Diabetes Mellitus Management

Diabetes mellitus is a chronic illness that requires continuing medical care and education to prevent acute complications and reduce the risk of chronic complications such as retinopathy, nephropathy, and neuropathy. The Diabetes Control and Complications Trial (DCCT) demonstrated that in patients with type 1 diabetes the risk of developing these complications was reduced 50 to 75% by intensive treatment regimens that decreased the average hemoglobin A1c level to 7.2%. The reduction in risk of these complications correlated continuously with the reduction in hemoglobin A1c levels, implying that complete normalization of glycemia levels may prevent complications.

In view of the DCCT's findings, the American Diabetes Association has recommended the following goals for glycemic control in patients with type 1 diabetes. Similar goals have been recommended for patients with type 2 diabetes. The targets should be adjusted in patients with a history of hypoglycemia.

Biochemical Index	Nondiabetic	Diabetic Goal	Action suggested
Preprandial glucose	<115 mg/dL	80 - 120 mg/dL	<80 or >140
Bedtime glucose	<120 mg/dL	100 - 140 mg/dL	<100 or >160
Hemoglobin A1c	<6%	<7%	>8%

Initial Patient Visit
During the initial visit, laboratory tests should be performed to establish the diagnosis of diabetes mellitus, determine the degree of past and present glycemic control, and determine the presence or absence of chronic complications and risk factors. Recommended tests include:

Fasting plasma glucose ( random plasma glucose may be obtained in an undiagnosed symptomatic patient for diagnosis)
Glycated hemoglobin
Fasting lipid profile including cholesterol, HDL cholesterol, LDL cholesterol, & triglycerides in adults and children older than 2 years
Serum creatinine in adults and children with proteinuria
Urinalysis including glucose, ketones, protein, and sediment
Urine culture if the sediment is abnormal or patient is symptomatic
Urine microalbumin for postpubertal patients with diabetes for at least 5 years and all patients with type 2 diabetes (timed specimen or albumin/creatinine ratio)
Thyroid function tests when clinically indicated

Patients should be instructed in self monitoring of blood glucose and urine ketones and the use of a record system. The frequency of blood glucose monitoring should be individualized according to the severity of illness, treatment plan, and response to treatment.

Continuing Care

Periodic follow-up tests play an essential part in the continuing management of every patient with diabetes. Recommended tests and the suggested frequency of testing are summarized in the following table.

Laboratory Test	Patient Population	Frequency of Testing
HbA1c	Stable glycemic control	At least 1 to 2 times per year
	Poor control or changed therapy	Quarterly
Lipid profile	Initial profile abnormal	Annually
	Treatment for dyslipidemia	As needed to monitor therapy
	Children with normal lipid values	Every 5 years
Urinalysis	Adults	Annually
Microalbumin	Type 1 diabetes beginning at puberty & after 5 years duration	Annually
	Type 2 diabetes at time of diagnosis	Annually
Creatinine clearance	Patients with albuminuria or proteinuria	As needed to monitor nephropathy
Serum potassium	Hypertensive patients treated with ACE inhibitors	As needed to monitor for hyperkalemia

Glycated hemoglobin should be performed routinely in all patients with diabetes; first to document the degree of glycemic control at initial assessment and then as part of continuing care. Since glycated hemoglobin reflects the mean blood glucose level over the preceding two to three months, repeat measurements approximately every three months are required to determine whether a patient's metabolic control has remained continuously within the target range. Patients with stable glycemic control may require less frequent testing. Glycated hemoglobin levels performed in different laboratories should not be compared or trended.

Adult patients with diabetes should be tested for lipid disorders annually with a fasting cholesterol, HDL cholesterol, calculated LDL cholesterol, and triglycerides. If all values are within normal limits, less frequent testing may be necessary. Acceptable, borderline, and high risk lipid levels for adults are listed in the following table.

Risk for Adult Diabetics	Cholesterol (mg/dL)	HDL (mg/dL)	LDL (mg/dL)	Triglycerides (mg/dL)
Acceptable	<200		<130	<200
Borderline	200 - 239		130-159	200 - 399
High	>239	<36	>159	>399

Borderline or abnormal values should be repeated for confirmation. Lipid values should be reevaluated in the presence of a macrovascular event. A lipid profile should be performed on children older than two years after glucose control has been established. Borderline or abnormal results should be repeated for confirmation. If values fall within accepted risk levels, assessment should be repeated every five years.

Routine urinalysis should be performed yearly in adults. If positive for protein, quantitation is helpful in monitoring treatment. If urinalysis is negative for protein, a test for microalbumin is necessary. Microalbumin testing of patients with type 1 diabetes should begin at puberty and after five years duration. Patients with type 2 diabetes should be tested at the time of diagnosis. First void or other morning urine collections are preferred because of the diurnal variation in albumin excretion. Three different microalbumin tests are available:

Measurement of albumin/creatinine ratio on a random, spot collection
24 hour collection with creatinine
Timed collection (e.g. 10 hour)

Random urine specimens are often most convenient for outpatients and are generally accurate. There is marked day to day variability in albumin excretion; therefore, at least two of three microalbumin levels should be elevated during a three to six month period before a patient is considered to have microalbuminuria. Renal function should be monitored with periodic measurements of creatinine clearance. Hypertensive diabetic patients who are treated with ACE inhibitors should be monitored for hyperkalemia.




Date Rape Drugs DDimer for DIC DDimer for DVT Dehydroepiandrosterone Dehydroepiandrosterone Sulfate Deoxycorticosteroids Deoxyribonuclease B Ab Dexamethasone Suppression Cushing Syndrome Dexamethasone Suppression Depression Dexamethasone Suppression Test Diabetes Mellitus Diabetes Mellitus Management Differential Leukocyte Count Digoxin Dilute Russel Viper Venom Time Direct Antiglobulin Test Disseminated Intravascular Coagulation DNA Antibody Donath Landsteiner Antibody Drug Induced Thrombocytopenia Drug of Abuse Screen Drugs of Abuse Workplace Testing