Diabetes Mellitus Type I
5 y/o M with h/o prolonged candida infections presents with acute onset lethargy, polyuria, and polydipsia. Parents report family h/o DM type 1. Weight loss noted on exam.
Labs
Urine positive for ketones
BMP shows plasma glucose > 200 mg/dL
Positive autoantibodies to islet cells, insulin, glutamic acid decarboxylase, insulinoma-associated antigen-2, and zinc transporter 8
Obtain TSH to screen for concomitant thyroid disease; if abnormal test for antithyroid peroxidase and antithyroglobulin antibodies
Treatment
Stabilize pt according to DKA protocol
Initiate basal insulin glargine at 0.1 u/kg/day and follow-up fingersticks in 1 week; increase dose by 10% weekly until morning fingerstick glucose consistently < 130 but > 90 u/dL
Start 0.1 u/kg/day short acting insulin aspart divided between breakfast, lunch and dinner; adjust by 10% weekly until preprandial fingerstick glucose < 130 but > 90 u/dL
Education
Parents and pt educated about insulin injection
Parents and pt educated about pre-meal and pre-bedtime fingerstick glucose monitoring with goals of 90-130 mg/dL and 90-150 mg/dL, respectively
Parents counseled that failure to adhere to insulin regimen may result in blindness, heart/vascular disease, kidney failure, and/or limb amputation
Follow up as outpatient
Monitor for development of HTN
Consider starting lisinopril if urine albumin-to-creatinine ratio > 30 mg/g
Starting at age 10 years
Obtain lipid profile; start statin if LDL > 160 mg/dL
Perform yearly foot exam
Refer for yearly ophthalmology exams
Consider referral for insulin pump
Notes
Onset has a bimodal distribution with peaks occurring at age 4-6 years and 10-14 years
HbA1c
HbA1c may be inaccurate if onset occurred fewer than 3 months ago; obtain BMP
Long term HbA1c goal in pediatric patients is less than 7.5%
Increased risk for other autoimmune diseases:
Consider screening for Celiac disease if presenting with diarrhea
Also consider Addison’s disease, autoimmune hepatitis, and/or myasthenia gravis if associated symptoms develop
Renal disease
Monitor for development with yearly urinary albumin-to-creatinine ratio
Most common cause of hypoglycemia in previously controlled DM I
Diabetes Mellitus Type 2
Acanthosis nigricans
Non-caucasian patient < 65 years with h/o schizophrenia, NAFL, PCOS, gestational diabetes presents for health maintenance exam. ROS positive for fatigue, blurry vision, polyuria/polydipsia, and numbness/tingling in the lower extremities. BP > 140/90, acanthosis nigricans, and foot ulcer on exam.
Initial Labs
No h/o asplenia, anemia, or recent acute blood loss with HbA1c > 6.4%
Obtain lipid panel
HbA1c and Associated Therapy
HbA1c < 9%
GFR > 30: Start metformin and recheck HbA1c every 3-6 months
If follow-up HbA1c > 7%, add up to 2 additional oral agents before starting insulin (see HbA1c > 9%)
HbA1c 9-10%: Initiate metformin and empagliflozin (Jardiance); pt counseled about risk for UTI/pancreatitis and need for repeat HbA1c in 3 months
HbA1c > 7% after 3 months: Start liraglutide (Victoza) and recheck HbA1c in 3 months
HbA1c > 7% after 3 months on 3 oral agents: Start insulin (see HbA1c > 10%)
Initial HbA1c > 10%
Initiate basal insulin glargine (Lantus) at 0.1 u/kg/day
Initiate finger-stick log and follow-up in 1 week
Increase dose by 10% weekly until morning fingerstick glucose consistently < 130 but > 80 mg/dL
Titrate to to 0.4-1.0 u/kg/day until morning fingerstick goals are achieved and decrease by 10% for hypoglycemic events (morning fingerstick < 70)
If HbA1c > 7% after 3 months: Start 0.1 u/kg/day short acting insulin aspart (Novolog) divided between breakfast, lunch and dinner (e.g. 120 kg = 12u = 4u at each meal). Adjust by 10% weekly until preprandial fingerstick glucose < 130 but > 80 mg/dL.
Monitor HbA1c every 3-6 months
Obtain microalbumin-to-creatinine ratio and perform foot exam yearly
Additional Treatment
Stain therapy
ASCVD < 7.5%: Start rosuvastatin 10mg
ASCVD > 7.5%: Start rosuvastatin 20mg
Administer pneumococcal vaccine (PPSV23)
Counseling
Refer pt for intensive behavioral counseling interventions focusing on diet/exercise
Pt advised that failure to adhere to therapy may result in blindness, cardiovascular disease, kidney failure, and/or limb amputation
Notes
Patients at increased risk for developing diabetes
Member of ethnic groups including Asian, black, Hispanic, Native American/Pacific Islander
Use of antipsychotics
HbA1c value of 5.7 to 6.4% (“pre-diabetes”)
Screening
Screen patients age 40 to 70 years who with BMI 25.0 or greater; repeat every 3 years if results are normal
Screening may be considered in patients under 40 with BMI > 85th percentile or those with risk factors such as ethnicity, family history, PCOS, HTN, and/or HLD
Positive screen includes one of the following
HbA1C level > 6.4%
Fasting plasma glucose 126 mg/dL or greater
Plasma glucose 200 mg/dL or greater for fasting level and/or 75 g 2-hour glucose tolerance test
HbA1c
HbA1c goals
Age less than 65: Goal < 7.0%
Age 65 or greater: Goal 7.0 to 7.9%
HbA1c assumes RBC lifespan of approximately 3 months
Falsely low values occur with hemolytic anemias, acute blood loss
Falsely elevated values occur with asplenia, iron deficiency/aplastic anemias
Cannot be used in pregnancy (see gestational DM)
Fingerstick glucose goals
Home
Morning fingerstick glucose: 70-100 mg/dL
Preprandial: 80-130 mg/dL
Hospital fingerstick glucose: 140-180 mg/dL
Non-insulin medications
Metformin
Contraindicated in patients with GFR < 30 mL/minute/1.73 m^2
Once initiated, should be continued as long as tolerated; additional agents including insulin should be added to metformin (ADA Guidelines)
May lower B12; check levels periodically, especially if anemia or peripheral neuropathy develops
If empagliflozin or liraglutide not tolerated, start pioglitazone
See DM type 2 medications for more information