Patient will present as → a young patient with weight loss, increased thirst, and urination. The patient has felt tired and nauseous. On examination her weight is below the 5th percentile, she looks thin, and her skin is pale. her blood pressure is 100/70 and her pulse is 104 bpm. Her respirations are deep at a rate of 28 breaths/minute. Her breath smells fruity
90% of Type I DM is autoimmune in origin with antibodies to insulin and islet cells. Pancreatic β cells fail to respond to stimuli and undergo autoimmune destruction
- Some patients experience a long but transient phase of near-normal glucose levels after acute onset of the disease (honeymoon phase) due to partial recovery of insulin secretion
- Type 1 occurs most often in young people (before school age or near puberty) for normal or low weight
Key terms to know for your exam:
- Dawn Phenomenon: Normal glucose until 2-8 am when it rises. Results from decreased insulin sensitivity and nightly surge of counter regulatory hormones during nighttime fasting
- Treat with bedtime injection of NPH to blunt morning hyperglycemia, avoiding carbohydrate snack late at night
- Somogyi effect: Nocturnal hypoglycemia followed by rebound hyperglycemia due to surge in growth hormone
- Treat with decreased nighttime NPH dose or give bedtime snack
- Insulin waning: progressive rise in glucose from bed to morning
- Treat with change of insulin dose to bedtime
Diabetic ketoacidosis (DKA): Fruity breath, weight loss, rapid respirations, hypotension
- Diabetic ketoacidosis (DKA) should always be handled in a hospitalized setting, usually an intensive care unit, and often with an endocrinologist’s consultation, if appropriate
- TREAT WITH FLUIDS
- Patients with DKA are always dehydrated and need large-volume IV fluid resuscitation, usually isotonic fluids such as normal saline
- Insulin should always be administered by an IV pump to guard against accidental overdose
Labs (secondary to little or no endogenous insulin secretion)
- Random plasma glucose of > 200 mg/dl with classic symptoms or fasting levels of ≥ 126 mg/dl on more than one occasion is diagnostic.
- Glucosuria; they also may have ketonemia and/or ketonuria.
- HGB A1c represents glucose control over previous 8-12 weeks. 6.5% or higher is diagnostic of DM.
Dietary control + Insulin (all type 1 will need insulin) - *know the differences between insulin types
- A1C goal < 7 - check every 3 months
- Basal insulin (such as Glargine) with once or twice daily long-acting or intermediate-acting insulin or continuous subcutaneous insulin via pump
- Pre Meal bolus of short (regular) or rapid acting insulin (such as Humalog) – dose based on FSBs before meal, size and composition of meal, and anticipated activity levels
- Glucose monitoring 4-7 times daily – before meals, mid-morning, mid-afternoon, before bedtime, and occasionally at 3am
Example of insulin regimen:
- Breakfast: Rapid acting → Lunch: Rapid acting → Dinner: Rapid acting → Bedtime: Long acting
Daily aspirin is used in primary prevention:
- This includes men > 50 years of age and women > 60 years of age, with at least one CVD risk factor such as HTN, dyslipidemia, smoking or albuminuria.
- Annual foot examination
- Annual ophthalmologic monitoring
- Vaccinations - annual flu exam, Tdap, PCV13, Pneumococcal vaccines etc.
Often ACE inhibitors and statins to prevent complications
- In patients 18 to 59 years of age without major comorbidities, and in patients 60 years or older who have diabetes, chronic kidney disease (CKD), or both conditions, the new goal blood pressure level is <140/90 mm Hg.
- ACE inhibitors or ARBs are indicated for patients with evidence of early nephropathy (microalbuminuria or proteinuria), even in the absence of hypertension, and are a good choice for treating hypertension in patients who have DM and who have not yet shown renal impairment.
- Statins are currently recommended by the American Heart Association/American College of Cardiology guidelines for all diabetic patients 40 to 75 yr of age. Moderate to high intensity treatment is used, and there are no target lipid levels.
Know the onset, peak and duration of various insulins
 Osmosis |
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The dawn phenomenon is the presence of hyperglycemia upon awakening. The increase in blood glucose is caused by increased hormone production in the early morning hours. Between the hours 2AM-6AM, the body naturally increases production of growth hormone and cortisol. Treatment involves changing the patient’s current insulin regimen. The patient may have their current administration times changed, be given a long-acting insulin in the evening, or be given an insulin pump. Since insulin affects blood glucose levels, the patient’s glucose levels should be closely monitored particularly between 2AM-6AM. Instruct the patient to limit carbohydrates before bedtime to avoid spikes in blood sugar during the night.
Play Video + QuizDiabetic ketoacidosis (DKA)
Diabetic ketoacidosis (DKA) is a medical emergency and complication of diabetes. Patients have increased insulin requirements, which leads to a shortage. As a response, the body begins burning excess fat (and fatty acids), causing ketone body buildup. Lab values seen in DKA include blood sugars above 250 mg/dL, and anion gap metabolic acidosis with pH below 7.3 and bicarbonate below 18. Patients will also show present plasma ketones. Due to an extracellular shift, patients may be hyperkalemic.
| Diabetic Ketoacidosis (DKA) Treatment | Play Video + Quiz |
| Diabetic Ketoacidosis (DKA) Signs and Symptoms | Play Video + Quiz |
| Diabetic Ketoacidosis (DKA) Diagnosis and Labs | Play Video + Quiz |
Diabetic glomerulonephropathy
Diabetic glomerulonephropathy is the kidney disease seen in patients with significantly progressed diabetes. There is damage to the kidney due to nonenzymatic glycosylation of the basement membrane which alters the permeability of arterioles and glomeruli and results in nephrotic syndrome. Patients will have increased GFR due to preferential efferent sclerosis, mesangial expansion due to hyperfiltration pressure, and will ultimately enter kidney failure if glucose levels are not controlled.
Play Video + QuizQuestion 1 |
diabetes insipidus | |
early diabetic ketoacidosis | |
type 2 diabetes mellitus | |
alcohol intoxication |
Question 2 |
treat her in the office with 1 L of intravenous (IV) normal saline to correct her dehydration and then send her home with a prescription for an antinausea agent. Tell her to continue to push fluids; order a CBC, chemistry screen, and urinalysis; and see her back in 3 days for follow-up and to discuss the results. She is to call if she is feeling worse. | |
start the patient on desmopressin (DDAVP), order some basic laboratory tests, have the patient push fluids, and refer her to an endocrinologist | |
check an office finger-stick glucose level and a urine dipstick, and if your suspicions are confirmed, admit Jackie to the hospital for stabilization and management with possible consultation with an endocrinologist |
Question 3 |
high-volume IV isotonic or half-normal saline fluids and regular insulin by IV pump | |
IV bicarbonate should be routinely used to correct the likely acidosis | |
give D5NS IV fluid until Jackie can reestablish adequate oral intake | |
subcutaneous insulin every 4 to 6 hours in a sliding scale, with laboratory tests every 12 hours until the situation is stabilized |
Question 4 |
10 mg/dl | |
20 mg/dl | |
30 mg/dl | |
80 mg/dl | |
200 mg/dl |
Question 5 |
age at onset is usually before 30 years | |
it is associated with other autoimmune disorders | |
there is approximately a 90% concordance in monozygotic twins for this type of DM | |
islet cell antibodies are found in approximately 90% of cases | |
suboptimal vitamin D nutrition is associated with increased incidence |
Question 6 |
treatment with insulin or sulfonylureas has clearly been shown to worsen macrovascular disease by worsening of hyperinsulinemia | |
low-density lipoprotein (LDL) level should be kept at least < 2.6 mmol/L (100 mg/dL), and probably < 70 mg/dL, if the patient has confirmed vascular disease | |
blood pressure goal is < 130/80 mm Hg | |
strict blood pressure control is more beneficial than tight glycemic control in reducing macrovascular complications | |
virtually all type 2 diabetics older than 40 years who do not have a contraindication to statins should be receiving them |
Question 7 |
the initial fluid replacement should generally be normal (0.9%) saline unless there is severe hypernatremia | |
fluid deficits are often on the order of 6 to 8 L | |
potassium level should be monitored frequently (every hour at first and then every 2 to 4 hours) during the initial treatment phase of DKA | |
in the otherwise healthy adult with DKA, a reasonable rate of infusion generally needed for the first 3 hours of treating full DKA is 150 mL/hour |
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