Snapshot A 46-year-old obese woman presents to the family practice clinic for her yearly exam. She reports that over the past few weeks, she has had some increased urinary frequency and thirst and recently went to an urgent care center for a urinary tract infection. She denies any fevers or chills. A random blood glucose level is 235 mg/dL and her hemoglobin A1c comes back at 10.0. Introduction Type I vs Type II Diabetes Type I Diabetes Type II Diabetes Pathogenesis Immune-mediated destruction of beta cells leading to ↓ insulin production Sensitive to insulin ↑ End-organ resistance to insulin, leading to pancreatic beta-cell defects Not sensitive to insulin Demographics Onset at younger age Onset at older age Associated with HLA-DR3 and HLA-DR-4 Other autoimmune diseases (e.g., Celiac disease (most common) or autoimmune thyroid disorders) Consider screening for these (e.g., anti-tissue transglutaminase or TSH, respectively) Obesity Hypertension Metabolic syndrome, defined as at least 3 out of 5 of: Abdominal obesity (waist circumference ≥40 inches in men, ≥35 inches in women) Fasting glucose ≥100-110 mg/dL Serum triglycerides ≥150 mg/dL Serum HDL cholesterol <40 mg/dL in men or <50 mg/dL in women Blood pressure ≥130/85 Histology if biopsied Leukocyte infiltrate Amyloid polypeptide deposition Presentation Classic symptoms polyuria in children, can present as nocturnal enuresis polydipsia polyphagia weight loss fatigue blurry vision Symptoms and Physical Exam in Type I vs Type II Diabetes Type I Diabetes Type II Diabetes Classic Symptoms Common Not as Common Acute manifestations Diabetic ketoacidosis Hyperosmolar hyperglycemic state Signs of complications Candidal infections Acanthosis nigricans Vascular disease examination cold, hairless lower extremities with diminished pulses Fundoscopic examination hemorrhages, exudates, and neovascularization Neuropathy cranial nerve III ischemia Candidal infections Acanthosis nigricans Vascular disease examination cold, hairless lower extremities with diminished pulses Fundoscopic examination hemorrhages, exudates, and neovascularization Neuropathy cranial nerve III ischemia Studies Diagnostic testing studies hemoglobin A1c ≥ 6.5 indicates glucose levels from the previous 8-12 weeks ↑ blood glucose all adults 40 - 70 years who are overweight or obese should be screened Differential Glucagonoma distinguishing factor presents with hyperglycemia as there is overproduction of glucagon, which increases glycogenolysis and gluconeogenesis also presents with necrolytic migratory erythema, weight loss, hypercoagulable state, and depression treatment is octreotide or surgery Diagnosis Diagnostic criteria 1 of the following hemoglobin A1c ≥ 6.5% 2 separate fasting plasma glucose ≥ 126 mg/dL 2-hour oral glucose tolerance test ≥ 200 mg/dL random glucose ≥ 200 mg/dL along with classic symptoms (polyuria, polydipsia, and polyphagia) Treatment Management approach strict glycemic control to prevent microvascular complications lifestyle modifications and management of hypertension or hyperlipidemia to prevent macrovascular complications Type I diabetes first-line insulin does not respond to lifestyle changes Type II diabetes first-line lifestyle changes diet exercise weight loss insulin oral agents metformin first-line, especially in patients with obesity contraindicated with renal insufficiency use of contrast for imaging Complications Complications of diabetes macrovascular coronary artery disease peripheral artery disease stroke microvascular diabetic retinopathy diabetic nephropathy diagnosis urine albumin-to-creatinine ratio testing is the most sensitive test to detect moderately elevated levels of urinary albumin excretion treatment angiotensin-converting enzyme inhibitors angiotensin II receptor blockers diabetic neuropathy treatment duloxetine, gabapentin, pregabalin, and NSAIDs autonomic dysfunction gastroparesis treatment lifestyle modifications metoclopramide or erythromycin complications small bowel bacterial overgrowth (diarrhea) treat with rifaximin diabetic foot treatment debridement and antibiotics amputation neurogenic bladder treatment bethanechol intermittent straight catheterization