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Sections Type 1 Diabetes Mellitus
- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Self-Monitoring of Glucose Levels
- Continuous Glucose Monitoring
- Insulin Therapy
- Management of Hypoglycemia
- Management of Hyperglycemia
- Diet
- Activity
- Management of Complications
- Glycemic Control During Serious Medical Illness and Surgery
- Glycemic Control During Pregnancy
- Prevention
- Consultations
- Show All
- Guidelines
- Medication
- Questions & Answers
- References
Diagnostic Considerations
The following conditions and factors should be taken into account in considering a diagnosis of type 1 diabetes mellitus (DM):
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Type 2 DM
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Monogenic DM, [100] previously known as maturity-onset diabetes of youth (MODY), a rare autosomal dominant condition found primarily in whites
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Secondary hyperglycemia
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Disorders of target tissues (liver, muscles, adipose tissue)
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Endocrine disorders - Endocrine tumor causing increased production of growth hormone, glucocorticoids, catecholamines, glucagon, and somatostatin; Addison disease; Graves disease; Hashimoto thyroiditis; acanthosis nigricans (genetic disorders with insulin resistance)
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Drugs - Thiazide diuretics, phenytoin, and glucocorticoids
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Chronic pancreatitis
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Cystic fibrosis
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Prader-Willi syndrome - Intellectual disability, muscular hypotonia, obesity, short stature, and hypogonadism associated with DM
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Nondiabetic glycosuria
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Renal glycosuria - Glucose appears in urine despite normal glucose concentration in blood; this may occur because of an autosomal genetic disorder or dysfunction of the proximal renal tubule (eg, Fanconi syndrome or chronic renal failure), or it may occur during pregnancy as a consequence of the increased glucose load placed on tubules by the elevated glucose filtration rate
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Peripheral neuropathy from alcohol abuse or vitamin B-12 deficiency
Type 1 versus type 2 diabetes
Determining whether a patient has type 1 or type 2 DM is an important diagnostic and therapeutic concern because patients with type 1 DM depend on continuous exogenous insulin for survival. A patient whose diabetes is controlled with diet or an oral antidiabetic agent clearly has type 2 DM. A lean patient who has had diabetes since childhood, who has always been dependent on insulin, or who has a history of diabetic ketoacidosis (DKA) almost certainly has type 1 DM.
Distinguishing the type of diabetes can be difficult in (1) patients who are treated with insulin and who are younger but clinically appear to have type 2 DM and (2) older patients with late-onset diabetes who nonetheless take insulin and seem to share characteristics of patients with type 1 DM. (This latter group is now said to have latent autoimmune diabetes of the adult [LADA].) It should be noted that for many patients, it will not be possible to fully distinguish type 1 DM from type 2.
When in doubt, treat the patient with insulin and close monitoring of glucose levels. It is not unusual for adolescents or young adults, particularly Hispanic or African-American patients, to present with DKA and subsequently be found to have type 2 DM.
Monogenic diabetes
Although monogenic diabetes syndromes are not very common, representing fewer than 5% of pediatric diabetes cases, it is important to avoid misdiagnosis of monogenic DM as type 1 or type 2 DM. The American Diabetes Association (ADA) advises considering a diagnosis of monogenic diabetes when the following criteria are present [5] :
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Diabetes is diagnosed within 6 months of birth
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A strong family history of diabetes is present, without type 2 features (eg, obesity or higher-risk ethnicity)
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Mild fasting hyperglycemia is observed, especially in young, nonobese children
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Diabetes is present, but islet cell autoantibodies, obesity, and insulin resistance are absent
If a form of monogenic diabetes is suspected, it is increasingly feasible to obtain a true genetic diagnosis through commercially available genetic testing. For further information about the diagnosis and management of monogenic diabetes, the ADA suggests consulting the 2009 clinical practice consensus guidelines of the International Society for Pediatric and Adolescent Diabetes (ISPAD) at the ISPAD website. [5, 101]
Differential Diagnoses
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Tables
Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Eastern Virginia Medical School
Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinology, American College of Physicians, American Diabetes Association, Endocrine Society
Disclosure: Nothing to disclose.
George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for Physician Leadership, American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society, International Society for Clinical Densitometry, Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.
Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.
Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy ofSciences,and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Aneela Naureen Hussain, MD, FAAFM Assistant Professor, Department of Family Medicine, State University of New York Downstate Medical Center; Consulting Staff, Department of Family Medicine, University Hospital of Brooklyn
Aneela Naureen Hussain, MD, FAAFM is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Medical Women's Association, Medical Society of the State of New York, and Society of Teachers of Family Medicine
Disclosure: Nothing to disclose.
Anne L Peters, MD, CDE Director of Clinical Diabetes Programs, Professor, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California, Los Angeles County/University of Southern California Medical Center
Anne L Peters, MD, CDE is a member of the following medical societies: American College of Physicians and American Diabetes Association
Disclosure: Amylin Honoraria Speaking and teaching; AstraZeneca Consulting fee Consulting; Lilly Consulting fee Consulting; Takeda Consulting fee Consulting; Bristol Myers Squibb Honoraria Speaking and teaching; NovoNordisk Consulting fee Consulting; Medtronic Minimed Consulting fee Consulting; Dexcom Honoraria Speaking and teaching; Roche Honoraria Speaking and teaching
Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics
Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society
Disclosure: Nothing to disclose.
Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Miriam T Vincent, MD, PhD Professor and Chair, Department of Family Practice, State University of New York Downstate Medical Center
Miriam T Vincent, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association for the Advancement of Science, Medical Society of the State of New York, North American Primary Care Research Group, Sigma Xi, and Society of Teachers of Family Medicine
Disclosure: Joslin Diabetes Group, Harvard Honoraria Speaking and teaching
Scott R Votey, MD Director of Emergency Medicine Residency, Ronald Reagan UCLA Medical Center; Professor of Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine
Scott R Votey, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Frederick H Ziel, MD Associate Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Physician-In-Charge, Endocrinology/Diabetes Center, Director of Medical Education, Kaiser Permanente Woodland Hills; Chair of Endocrinology, Co-Chair of Diabetes Complete Care Program, Southern California Permanente Medical Group
Frederick H Ziel, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society for Bone and Mineral Research, California Medical Association, Endocrine Society, andInternational Society for Clinical Densitometry
Disclosure: Nothing to disclose.
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Sections Type 1 Diabetes Mellitus
- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Self-Monitoring of Glucose Levels
- Continuous Glucose Monitoring
- Insulin Therapy
- Management of Hypoglycemia
- Management of Hyperglycemia
- Diet
- Activity
- Management of Complications
- Glycemic Control During Serious Medical Illness and Surgery
- Glycemic Control During Pregnancy
- Prevention
- Consultations
- Show All
- Guidelines
- Medication
- Questions & Answers
- References
