Diabetes mellitus (main)

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Background

  • Growing in worldwide prevalence
  • Results from either inability of the body to release insulin from the pancreas or a resistance against the actions of insulin

Clinical Features

  • Patients with diabetes may be asymptomatic
  • Acute symptoms range from those of nonketotic hyperglycemia (e.g. polyuria, polydipsia) to DKA (ill appearance, acetone breath, Kussmaul's breathing, somnolence)

Differential Diagnosis

Hyperglycemia

Evaluation

  • Diabetes mellitus itself is not normally a diagnosis sought in the emergency department (i.e. via A1C)
  • Hyperglycemia can be found on laboratory testing
    • Asymptomatic patients do not necessarily require additional testing
    • Symptomatic or potentially symptomatic patients require additional testing
      • Check CBC, BMP, and ketones (if sick, additionally see DKA workup)
      • UA is only necessary if you are ruling out urinary infection or do not have serum ketones available and are using it as a screening mechanism

American Diabetes Association Diagnostic Criteria

Need 1 of the following:[1]

  • HbA1C ≥6.5%
  • FPG ≥126mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least eight hours
  • Two-hour plasma glucose ≥200mg/dL (11.1 mmol/L) during an oral glucose tolerance test
  • In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200mg/dL (11.1 mmol/L)
    • Most common way diagnosed in ED

Management

Type II Diabetes Outpatient Management

  • 1st line: Metformin 500mg BID → 1000mg BID, do not give in people with abnormal LFT's, CHF Stage 3/4 and ARI, CKD
  • 2nd Agent: Glipizide start 2.5mg BID → 5mg BID, need to monitor for hypoglycemia
  • 3rd Agent: Pioglitazone
  • After 3 agents: need to start insulin if not controlled
    • NPH BID or Lantus Qday (0.5mg/kg) and titrate to Fasting Blood Sugar

Disposition

See Also

References

  1. American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care 2013; 36 Suppl 1:S11.
  2. EBQ:Relevance of Discharge Glucose Levels

Authors:

Ross Donaldson