II. Definitions
- Diabetes Mellitus
- Metabolic disorder of Carbohydrate economy
- Deficiency of pancreatic beta cell Insulin secretion
- Resistance to Insulin effect peripherally
III. Epidemiology
-
Prevalence (U.S., 2015)
- Diabetes Mellitus: 30.3 Million (>9% of the U.S. population, 23% of whom are undiagnosed)
- Type I Diabetes Mellitus: 1.25 Million (4% of diabetics)
- Type II Diabetes Mellitus: 29 Million
- Prediabetes: 84.1 Million
- Diabetes Mellitus: 30.3 Million (>9% of the U.S. population, 23% of whom are undiagnosed)
-
Incidence (U.S., 2015)
- Type 1 Diabetes: 17,900 new cases in 2012 in age <20 years
- Type 2 Diabetes: 1.5 million new cases of diabetes in adults (6.7 per 1,000 persons)
- Gestational Diabetes Mellitus: 2-10% of all U.S. pregnancies
- Fastest growing groups
- Ages 30 to 39 years
- Type II Diabetes in children
- References
- American Diabetes Association
- Centers for Disease Control
IV. Types
-
Type I Diabetes Mellitus
- Juvenile Diabetes Mellitus
- Insulin Dependent Diabetes Mellitus (IDDM)
- Latent Autoimmune Diabetes in Adults (LADA)
- Autoimmune associations with infectious triggers (e.g. CMV, Coxsachievirus B, Mumps, Congenital Rubella, HCV)
-
Type II Diabetes Mellitus
- Adult Onset Diabetes Mellitus
- Non-Insulin Dependent Diabetes Mellitus (NIDDM)
- Pediatric Type II Diabetes Mellitus (Pediatric NIDDM)
- Maturity onset Diabetes of youth (MODY)
- Gestational Diabetes
-
Genetic Syndromes Associated with Diabetes Mellitus
- Type I Diabetes MellitusGenetic predisposition
- Associated with HLA-DR4, HLA-DR3
- Maturity onset Diabetes of youth (MODY)
- Caused by HNF4A, GCK or HNF1A gene defect in 95% of cases
- Insulin action genetic defects (rare)
- Type A Insulin Resistance (TAIRS)
- Donohue syndrome (Leprechaunism, INSR gene mutation)
- Rabson–Mendenhall syndrome
- Lipodystrophy Syndromes
- Other Genetic Syndromes in which Diabetes Mellitus is more common
- Down Syndrome
- Friedreich's Ataxia
- Huntington's Chorea
- Klinefelter Syndrome
- Myotonic Dystrophy
- Porphyria
- Prader-Willi Syndrome
- Turner Syndrome
- Wolfram Syndrome (DIDMOAD)
- References
- Type I Diabetes MellitusGenetic predisposition
- Other factors associated with Diabetes Mellitus
- See Medication Causes of Hyperglycemia
- Pancreatic exocrine dysfunction
- Chronic Pancreatitis
- Cystic Fibrosis
- Hemochromatosis
- Pancreatic Cancer
- Status Pancreatectomy
- Endocrinopathy
- References
V. Symptoms
- Classic (75% of cases of Type I Diabetes Mellitus)
- Polyuria or Nocturia
- Polydipsia
- Unexplained Weight Loss
- Other symptoms
- Increased appetite
- Blurred Vision
- Frequent Urinary Tract Infections
- Frequent yeast infections
- Fatigue
- Dry or pruritic skin
- Numbness or tingling in the extremities
VI. Diagnosis: Two of the following
- See Diabetes Screening
- Random Serum Glucose
- Serum Glucose over 200 mg/dl with symptoms
-
Fasting Serum Glucose
- Serum Glucose exceeds 126 mg/dl on 2 different days
- Postprandial Glucose (2 hours post meal)
- Serum Glucose over 200 mg/dl
- Precedes Fasting Glucose increase
- More predictive of Diabetes Mellitus Complications
- Casual Plasma Glucose (random Glucose)
- Same criteria as postprandial Glucose
- Oral Glucose Tolerance Test (OGGT)
- Two hour Glucose Tolerance Test (75 gram) >200 mg/dl
- Consider in patients with Insulin Resistance
- Patients with pre-diabetes to qualify for education
-
Hemoglobin A1C
- Hemoglobin A1C >6.5%
VII. Differential Diagnosis: Hyperglycemia
- See Hyperglycemia
- Stress response
- Blood Glucose typically <200 mg/dl
- Non-diabetic patient following a large meal
- Blood Glucose typically <160 mg/dl
VIII. Labs: Other monitoring
- Home Serum Glucose monitoring
- Over 50% of values should fall in target range
IX. Management: Severe Hyperglycemia at diagnosis
- Strongly consider Insulin at onset if severe Hyperglycemia
- Criteria
- Blood Glucose >300 mg/dl
- Hemoglobin A1C >9.0
- Protocol based on Urine Ketones
- Urine Ketones positive
- Evaluate for Diabetic Ketoacidosis
- Serum Beta Hydroxybutyrate (Serum Ketones) positive in Diabetic Ketoacidosis
- Basic metabolic panel findings suggestive of Diabetic Ketoacidosis
- Decreased serum bicarbonate
- Increased Anion Gap suggests
- Urine Ketones negative
- Confirm adequate hydration
- Consider Intravenous Fluids
- Type I vs Type II is not critical initially
- Both are given Insulin at this Hyperglycemia level
- Type II suspected
- Start Lantus Insulin at 10 to 14 units SQ today
- Low risk of Hypoglycemia
- Alternative for a stable, asymptomatic patient with suspected Type II Diabetes
- Persistent severe Hyperglycemia may be poorly responsive to oral agents initially
- Metformin might be started without Insulin
- Close interval follow-up
- Teach Glucose testing, Insulin injection today
- Formal Diabetic Education within 1 week
- Consider endocrinology Consultation later
- Give prescriptions today
- Meter, strips, lancets, Insulin, syringes
- Confirm adequate hydration
- Urine Ketones positive
X. Management: Initial Education
- Key Topics
- Type specific Diabetes Information
- Adjunctive Management
- See Prevention of Diabetes Mellitus Complications
- See Hypertension in Diabetes Mellitus
- See Coronary Artery Disease Prevention in Diabetes
- See Diabetic Nephropathy
- See Tobacco Cessation
- See Low Fat Diet
- See AntiHyperlipidemic
- See Obesity Management
- Weight loss
- Aspirin (Guidelines as of 2012)
- Historically considered in all diabetic patients
- Previously started by age 45 years in men and age 55 years in women
- Aspirin does not increase risk of Retinal Hemorrhage
- Indications for low dose Aspirin 81 mg daily
- Based on Framingham risk >10% (and no vascular disease, and no Bleeding Diathesis)
- Males over age 50 years or females over age 60 years and
- One additional Cardiovascular Risk Factor
- Tobacco Abuse
- Hypertension
- Dyslipidemia
- Albuminuria
- Family History of premature cardiovascular death
- Indications for Clopidogrel (Plavix) 75 mg daily
- Known cardiovascular disease
- Historically considered in all diabetic patients
- Consider ACE Inhibitor in all diabetic patients
- See Diabetic Nephropathy
- Indications are more
- Use low dose (2.5 to 5 mg) in normotensive patient
- Lipid disorders