Diabetes Mellitus

Aka: Diabetes Mellitus

1. See Also
   1. Type I Diabetes Mellitus
   2. Type II Diabetes Mellitus
   3. Insulin Resistance Syndrome
   4. Glucose Metabolism
   5. Diabetes Mellitus Education
   6. Diabetes Mellitus Complications
   7. Diabetic Ketoacidosis
   8. Hyperosmolar Hyperglycemic State
   9. Diabetes Mellitus Control in Hospital
   10. Diabetes Mellitus Glucose Management
   11. Hypertension in Diabetes Mellitus
   12. Hyperlipidemia in Diabetes Mellitus
   13. Diabetic Retinopathy
   14. Diabetic Nephropathy
   15. Diabetic Neuropathy
2. Definition
   1. Metabolic disorder of carbohydrate economy
   2. Deficiency of pancreatic beta cell Insulin secretion
   3. Resistance to Insulin effect peripherally
3. Epidemiology (U.S. statistics for 2004 per ADA)
   1. Prevalence
      1. Type I Diabetes Mellitus: 750,000
      2. Type II Diabetes Mellitus: 13 million
      3. Gestational Diabetes: 135,000
      4. Undiagnosed with diabetes: 5.2 million
   2. Incidence
      1. Type 1: 30,000 new cases per year
      2. Type 2: 850,000 new cases per year
      3. Gestational Diabetes Mellitus: 4% of all pregnancies
      4. Fastest growing groups
         1. Ages 30 to 39 years
         2. Type II Diabetes in children
4. Types
   1. Type I Diabetes Mellitus
      1. Juvenile Diabetes Mellitus
      2. Insulin Dependent Diabetes Mellitus (IDDM)
   2. Type II Diabetes Mellitus
      1. Adult onset Diabetes Mellitus
      2. Non-Insulin Dependent Diabetes Mellitus (NIDDM)
      3. Pediatric Type II Diabetes Mellitus (Pediatric NIDDM)
      4. Maturity onset Diabetes of youth (MODY)
5. Symptoms
   1. Classic (75% of cases of Type I Diabetes Mellitus)
      1. Polyuria or nocturia
      2. Polydipsia
      3. Unexplained Weight Loss
   2. Other symptoms
      1. Increased appetite
      2. Blurred vision
      3. Frequent Urinary Tract Infections
      4. Frequent yeast infections
      5. Fatigue
      6. Dry or pruritic skin
      7. Numbness or tingling in the extremities
6. Diagnosis: Two of the following
   1. Random Serum Glucose
      1. Serum Glucose over 200 mg/dl with symptoms
   2. Fasting Serum Glucose
      1. Serum Glucose exceeds 126 mg/dl on 2 different days
   3. Postprandial Glucose (2 hours post meal)
      1. Serum Glucose over 200 mg/dl
      2. Precedes fasting Glucose increase
      3. More predictive of Diabetes Mellitus Complications
   4. Casual Plasma Glucose (random Glucose)
      1. Same criteria as postprandial Glucose
   5. Oral Glucose Tolerance Test (OGGT)
      1. Two hour Glucose Tolerance Test (75 gram) >200 mg/dl
      2. Consider in patients with Insulin Resistance
         1. Patients with pre-diabetes to qualify for education
   6. Hemoglobin A1C
      1. Hemoglobin A1C >6.5%
7. Differential Diagnosis: Hyperglycemia
   1. See Hyperglycemia
   2. Stress response
      1. Blood Glucose typically <200 mg/dl
   3. Non-diabetic patient following a large meal
      1. Blood Glucose typically <160 mg/dl
8. Labs: Other monitoring
   1. Home Serum Glucose monitoring
      1. Over 50% of values should fall in target range
9. Management: Severe Hyperglycemia at diagnosis
   1. Strongly consider Insulin at onset if severe Hyperglycemia
   2. Criteria
      1. Blood Glucose >300 mg/dl
      2. Hemoglobin A1C >9.0
   3. Protocol based on Urine Ketones
      1. Urine Ketones positive
         1. Evaluate for Diabetic Ketoacidosis
         2. Serum beta hydroxybutyrate (Serum Ketones) positive in Diabetic Ketoacidosis
         3. Basic metabolic panel findings suggestive of Diabetic Ketoacidosis
            1. Decreased serum bicarbonate
            2. Increased Anion Gap suggests
      2. Urine Ketones negative
         1. Confirm adequate hydration
            1. Consider intravenous fluids
         2. Type I vs Type II is not critical initially
            1. Both are given Insulin at this Hyperglycemia level
            2. Type II suspected
               1. Consider adding Metformin if normal Renal Function
                  1. Start Metformin 500 mg orally daily to twice daily
               2. Insulin can likely be weaned later
                  1. Glucose toxicity causes low Insulin level
                  2. Endogenous Insulin will later normalize
         3. Start Lantus Insulin at 10 to 14 units SQ today
            1. Low risk of Hypoglycemia
            2. Alternative for a stable, asymptomatic patient with suspected Type II Diabetes (e.g. Emergency Department)
               1. Metformin might be started without Insulin
               2. Close interval follow-up, as persistent severe Hyperglycemia may be poorly responsive to oral agents initially
         4. Teach Glucose testing, Insulin injection today
            1. Formal Diabetic Education within 1 week
            2. Consider endocrinology consultation later
         5. Give prescriptions today
            1. Meter, strips, lancets, Insulin, syringes
10. Management: Initial Education
    1. Key Topics
       1. See Diabetes Mellitus Glucose Management
       2. See Diabetes Mellitus Education
    2. Type specific Diabetes Information
       1. See Type I Diabetes Mellitus
       2. See Type II Diabetes Mellitus
    3. Adjunctive Management
       1. See Prevention of Diabetes Mellitus Complications
       2. See Hypertension in Diabetes Mellitus
       3. See Coronary Artery Disease Prevention in Diabetes
       4. See Diabetic Nephropathy
       5. See Tobacco Cessation
       6. See Low Fat Diet
       7. See AntiHyperlipidemic
       8. See Obesity Management
       9. Weight loss
       10. Aspirin (Guidelines as of 2012)
           1. Has historically been considered in all diabetic patients or starting at age 45 years in men and age 55 years in women
           2. Aspirin does not increase risk of Retinal Hemorrhage
           3. Indications for low dose Aspirin 81 mg daily (Framingham risk >10%, no vascular disease, and no Bleeding Diathesis)
              1. Males over age 50 years or females over age 60 years and
              2. One additional Cardiovascular Risk Factor
                 1. Tobacco abuse
                 2. Hypertension
                 3. Dyslipidemia
                 4. Albuminuria
                 5. Family History of premature cardiovascular death
           4. Indications for Clopidogrel (Plavix) 75 mg daily
              1. Known cardiovascular disease
       11. Consider ACE Inhibitor in all diabetic patients
           1. See Diabetic Nephropathy
           2. Indications are more
           3. Use low dose (2.5 to 5 mg) in normotensive patient
       12. Lipid disorders
           1. See Coronary Artery Disease Prevention in Diabetes
           2. See Low Fat Diet
           3. See AntiHyperlipidemic