Which of the following are common precipitating factors for DKA and hyperosmolar hyperglycemic state (HHS)?

• A. Regular exercise and dehydration.
• B. Illness/infection, nonadherence to insulin therapy, dehydration, severe stress.
• C. Adequate hydration and strict adherence to insulin therapy.
• D. Cold exposure without illness.

Answer: (B)

Precipitating factors for DKA and HHS are events that worsen insulin deficiency or dramatically raise glucose production through counterregulatory hormones. Illness or infection triggers stress hormones like cortisol and adrenaline, which boost glucose production and ketogenesis, making DKA more likely and HHS if insulin is insufficient. When someone doesn’t take enough insulin, there isn’t enough insulin to counter these effects, allowing hyperglycemia to escalate and ketones to form. Dehydration further worsens the picture by reducing kidney perfusion and the body's ability to clear glucose and ketones, amplifying hyperglycemia and osmolarity. Severe stress from surgery, trauma, or other illness also raises these hormones and pushes glucose up.

Regular exercise and dehydration can affect glucose, but exercise is not a primary, consistent trigger for these crises, and dehydration alone is not as predictive without the other hormonal triggers. Adequate hydration with strict adherence to insulin would help prevent crises, not precipitate them. Cold exposure without illness lacks the hormonal and metabolic triggers needed to drive DKA or HHS.

Therefore, illness/infection, nonadherence to insulin therapy, dehydration, and severe stress are the common precipitating factors for both DKA and HHS.