Approach to Uncomplicated Diabetes Mellitus : Simplified

A) GLUCOSE LEVEL

1. Post-prandial:

  • 140-200 mg/dl: Impaired glucose tolerance (Pre-diabetes)
    • Diabetes prevented with: weight loss, exercise, metformin (in high risk)
  • ≥200 mg/dl (+ Clinical symptoms): Diabetes confirmed

2. Fasting:

  • 100-126 mg/dl: Impaired fasting glucose (Pre-diabetes)
  • ≥126 mg/dl (+ Clinical symptoms): Diabetes confirmed

B) CONFIRMATION OF DIABETES MELLITUS

1. Postpranial glucose ≥200 mg/dl or Fasting glucose ≥126 mg/dl + Clinical Symptoms

2. ≥200 mg/dl glucose level after 2 hours of 75 gm glucose load (Oral glucose tolerance test)

3. HbA1c ≥ 6.5% (not recommended)

C) SECONDARY DIABETES MELLITUS

1. Drugs: Steroids, Thiazides, Diazoxide, Protease inhibitors

2. Genetic: Down’s syndrome, Turner’s syndrome, Klinefelter’s syndrome

3. Endocrinopathies: Cushing’s syndrome, Acromegaly, Hyperthyroidism, Pheochromocytoma

4. Exocrine pancreatic diseases: Hemochromatosis, pancreatitis, malignancy, cystic fibrosis

Management of secondary diabetes: Investigate and treat accordingly

D) TYPE 1 DIABETES MELLITUS

Absolute insulin deficiency; characterized by low level of insulin and C-peptide

Insulin:

Method of delivery: subcutaneous injection

Administration: 90 degrees to skin on anterior abdominal wall, upper arms, thighs or buttocks

Delivery devices: glass syringe, plastic syringe, pen device, infusion pump

insulin types

Regimens:

a. Twice daily administration: Soluble + Isophane (1:2)

  • Before breakfast: 2/3rd dose
  • Before dinner: 1/3rd dose

b. Multiple injection regimen:

  • Before each meal: short-acting insulin
  • Basal bolus: intermediate or long-acting insulin X 1-2/day

c. Alternate: Continuous subcutaneous infusion (CSI)

Adverse effects of insulin:

  1. Hypoglycemia
  2. Weight gain
  3. Peripheral edema
  4. Local allergy
  5. Lipohypothrophu/atrophy

Patient is taught to count carbohydrate and to calculate both correction and prandial dosing.

If ESRD: Consider transplantation of isolated pancreatic islets

E) Type 2 DIABETES MELLITUS

Relative insulin deficiency; characterized by normal or high level of C-peptide

Aim: Target HbA1c <7%

1. Diet control:

a. Carbohydrate (45-60%): Sucrose upto 10%

b. Fat (<35%):

  • n-6 PUFA: <10%
  • n-3 PUFA: 1 portion oily fish X 1-2/wk
  • Monounsaturated fatty acid: 10-20%
  • Saturated fatty acid: <10%

c. Protein (10-15%): <1 gm/kg/day

d. Salt: <6 gm/day

2. Weight loss: ~ 10%

3. Exercise: ≥30 min/day

4. Vaccinations

5. Anti-Diabetics:

oral antidiabetics

a. 1st line:

  • Metformin (Contraindicated if Creatinine >1.5 mg/dl) OR
  • Sulfonylureas (If metformin intolerance or with weight loss/osmotic symptoms)

b. 2nd line:

  • Sulfonylureas OR
  • Thiazolidinediones (If hypoglycemia is concern and no congestive heart failure) OR
  • DPP-4 inhibitor (If hypoglycemia is concern or weight gain is concern)

c. 3rd line:

  • Continue Metformin or Sulfonylureas if tolerated and Add –
  • Thiazolidinediones or DDP-4 inhibitor OR
  • Insulin (Initial basal; add prandial if required; start 0.3 U/kg) OR
  • GLP-1 agonist (if obese and <10 years from diagnosis)

choosing hypoglycemics

Aim: BP <130/80 mmHg

  • ACE inhibitor +/- CCBs or Diuretics

Aim: Urinary microalbuminuria (>30 mg/g creatinine)

  • ACE inhibitor or ARBs

Aim: LDL <100 mg/dl

  • Statins

Aim: HDL >40 mg/dl

  • Fibrate or nicotinic acid
  • Exercise

Other:

  • Aspirin: If >40 years
  • Yearly dilated eye examination

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