoacidosis (DKA) protocols, which are similar in principle to HHS management.
• Intravenous insulin infusion is preferred because it allows precise control of blood glucose and ketone clearance, with adjustments based on frequent monitoring.
• Once plasma glucose falls to 10–15 mmol/l, glucose-containing fluids are given to allow continuation of insulin infusion to clear ketones safely.
• Potassium replacement should begin early with frequent monitoring to avoid hypokalaemia during insulin therapy.
• In primary care, the focus should be on recognising HHS promptly, initiating fluid resuscitation if possible, and urgent hospital referral for intravenous insulin and electrolyte management.

Therefore, insulin management of HHS is not typically initiated in primary care but managed in hospital with intravenous insulin infusion, fluid replacement, and electrolyte monitoring under specialist supervision.

References: The UK NICE guideline NG17 on Type 1 diabetes management details insulin infusion for DKA, which is analogous to HHS management, and emphasises hospital-based care for acute hyperglycaemic emergencies ¹.