Differential diagnosis for diabetes
- Type 1 diabetes (T1DM),
- Type 2 diabetes (T2DM)
- Chemical/medication induced diabetes
- Stress induced hyperglycemia
- Monogenic onset diabetes of young / Maturity onset diabetes of Young ( MODY)
- Diabetes is defined as fasting blood glucose > 126 mg/dl, 2 hours post prandial glucose > 200 mg/dl after glucose load of 1 gm/kg (maximum dose: 75 gm), HbA1c > 6.5%, or random blood glucose > 200 mg/dl in patient with classic symptoms of hyperglycemia.
- In the absence of unequivocal hyperglycemia, result should be repeated.
- Simultaneous c-peptide level is inappropriately low.
- Presence of pancreatic auto-antibodies : islet cell antibodies (ICA), GAD-65, insulin antibodies, IA2A and ZnT8.
- Most commercial laboratories may have the assays to test for some/most of the autoantibodies accurately.
- Should be done after discussion with the endocrinologist.
- Electrolyte abnormalities are common and may include pseudo-hyponatremia (secondary to blood glucose elevation), metabolic acidosis, elevated blood urea nitrogen and creatinine (secondary to dehydration), and hypokalemia or hypophosphatemia (total body depletion)
- Other tests to screen for simultaneous autoimmune disorders: Serum TSH, free T4, T3, and anti-thyroid antibodies (thyroid peroxidase antibody, thyroglobulin antibodies), tissue transglutaminase IgA antibodies, total IgA concentration
Diabetes care involves close supervision, intensive education and frequent monitoring. It involves:
- Insulin administration by multiple daily subcutaneous injection or insulin pump.
- Rapid acting analogs (Lispro, Aspart, Glulisine)
- Long acting insulin (NPH),
- Basal insulin analogues (Glargine, Detemir)
- Sulfonylurea, gliptins, gliflozins, and Metformin are not indicated for individuals with T1DM
- Glycemic control is monitored with multiple daily self-monitoring of blood glucose (SMBG), continuous subcutaneous glucose monitoring system and quarterly hemoglobin A1c.
- All patients with DKA should be admitted to in-patient or ICU set up and treated with IV fluids, IV insulin infusion, frequent blood glucose, and electrolyte monitoring.
- Patients and their care givers should receive diabetes self-management education including medical nutrition therapy, self-monitoring of blood glucose, insulin administration, need for monitoring of chronic complication, management of lipid abnormality, and hypertension.
Suggested References and Additional Reading:
- American Diabetes Association. Standards of medical care in diabetes-2021 abridged for primary care providers. Clinical Diabetes: a publication of the American Diabetes Association. 2021;39(1):14-43.
- American Diabetes Association. Children and adolescents: Standards of medical care in diabetes-2021. Diabetes Care 2021;44(suppl 1):S180-S199.