Diabetes Mellitus

Aka: Diabetes Mellitus

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II. Definitions

  1. Diabetes Mellitus
    1. Metabolic disorder of Carbohydrate economy
    2. Deficiency of pancreatic beta cell Insulin secretion
    3. Resistance to Insulin effect peripherally

III. Epidemiology

  1. Prevalence (U.S., 2015)
    1. Diabetes Mellitus: 30.3 Million (>9% of the U.S. population, 23% of whom are undiagnosed)
      1. Type I Diabetes Mellitus: 1.25 Million (4% of diabetics)
      2. Type II Diabetes Mellitus: 29 Million
    2. Prediabetes: 84.1 Million
  2. Incidence (U.S., 2015)
    1. Type 1 Diabetes: 17,900 new cases in 2012 in age <20 years
    2. Type 2 Diabetes: 1.5 million new cases of diabetes in adults (6.7 per 1,000 persons)
    3. Gestational Diabetes Mellitus: 2-10% of all U.S. pregnancies
    4. Fastest growing groups
      1. Ages 30 to 39 years
      2. Type II Diabetes in children
  3. References
    1. American Diabetes Association
      1. http://www.diabetes.org/diabetes-basics/statistics/
    2. Centers for Disease Control
      1. https://www.cdc.gov/diabetes/data/statistics/statistics-report.html

IV. Types

  1. Type I Diabetes Mellitus
    1. Juvenile Diabetes Mellitus
    2. Insulin Dependent Diabetes Mellitus (IDDM)
    3. Latent Autoimmune Diabetes in Adults (LADA)
    4. Autoimmune associations with infectious triggers (e.g. CMV, Coxsachievirus B, Mumps, Congenital Rubella, HCV)
  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. Gestational Diabetes
  3. Genetic Syndromes Associated with Diabetes Mellitus
    1. Type I Diabetes MellitusGenetic predisposition
      1. Associated with HLA-DR4, HLA-DR3
    2. Maturity onset Diabetes of youth (MODY)
      1. Caused by HNF4A, GCK or HNF1A gene defect in 95% of cases
    3. Insulin action genetic defects (rare)
      1. Type A Insulin Resistance (TAIRS)
      2. Donohue syndrome (Leprechaunism, INSR gene mutation)
      3. Rabson–Mendenhall syndrome
      4. Lipodystrophy Syndromes
    4. Other Genetic Syndromes in which Diabetes Mellitus is more common
      1. Down Syndrome
      2. Friedreich's Ataxia
      3. Huntington's Chorea
      4. Klinefelter Syndrome
      5. Myotonic Dystrophy
      6. Porphyria
      7. Prader-Willi Syndrome
      8. Turner Syndrome
      9. Wolfram Syndrome (DIDMOAD)
    5. References
      1. Goyal (2023) World J Diabetes 14(6):656-79 +PMID: 37383588 [PubMed]
  4. Other factors associated with Diabetes Mellitus
    1. See Medication Causes of Hyperglycemia
    2. Pancreatic exocrine dysfunction
      1. Chronic Pancreatitis
      2. Cystic Fibrosis
      3. Hemochromatosis
      4. Pancreatic Cancer
      5. Status Pancreatectomy
    3. Endocrinopathy
      1. Acromegaly
      2. Cushing Syndrome
      3. Hyperthyroidism
      4. Pheochromocytoma
      5. Glucagonoma
    4. References
      1. Popoviciu (2023) Int J Mol Sci 24(16):12676 +PMID: 37628857 [PubMed]

V. 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

VI. Diagnosis: Two of the following

  1. See Diabetes Screening
  2. Random Serum Glucose
    1. Serum Glucose over 200 mg/dl with symptoms
  3. Fasting Serum Glucose
    1. Serum Glucose exceeds 126 mg/dl on 2 different days
  4. 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
  5. Casual Plasma Glucose (random Glucose)
    1. Same criteria as postprandial Glucose
  6. 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
  7. Hemoglobin A1C
    1. Hemoglobin A1C >6.5%

VII. 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

VIII. Labs: Other monitoring

  1. Home Serum Glucose monitoring
    1. Over 50% of values should fall in target range

IX. 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
          1. Persistent severe Hyperglycemia may be poorly responsive to oral agents initially
          2. Metformin might be started without Insulin
          3. Close interval follow-up
      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

X. 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. Historically considered in all diabetic patients
        1. Previously started by 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
        1. Based on Framingham risk >10% (and no vascular disease, and no Bleeding Diathesis)
        2. Males over age 50 years or females over age 60 years and
        3. 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

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