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Normal mg/dL (mmol/L) | Impaired* mg/dL (mmol/L) | Diabetes Mellitus mg/dL (mmol/L) | |
|---|---|---|---|
Fasting plasma glucose | <100 (5.6) | 100–125 (5.6–6.9) | ≥126† (7) |
2-h OGTT | <140 (7.8) | 140–199 (7.8–11) | ≥200† (11.1) |
Random glucose | <200 (11.1) | ≥200 (11.1) | ≥200 (11.1) + classic symptoms‡ |
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Type I | Type 2 | |
|---|---|---|
Age of onset | Variable | Pubertal |
Classic symptoms | Days or weeks | Subacute or absent |
Physical exam | Weight loss | Obese, acanthosis nigricans, features of PCOS |
Predominant race | Caucasian | Non-caucasian |
C-peptide level | Low | High |
Autoantibodies | Positive | Negative |
Ketoacidosis | Common, recurrent | Less common (∼1/3), very rarely recurrent |
- Categories
- Type 1 DM: ∼65% of pediatric patients with DM; 5% to 10% of adults with DM.
- Mechanism: Absolute insulin deficiency caused by autoimmune β-cell destruction (∼90% of cases); idiopathic (∼10% of cases).
- Presentation: Acute onset (<1 mo) of classic symptoms (weight loss, polyuria, polydipsia ± polyphagia, lethargy, or vaginal yeast infection); 25% present with DKA.
- Diagnosis: See table “Diagnosing Diabetes Mellitus and Impaired Glucose Regulation.”
- Screening: Not recommended (short asymptomatic period; no effective prevention).
- Mechanism: Absolute insulin deficiency caused by autoimmune β-cell destruction (∼90% of cases); idiopathic (∼10% of cases).
- Type 2 DM: ∼35% of pediatric patients with DM; 90% to 95% of adults with DM.
- Mechanism: Insulin resistance and relative insulin deficiency.
- Presentation: Usually subacute; many are asymptomatic, overweight (BMI >85%) or obese; absent or mild polyuria; acanthosis nigricans; glucosuria; usually no ketonuria.
- Diagnosis: Establish hyperglycemia and then differentiate from type 1 (see table ” Characteristics Suggesting Type 1 versus Type 2 Diabetes Mellitus”).
- Screening: See table “Recommendations For Type 2 Diabetes Mellitus Screening”.
- Prevention: Avoid weight gain into the overweight or obese range. If overweight → weight loss and exercise (independent of weight loss) may delay, prevent, or reverse the course of Type 2 DM.
- Mechanism: Insulin resistance and relative insulin deficiency.
- Type 1 DM: ∼65% of pediatric patients with DM; 5% to 10% of adults with DM.
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Recommendations for Type 2 Diabetes Mellitus Screening* |
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Age >10 yr or onset of puberty (whichever is earlier) and overweight (BMI >85th percentile or >120% of IBW for height) and any two of the following:
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- Secondary causes of DM: Genetic defects of β-cell function (formerly MODY; AD inheritance, multiple family members with hyperglycemia onset <25 yo), gestational DM, drug- induced (eg, L-aspariginase, steroids, tacrolimus, cyclosporine, β-blockers, phenytoin, protease inhibitors), diseases with pancreatic destruction (eg, CF, trauma, pancreatitis), infections (eg, rubella, CMV), genetic syndromes with insulin deficiency or resistance (eg, Down, Prader-Willi, Turner, Klinefelter syndromes).
- Inpatient management
- DKA: See chapter 9 for DKA management.
- New stable type 1 diabetic (not in DKA):
- Criteria for admission to regular ward (vary by institution): Normal mental status, tolerating PO intake, and serum HCO3 ≥16 mEq/L (≤5 yo) or ≥12 mEq/L (>5 yo).
- Orders: see table “Suggested Orders For The New Diabetic”.
- Insulin management: See table “Pharmacokinetics of Different Types of Insulin” and table “Insulin Regimens for Controlling Blood Sugar in Patients with Type 1 Diabetes Mellitus”
- Criteria for admission to regular ward (vary by institution): Normal mental status, tolerating PO intake, and serum HCO3 ≥16 mEq/L (≤5 yo) or ≥12 mEq/L (>5 yo).
- DKA: See chapter 9 for DKA management.
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Suggested Orders for the New Diabetic |
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Insulin regimen: See table Insulin Regimens for Controlling Blood Sugar in Patients with Type 1 Diabetes Mellitus |
Diet Carbohydrate consistent—3 meals and 2 snacks per day (3 if child <5 yr) |
Labs
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To bedside
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Consultations
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Initiate diabetes education
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Types of Insulin | Onset (h) | Peak Glycemic Effect (h) | Duration (h) |
|---|---|---|---|
Rapid Acting | |||
Insulin lispro (Humalog®) | 0.2–0.5 | 1.5–2.5 | 3–4 |
Insulin aspart (NovoLog®) | 0.2–0.5 | 1–3 | 3–5 |
Insulin glulisine (Apidra®) | 0.2–0.5 | 1.6–2.8 | 4–5 |
Short Acting | |||
Insulin regular (Humulin® R, Novolin® R) | 0.5 | 2.5–5 | 4–12 |
Intermediate Acting | |||
Insulin NPH (isophane suspension) (Humulin® N, Novolin® N) | 1–2 | 4–12 | 18–24 |
Intermediate to Long Acting | |||
Insulin detemir (Levemir®) | 3–4 | 3–14 | 6–23 |
Long Acting | |||
Insulin glargine (Lantus®) | 3–4 | * | ≥24 |
Combinations | |||
Insulin aspart protamine suspension and insulin aspart (Novolog® Mix 70/30) | 0.2 | 1–4 | 18–24 |
Insulin lispro protamine and insulin lispro (Humalog® Mix 75/25™) | 0.2–0.5 | 2–12 | 18–24 |
Insulin NPH suspension and insulin regular solution (Novolin® 70/30) | 0.5 | 2–12 | 18–24 |
Insulin Regimens for Controlling Blood Sugar in Patients with Type 1 Diabetes Mellitus
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Blood Glucose Goal Ranges* mg/dL (mmol/L) | |||
|---|---|---|---|
Age (yr) | Preprandial | Bedtime/overnight | HbA1c (%) |
<6 | 100–180 (5.6–10) | 110–200 (6.1–11.1) | 7.5–8.5 |
6–12 | 90–180 (5–10) | 100–180 (5.6–10) | <8 |
13–19 | 90–130 (5–7.2) | 90–150 (5–8.3) | <7.5 |
- Management of insulin for special situations
- Insulin-dependent patient who is NPO for a procedure:
- If for a procedure, do as first case to minimize NPO time (if possible).
- NPO according to anesthesiologist recommendations:
- ↓ AM basal insulin by 10% (if on pump), 20% (if using long-acting insulin), or 50% (if using intermediate-acting insulin).
- Give short or rapid-acting insulin only if on dextrose-containing fluids; use a conservative correction factor Q4h with FSBG target of 150 mg/dL (8.3 mmol/L).
- ↓ AM basal insulin by 10% (if on pump), 20% (if using long-acting insulin), or 50% (if using intermediate-acting insulin).
- Check FSBG Q1–2h while the patient is NPO.
- Resume usual regimen as soon as the patient resumes eating.
- Start dextrose-containing fluids if NPO > 8h.
- May need aggressive hydration and insulin drip if NPO for serious illness.
- If for a procedure, do as first case to minimize NPO time (if possible).
- Sliding scale insulin:
- Calculated by correction factor (see table above).
- Provide written sliding-scale instructions (eg, list of ranges above normal glucose level and corresponding insulin dose to administer) when simplicity is necessary, such as when inpatient and nursing or primary team uncomfortable with insulin calculations, or when outpatient on mixed or split regimen and patient/caregiver has poor compliance and understanding.
- Calculated by correction factor (see table above).
- Adjusting insulin doses:
- Look for patterns over several days or weeks.
- Adjust dose several hours before the time of the undesirable FSBG reading.
- Do not change insulin by >2 units or >10% of current dose unless otherwise directed.
- Observe FSBG trends ≥2 days before making another change.
- Differentiate AM hyperglycemia caused by (1) dawn phenomenon (insulin resistance in the early morning hours due to normal growth hormone surge → FSBG at 2 AM near goal but 7 AM ↑) versus (2) Somogyi effect (excessive insulin during the overnight period causing hypoglycemia → cortisol, glucagon, epinephrine released in response to hypoglycemia → FSBG at 2 AM ↓ and 7 AM ↑).
- Honeymoon effect: After initiation of insulin in a new diabetic, the patient may transiently (usually weeks to months) require less insulin. Prepare the patient or family for this.
- Upon hospital discharge, expect to lower the insulin dose by 10% (more exercise at home + honeymoon effect).
- Look for patterns over several days or weeks.
- Hypoglycemia:
- Adjust insulin, administer carbohydrates or glucagon. Also see figure “Management of hypoglycemia in diabetes”.
- Insulin-dependent patient who is NPO for a procedure:
- Outpatient Management and Counseling for Patients with Diabetes
- Type 1 Diabetes Mellitus
- Blood sugar monitoring:
- Check FSBG before meals, at bedtime, and for symptoms of hypoglycemia; ↑ frequency if ill. Check ketones (urine or fingerstick) when FSBG >300 mg/dL (16.6 mmol/L) two times consecutively, if FSBG >300 mg/dL before exercise, when feeling ill (especially with nausea or vomiting), or if ketones were present at previous check.
- Check HgbA1c every 3 mo.
- Check FSBG before meals, at bedtime, and for symptoms of hypoglycemia; ↑ frequency if ill. Check ketones (urine or fingerstick) when FSBG >300 mg/dL (16.6 mmol/L) two times consecutively, if FSBG >300 mg/dL before exercise, when feeling ill (especially with nausea or vomiting), or if ketones were present at previous check.
- Preventing DKA:
- Caregivers, friends, and roommates need to be aware of the diagnosis of DM, early signs of DKA, and sick-day management.
- Parents or guardians should administer insulin injections at the beginning; gradually shift responsibility to the child starting at age ∼8yo with direct supervision initially.
- Review FSBG log at each visit and more frequently via phone/e-mail, especially in the first few months after diagnosis.
- Never stop basal insulin in type 1 DM, even during illness with poor PO intake. Substitution with liquid CHO (eg, 7-Up, juices) or dextrose-containing IVF may be necessary. May need to decrease (Editor use a downward arrow) basal insulin dose/rate and stop giving insulin with meals if patient is not eating.
- Caregivers, friends, and roommates need to be aware of the diagnosis of DM, early signs of DKA, and sick-day management.
- Preventing hypoglycemia:
- Anticipate activities and situations (eg, exercise, fasting, ↓ meal intake) that may cause hypoglycemia → ↑ frequency of monitoring FSBG → be prepared to treat hypoglycemia, ie, FSBG < 80 mg/dL (4.4 mmol/L) ± symptoms.
- Always carry 15-g glucose snacks and glucagon to treat severe hypoglycemia (See figure “Management of hypoglycemia in diabetes”).
- At each visit: Review FSBG log and assess for hypoglycemia unawareness.
- Teachers, friends, coaches, or babysitters need to be aware of diagnosis of DM and how to identify and treat hypoglycemia.
- A medical ID tag should be worn at all times.
- Anticipate activities and situations (eg, exercise, fasting, ↓ meal intake) that may cause hypoglycemia → ↑ frequency of monitoring FSBG → be prepared to treat hypoglycemia, ie, FSBG < 80 mg/dL (4.4 mmol/L) ± symptoms.
- Exercise:
- Physical activity improves glycemic control (both type 1 and 2 DM).
- Check FSBG 15 minutes before exercise.
- Delay exercise if ketones are present or if FSBG <80 mg/dL.
- Before exercise, take 15 g (for young adults) of CHO for every 30 min of vigorous exercise and adjust subsequently depending on blood glucose response.
- Monitor FSBG hourly during vigorous exercise.
- Take 15 g of readily absorbed glucose if FSBG <100 mg/dL (5.6 mmol/L) during exercise.
- Expect transient hyperglycemia in the first hours after exercise. Do not rush to correct unless it persists or is associated with ketones.
- Delay exercise if ketones are present or if FSBG <80 mg/dL.
- Maintain good hydration throughout exercise
- At the onset of a new sports season, check FSBG 12 hours after exercise.
- Physical activity improves glycemic control (both type 1 and 2 DM).
- Nephropathy:
- Random spot urine microalbumin/Cr at diagnosis (if 10 yr of age or older) or 5 yr after diagnosis with DM. Repeat test is required for confirmation.
- Confirmed ↑ of urine microalbumin (consider other causes, such as exercise-induced; see chapter 21): Treat with ACEI if caused by diabetic nephropathy.
- Random spot urine microalbumin/Cr at diagnosis (if 10 yr of age or older) or 5 yr after diagnosis with DM. Repeat test is required for confirmation.
- Hypertension:
- Evaluate for cause; ACEI therapy for hypertension (see chapter 21).
- Dyslipidemia:
- If FH is positive for hypercholesterolemia, cardiovascular event at <55 yr of age, or if unknown then check fasting lipids within 1 yr of diagnosis starting at age 3 yr.
- If FH is negative then check fasting lipids at age 10 yr (puberty) or 5 yr after diagnosis.
- For both groups repeat fasting lipid check Q5 yr if normal but annually if abnormal.
- If FH is positive for hypercholesterolemia, cardiovascular event at <55 yr of age, or if unknown then check fasting lipids within 1 yr of diagnosis starting at age 3 yr.
- Retinopathy: Ophthalmology screening for patients ≥10 yr of age who have had DM for 3 to 5 yr; for women, preconception and during first trimester.
- Thyroid disease: Check TSH in newly diagnosed patients after several weeks of good metabolic control. Repeat screening every 1 to 2 yr.
- Adjustment and psychiatric disorders: Screen if patient has recurrent DKA or difficulty achieving treatment goals. Annually screen for depression in individuals with type 1 DM after 10 yr of age. Eating disorders are much more common in adolescent women with diabetes compared to the general population.
- Risk behavior: Test glucose before driving; have source of glucose in the car; preconception counseling for women contemplating sexual activity; avoid alcohol and drug abuse (can mask or mimic hypoglycemia)
- Blood sugar monitoring:
- Type 2 Diabetes Mellitus
- Exercise, dietary changes, and weight loss are essential.
- Follow recommendations for nephropathy, hypertension, dyslipidemia, retinopathy, and thyroid disease as for patients with type 1 DM. Type 2 DM patients may need to be referred for evaluation of complications as early as at diagnosis.
- Consider insulin in addition to metformin in patients who present with fasting blood glucose >250 mg/dL (13.9 mmol/L) or HbA1c >9%.
- Strict glycemic control leads to fewer-long term complications.
- Reduce frequency of FSBG checks to two times per day after achieving good glycemic control.
- Exercise, dietary changes, and weight loss are essential.
- Type 1 Diabetes Mellitus
- Definition: Venous plasma glucose <40 mg/dL (2.2 mmol/L) or symptoms of hypoglycemia with plasma glucose <60 mg/dL (3.3 mmol/L).
- Etiology
- Determine if patient has a known reason for hypoglycemia.
- In patients with history of DM, the following factors need to be considered: dose excess, ill-timed or wrong type of insulin or other diabetes medications, ↓ oral intake, ↓ glucose absorption (eg, diarrhea), ↓ insulin clearance (eg, renal failure), ↑ physical activity, or alcohol ingestion.
- For patients without DM, see Figure 14-2.
- Determine if patient has a known reason for hypoglycemia.
- Diagnosis and management: See Figure 14-2.
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