DM
Diabetes Mellitus
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Diabetes Mellitus
See Also
Type I Diabetes Mellitus
Type II Diabetes Mellitus
Insulin Resistance Syndrome
Glucose Metabolism
Diabetes Mellitus Education
Diabetes Mellitus Complications
Diabetic Ketoacidosis
Hyperosmolar Hyperglycemic State
Diabetes Mellitus Control in Hospital
Diabetes Mellitus Glucose Management
Hypertension in Diabetes Mellitus
Hyperlipidemia in Diabetes Mellitus
Diabetic Retinopathy
Diabetic Nephropathy
Diabetic Neuropathy
Definition
Metabolic disorder of
Carbohydrate
economy
Deficiency of pancreatic beta cell
Insulin
secretion
Resistance to
Insulin
effect peripherally
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
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
http://www.diabetes.org/diabetes-basics/statistics/
Centers for Disease Control
https://www.cdc.gov/diabetes/data/statistics/statistics-report.html
Types
Type I Diabetes Mellitus
Juvenile Diabetes Mellitus
Insulin Dependent Diabetes Mellitus
(
IDDM
)
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
)
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 Infection
s
Frequent yeast infections
Fatigue
Dry or pruritic skin
Numbness or tingling in the extremities
Diagnosis
Two of the following
See
Diabetes Screening
Random
Serum Glucose
Serum Glucose
over 200 mg/dl with symptoms
Fastin
g
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
Fastin
g
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%
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
Labs
Other monitoring
Home
Serum Glucose
monitoring
Over 50% of values should fall in target range
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 Ketone
s
Urine Ketone
s positive
Evaluate for
Diabetic Ketoacidosis
Serum Beta Hydroxybutyrate
(
Serum Ketone
s) positive in
Diabetic Ketoacidosis
Basic metabolic panel findings suggestive of
Diabetic Ketoacidosis
Decreased serum bicarbonate
Increased
Anion Gap
suggests
Urine Ketone
s negative
Confirm adequate hydration
Consider
Intravenous Fluid
s
Type I vs Type II is not critical initially
Both are given
Insulin
at this
Hyperglycemia
level
Type II suspected
Consider adding
Metformin
if normal
Renal Function
Start
Metformin
500 mg orally daily to twice daily
Insulin
can likely be weaned later
Glucose
toxicity causes low
Insulin
level
Endogenous
Insulin
will later normalize
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
Management
Initial Education
Key Topics
See
Diabetes Mellitus Glucose Management
See
Diabetes Mellitus Education
Type specific Diabetes Information
See
Type I Diabetes Mellitus
See
Type II Diabetes Mellitus
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
Retina
l
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
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
See
Coronary Artery Disease Prevention in Diabetes
See
Low Fat Diet
See
AntiHyperlipidemic
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