36YO female lawyer diagnosed with diabetes mellitus (DM) (Etiology…
36YO female lawyer diagnosed with diabetes mellitus (DM)
Test HbA1c to determine how long pt has had hyperglycemia (last 2-3 months glucose control). May be falsely low in anemic patients, or falsely high in uremic patients.
Use HbA1c to check for control in the future. If >10% => severely uncontrolled. Treatment: insulin therapy with lifestyle intervention as initial Rx.
Liver function tests and renal panel to check for severe renal/hepatic insufficiency. If present, metformin is contraindicated as it may be associated with lactic acidosis. Use metformin with caution in those with eGFR < 45ml/min/1.73m2, cease usage if eGFR <30ml/min/1.73m2.
C-peptide proteins as marker of beta-cell fx => high levels imply T2DM. Low levels may be burnt out T2DM which requires insulin.
Overweight/obese => Primary DM. Other sx: insidious presentation; +ve family hx in 90%. Other sx: thirst; polyuria; weight loss; blurry vision
Cushingoid (moon-like facies; buffalo hump; striae on abdomen) and acromegalic features (coarse facial features; macroglossia; spade-like hand) => Endocrine or pancreatic endocrine neoplasms (RARE). Other sx: hypertension
Cystic fibrosis; chronic pancreatitis; pancreaticotomy (e.g. Whipple); hemochromatosis => Pancreatic disorders. Other sx of hemochromatosis: skin hyperpigmentation; unexplained fatigue; +ve family hx of iron overload
Morning sickness, missed periods, sexually active => pregnancy/gestational DM.
Recent surgery/hospitalization => steroid-induced hyperglycemia; TPN; glucose-containing drip.
Exenatide (GLP1 agonist) not recommended in T2 diabetes patients with hx of pancreatitis.
Class III/IV cardiac failure: use metformin with care. Long-acting sulfonylureas are not recommended.
TZDs are contraindicated in patients with acute coronary syndrome, IHD and all classes of heart failure.
If metabolic control sub-optimal => use insulin. May be initiated as a bedtime dose of intermediate-acting or long-acting insulin with maintenance of oral agents during the day.
If obese/overweight => weight reduction to be attempted gradually (0.25 to 1kg/week). Weight loss of 5-10% of body weight is realistic. Recommended that total calories from fat intake be kept to <30% of total caloric intake in diabetic patients.
Oral glucose lowering targets should be started if glycemic targets are not achieved in a timely and appropriate manner.