Diabetes Mellitis

There are two sub-classis of Diabetes Mellites (DM). Type 1 and Type 2; Type 1 DM, sometimes called Juvenile onset Diabetes (JDM) or Insulin Dependent (IDDM) is due to a deficiency or absence of endogenous Insulin. In most cases, there is an underlying autoimmune disorder where antibodies progressively destroy the insulin producing “Beta cells” in the Pancreas. Type 1 Diabetes usually manifests in the teenage years or early adulthood after a considerable number of these “Beta cells” have been destroyed. Thirty (30) % of DM1 cases are present initially as Diabetic Keto-acidosis (DKA), this is the most serious manifestation of DM. Diabetic Keto-acidosis (DKA) is best managed in a high acuity facility like a hospital emergency room (ER). Otherwise, when the presentation is mild, and DKA is not present, it can be managed in a non-acuity setting like a physician’s office or clinic.

Type 2 DM (DM2) is frequently asymptomatic when initially diagnosed, usually in a clinic or doctor’s office after a routine screening. Type 2 diabetes represents approximately 90% of adult-onset Diabetes. Usually, it can be managed in an office setting. Hyperglycemic Hyperosmolar State (HHS) is the most serious manifestation of DM2, and, like DKA, it is best managed in a high acuity facility like a hospital ER. 

Diabetes Mellites is common and because of the high morbidity and coexistent comorbid conditions, for which DM is an underlying contributing cause, and because of early mortality associated with this disease, especially if poorly managed or neglected, diligent early screening is crucial. Some of the comorbid conditions associated with DM include, Peripheral Vascular Disease (PVD), Heart Disease, Coronary Artery Disease (CAD), severe infections, stroke(CVA), peripheral neuropathy PN, and eye disease to list a few.

Routine screening begins for all adults by the age of 35 and repeated every 1 – 3 years for all adults, including those with no risk factors and no symptoms.  Adults should be tested at any age (18 years or older) when there are risks such as overweight or obesity (BMI 25 or BMI above 30), family history of DM 1 or 2, hypertension, suspicious symptoms / signs, physical inactivity and other conditions associated with insulin resistance. This is also true for any child with risk factors. We initially obtain a Fasting Blood Sugar (FBS). A normal range is 80 mg/dl to 105 mg/dl. We also obtain a Hemoglobin A1C. Results less than 5.7% is consistent with no disease. If the Hgb A1C is between 5.7% and 6.5%, or the FBS value is between 105 mg/dl and 125 mg/dl, a condition known as Prediabetes is present. Prediabetes needs to be addressed because there is a high incidence of progression to full DM, especially DM2. When the above levels are non-conclusive or when results do not agree, or if these tests are contraindicated, we perform a “Glucose Tolerance Test” (GTT) which is an old gold standard. This test is accurate but inconvenient because multiple blood sugar levels are necessary and because the test takes at least 2 hours to perform. We only need one of these 3 tests to be positive to diagnose Prediabetes or Diabetes.  It should also be noted that when a patient comes in with symptoms; Lethargy, General weakness, thirst, polydipsia, polyuria, a random BS  of or above 200mg/dl strongly suggests DM. The GTT begins with an initial fasting blood sugar followed by a standard glucose (sugar) load which the patient drinks.  At 2 hours, we test for blood sugar (BS). A value of 200mg/dl or higher is indicative of Diabetes. 

In addition to the above, there are tests that can differentiate Type 1 from Type 2 Diabetes. These additional tests include a test for autoantibodies against the pancreatic “beta cells” The value is elevated in DM1, and a quantitative C peptide level which is a marker for the Insulin molecule. This value is low in DM1. It is also prudent when these tests are abnormal, to obtain testing for thyroid, pituitary and adrenal gland function because these organs, like the pancreatic Beta cells, are all part of the endocrine syndrome and all are regulated by the pituitary gland. 

As stated earlier, in the office setting, type 2 Diabetes is the most common of the two sub-classes and it represents 90% of all adult DM cases. Prediabetes is of the type 2 variety. If the patient is overweight or obese, it should be addressed because it absolutely correlates with Insulin resistance and DM2. Behavior Modification, which includes a change in diet and eating habits, sleeping patterns, and activity patterns, is the initial treatment modality for Prediabetes. Today, there are very affective medications with few significant side effects. They include the GPL-1’s, and they are safe. When standard behavioral / diet modifications are ineffective, or if the BMI is above 30 lbs./inch 2 (Overweight begins at a BMI of 25. Obesity is defined by a BMI >30, and Morbid Obesity is present when the BMI is greater than35), we add them to the treatment. Ozempic (Semaglutide), Wegovy , and Tirzepatide (Mounjaro) are examples. They are approved for both the management of DM2 as well as for weight loss. A weight loss of 7% or more is associated with a significant reduction in insulin resistance. 

There are many classes of drugs today used to treat DM. They work through different mechanisms, and they have special indications which are beyond the scope of this writing.  By far, the most frequently prescribed initial medication,  is Metformin.  It is, overall, a safe drug with an established record. Its mechanism of action includes the blocking of hepatic “Gluconeogenesis”, thereby inhibiting the ability of the liver to deliver additional sugar to the blood stream. It also decreases Insulin resistance and is excellent as the initial pharmaceutical for DM2. One of the advantages of Metformin is that it does not cause hypoglycemia or “Insulin Shock”.

As stated previously, DM1 often presents in the early years. The care often involves daily medium to long-acting insulin, coupled with short acting insulin injections, titrated for spikes in the BS level. When using insulin, blood sugar levels should be measured daily. 

Successful management of either sub-class is assessed by following Hgb A1C levels which should be obtained on at least a yearly basis. For a diabetic, the level should always be less than 7%. A low Hgb A1C corresponds to better outcome over time. Ideally, the BS value should always be within the normal range. Blood sugars that are frequently above and below the normal range correspond to a higher Hgb A1C. A high Hgb A1C corresponds to a worse outcome over time. 

In the ER, when patients present with HHS or DKA, there is often 6 -8-liter water deficit. These patients are anxious, lethargic or comatose (HHS) and they are significantly dehydrated.  We begin management by ensuring an airway, the patient is placed on a heart EKG monitor, while restoring fluids and electrolytes and correcting these imbalances. This must be done rapidly but simultaneously with caution, especially in children, to prevent swelling of the brain. Therefore, there are special formulas and guidelines that must be followed. After initiation of the above (often several hours into treatment), Insulin is given. Not as a bolus (all at once), but rather as a continuous IV infusion. Electrolytes and blood sugar levels are closely monitored to avoid overshooting which can lead to brain swelling and / or insulin shock (severe lower than normal sugar level following stabilization in the ER, these patients are admitted to the Intensive Care Unit (ICU). 

In summary, we screen early for DM. We measure the effectiveness of treatment by following the Hgb A1C levels. Type 1 DM is due to insufficiency or lack of endogenous insulin and the underlying pathology is a genetic mutation often familial. Type 2 DM is due mostly to insulin resistance. Obesity is a frequent underlying factor causing resistance and should be diligently addressed. A weight loss of as little as 7% corresponds to a significant improvement in insulin resistance. There are new and effective drugs (GPL 1s), initially approved for adjuvant treatment of DM2 that are excellent for weight loss. Body stressors, inflammation, infections, poor management, or poor compliance can lead to HHS or DKA which are severe manifestations of the disease and managed aggressively in an appropriate high acuity facility. 

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