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Updated: Dec 10 2021

Diabetes Mellitus

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  • 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
      • 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
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