Diabetes mellitus (main): Difference between revisions
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*Growing in worldwide prevalence | *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 | *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, polyphagia) to [[DKA]] (ill appearance, acetone breath, Kussmaul's breathing, somnolence) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Hyperglycemia DDX}} | {{Hyperglycemia DDX}} | ||
==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 | |||
***Obtaining HbA1c prior to initiation of therapy helpful to establish a baseline | |||
===American Diabetes Association Diagnostic Criteria=== | |||
Need 1 of the following:<ref>American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care 2013; 36 Suppl 1:S11.</ref> | |||
*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== | |||
*There is no need to treat the glucose "number" (i.e. [[nonketotic hyperglycemia]] in the emergency setting (i.e. with insulin) | |||
**[[EBQ:Relevance of Discharge Glucose Levels|Higher discharge glucose levels are not associated with a greater risk of repeated ED visits, hospitalization, or other adverse outcomes.]] | |||
*For [[HHS|hyperosmolar hyperglycemic state]], [[DKA]], or another specific process see that particular page | |||
{{DM outpatient managment}} | |||
==Disposition== | |||
*Asymptomatic patients or those with [[nonketotic hyperglycemia]] can be discharged with follow up with primary care physician<ref>[[EBQ:Relevance of Discharge Glucose Levels]]</ref> | |||
==See Also== | ==See Also== | ||
*[[Hypoglycemia]] | *[[Hypoglycemia]] | ||
*[[EBQ:Sodium_Bicarbonate_use_in_DKA|Evidence Review Sodium Bicarbonate in DKA]] | *[[EBQ:Sodium_Bicarbonate_use_in_DKA|Evidence Review Sodium Bicarbonate in DKA]] | ||
*[[EBQ:Relevance of Discharge Glucose Levels]] | |||
==References== | |||
<references/> | |||
[[Category:Endocrinology]] | [[Category:Endocrinology]] | ||
Latest revision as of 14:45, 31 August 2019
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, polyphagia) to DKA (ill appearance, acetone breath, Kussmaul's breathing, somnolence)
Differential Diagnosis
Hyperglycemia
- Physiologic stress response (rarely causes glucose >200 mg/dL)
- Diabetes mellitus (main)
- Hemochromatosis
- Iron toxicity
- Sepsis
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
- Obtaining HbA1c prior to initiation of therapy helpful to establish a baseline
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
- There is no need to treat the glucose "number" (i.e. nonketotic hyperglycemia in the emergency setting (i.e. with insulin)
- For hyperosmolar hyperglycemic state, DKA, or another specific process see that particular page
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 (0.1 to 0.2mg/kg) and titrate to Fasting Blood Sugar
Disposition
- Asymptomatic patients or those with nonketotic hyperglycemia can be discharged with follow up with primary care physician[2]
See Also
References
- ↑ American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care 2013; 36 Suppl 1:S11.
- ↑ EBQ:Relevance of Discharge Glucose Levels