Diabetes mellitus (main)

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)
  • Nonketotic hyperglycemia
  • Hyperosmolar hyperglycemic state (HHS/HONC)
  • Diabetic ketoacidosis (adult)
  • Diabetic ketoacidosis (peds)
    • Cerebral edema in DKA
  • Diabetic foot infection
  • Diabetic peripheral neuropathy
• 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:

• 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)
  • Higher discharge glucose levels are not associated with a greater risk of repeated ED visits, hospitalization, or other adverse outcomes.
• 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

See Also

• Hypoglycemia
• Evidence Review Sodium Bicarbonate in DKA
• EBQ:Relevance of Discharge Glucose Levels