Diabetes mellitus (DM) is a group of metabolic diseases resulting from defects in insulin secretion and/or insulin resistance that can lead to significant morbidity and mortality in affected patients.

Classification of Diabetes Mellitus

• DM type 1 – 90-95% in pediatric population; absolute insulin deficiency
• DM type 2 – most are teenagers or older; insulin resistance
• Other types of DM due to other causes (eg, cystic fibrosis, drug-induced)
• Gestational diabetes mellitus (GDM) – exclusive to pregnant females

DM Type 1

• See Pediatrics tab

DM Type 2

Epidemiology

• Prevalence – affects >20 million in U.S.
  • 6.5% of population
• Age – usually diagnosed >30 years
• Sex – M:F, equal
• Occurrence – increase in teenage obesity is associated with increased occurrence of DM type 2

Inheritance

• 75% concordance rate between identical twins
• Several susceptibility genes have been identified

Risk Factors

• Obesity (BMI >25 kg/m²)
• Family history of DM type 2 in first- or second-degree relative
• Race/ethnicity – Native American, African American, Latino, Asian American, Pacific Islander
• Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome (PCOS), low birth weight)
• Maternal history of DM or GDM during child’s gestation

Pathophysiology

• Combination of progressive β-cell dysfunction with insulin secretory defect on the background of insulin resistance
• No known autoimmune destruction of the pancreas

Clinical Presentation

• May have polyuria, polydipsia or polyphagia
• Headache, fatigue, blurred vision, recurring Candida infections
• More often presents with microvascular, macrovascular and neuropathic complications
  • Tingling, numbness in extremities
  • Lipid abnormalities
  • Renal insufficiency
• Complications – hyperosmolar coma
  • Long-term complications
    • Cardiac – coronary artery disease
    • Immunologic – recurrent infections
    • Neurologic – neuropathy
    • Ophthalmic – retinopathy
    • Renal – proteinuria with renal failure
    • Vascular – small vessel disease with extremity loss

Treatment

• Insulin therapy required in type 1 and type 2 if patient presents with dehydration, ketosis or acidosis

GDM

Epidemiology

• Prevalence – 7% of all pregnancies

Risk Factors

• History of previous GDM
• Previous birth of baby >4.5 kg
• Severe obesity
• Strong family history of DM type 2
• Diagnosis of PCOS

Clinical Presentation

• Fetus is large for gestational age
• Post-term delivery
• Neonatal hypoglycemia
• Premature labor
• Preeclampsia

DM Type 1

Epidemiology

• Prevalence
  • Varies by nationality
  • >150,000 under 18 years in the U.S. have DM type 1
• Age
  • Majority diagnosed at or before adolescence
  • Up to 1/3 diagnosed during adolescence
• Sex – M:F, equal
• Inheritance
  • Interplay between genetic susceptibility and environmental factors

Pathophysiology

• Insulin produced in B-cells of the islets of Langerhans of the pancreas
• Insulin regulates how the body stores and uses glucose
• Absolute insulin deficiency of DM type 1 is a result of the following
  • Chronic inflammatory response against the islet cells
  • Destruction of islet cells by antibody production 
    • Three antibodies are present but not routinely used to diagnose or monitor DM type 1; may be assistive in testing family members of probands
      • Islet cell (ICA)
        • May be detected years prior to clinical symptoms
        • Almost exclusively in DM type 1
      • IA-2
        • Best predictor of eventual DM type 1 in siblings of diabetic patients
      • Glutamic acid decarboxylase (GAD65)
        • Found in ~70% of patients with DM type 1 at diagnosis
        • May be found prior to clinical disease and may predict who develops DM type 1 (even in adults)

Clinical Presentation

• Polydipsia, polyuria, polyphagia
• Nonspecific symptoms
  • Fatigue
  • Nausea, emesis
  • Weight loss
• Length of time from clinical presentation to diagnosis is typically a few weeks
• Complications – diabetic ketoacidosis

Treatment

• Insulin therapy required in type 1 and type 2 if patient presents with dehydration, ketosis or acidosis
• See consensus statement on use of insulin pump therapy from the European Society for Paediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes (endorsed by the American Diabetes Association and the European Association for the Study of Diabetes)

DM Type 2

• See Clinical Background tab

Diagnosis

Indications for Testing

• Fatigue, polyuria, polydipsia, weight loss

Criteria for Diagnosis

• Refer to Diagnosis tab

Laboratory Testing

• Fasting plasma glucose, 2-hour oral glucose tolerance test (OGTT), and random glucose are the preferred tests to diagnose diabetes in children
  • No guidelines indicate hemoglobinA1c (HbA1c) has diagnostic utility in children
• C-peptide testing can be used to confirm lack of insulin production, suggesting type 1 disease
• Use of C-peptide levels or insulin levels to diagnose diabetes is not recommended
• Consider insulin antibody testing to help differentiate DM type 1 from DM type 2
  • ADA (2008)
    • Type 1 –  antibodies and low C-peptide levels typical
      • Absence of antibodies or normal C-peptide levels does not rule out type 1, but it is uncommon

Screening 

• Children with known risk factors – screen at 10 years; repeat every 2 years if
  • BMI >85% and any 2 of the following
    • First- or second-degree relative with DM
    • Maternal history of DM or gestational DM
    • Member of at-risk minority group
    • Signs and symptoms of insulin resistance – PCOS, hypertension, acanthosis nigricans

Monitoring

• Hemoglobin A1c
  • Premise of testing
    • Glycation of hemoglobin is non-linear over time and occurs over the whole lifespan of the red blood cell
    • Correlates with risk of long-term complications and with diabetes control over previous 2-3 months
  • Target goal – <6.5% of glycated hemoglobin for children <6 years and <8% for ages 6-18
  • Laboratory testing recommendations 
    • 2 measurements per year for patients meeting goal of <6.5% (ADA 2008), ≤6.5% (ACE/AACE)
      • If patient is not hypoglycemic, goal should be <6%
    • More frequent monitoring in patients with HbA1c ≥7%; however, not more often than every 3 months
      • Do not use for diagnosis for diabetes
• Hypoglycemia
  • Not infrequent when children are using insulin
    • Diligence required for younger children

Indications for Testing

• Known risk factors for DM type 2
  • Obesity (BMI >25 kg/m²) – consider testing to detect pre-DM and DM type 2 in asymptomatic people
  • Family history of DM type 2 in first- or second-degree relative
  • Race/ethnicity – Native American, African American, Latino, Asian American, Pacific Islander
  • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, PCOS, low birthweight)
  • Maternal history of DM or GDM during gestation

Criteria for Diagnosis

• Consensus criteria for the diagnosis of DM or GDM (American Diabetes Association [ADA], American Association of Clinical Endocrinologists [AACE], United States Preventive Services Task Force [USPSTF], WHO [2010])
  • Diagnosis must meet one of the following
    • Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L)
      • Fasting is defined as no caloric intake for at least 8 hours
    • Symptoms of DM and a casual plasma glucose ≥200 mg/dL (11.1 mmol/L)
      • Casual is defined as any time of day without regard to time since last meal
      • Classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss
    • 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during oral glucose tolerance test (OGTT)
      • Test should be performed as described by WHO using a glucose load containing the equivalent of 75 grams of anhydrous glucose dissolved in water
  • Testing to differentiate DM type 1 from type 2
    • Insulin antibodies
      • ADA (2008)
        • DM type 1 – results typically have antibodies and low C-peptide levels
        • Absence of antibodies or normal C-peptide levels does not rule out type 1, but likelihood of DM type 1 is low
    • USPSTF (2008)
      • Screen all adults with sustained BP >135/80 mmHg
    • C-peptide testing – use to confirm lack of insulin production, suggesting DM type 1
      • Use of C-peptide levels or insulin levels to diagnose DM is not recommended

Laboratory Testing

• Initial testing – fasting plasma glucose, 2-hour OGTT, random glucose, or HbA1c are the preferred tests to diagnose diabetes in nonpregnant adults
  • Plasma glucose testing – use above consensus criteria
  • HbA1c ≥6.5% is diagnostic of DM
    • HbA1c 5.7-6.4% (borderline value) – indicates an increased risk of developing DM
    • ADA recommends HbA1c testing; USPTSF does not

Differential Diagnosis

• DM type 2
  • Thyroid disease
• DM type 1 (ketoacidosis)
  • Infection
    • Encephalitis
    • Meningitis
    • Sepsis
  • Acute abdomen
    • Appendicitis
• GDM
  • Infection
  • Acute abdomen
    • Appendicitis
    • Cholecystitis/cholelithiasis
    • Pregnancy-related abdominal problem
      • Intrauterine infection
  • Hypoglycemia
  • Hyperglycemia
    • Infection
    • Acute abdomen
      • Appendicitis
      • Cholecystitis/cholelithiasis
      • Pregnancy-related abdominal problems
        • Intrauterine infection
  • Thyroid disease

Adults (one of the following)

• Screening criteria for diabetes mellitus

  Screening Criteria for Diabetes Mellitus
  American Diabetes Association	U.S. Preventative Services Task Force
  Testing should be considered in all adults who are overweight (BMI ≥25) and have additional risk factors, including the following Physical inactivity First-degree relative with DM Member of high-risk ethnic population Women who delivered a neonate weighing >9 lb or were diagnosed with GDM Hypertension HDL-C level <35 mg/dL or triglyceride level >250 mg/dL Women with PCOS IGT or IFG noted on prior test results Other clinical conditions associated with insulin resistance History of cardiovascular disease In the absence of the above criteria, testing for DM and pre-DM should begin at 45 years If results are normal, testing should be repeated at least every 3 years, with consideration of more frequent testing depending on initial results and risk status	2008 USPSTF Screening is recommended for asymptomatic adults with sustained blood pressure >135/80 mmHg No recommendation for asymptomatic adults with blood pressure ≤135/80 mmHg Pre-2008 USPSTF Screening recommended for DM type 2 in adults with hypertension or hyperlipidemia Evidence is insufficient to recommend for or against routine screening of asymptomatic adults for DM type 2, IGT or IFG

Pregnant women

• Assess risk for GDM in all pregnant women at first prenatal visit (American College of Obstetricians and Gynecologists [ACOG])
  • USPSTF recommends individual patient screening for at-risk patients (no recommendation for screening all pregnant patients)
• Plasma glucose testing is an adequate initial screen during first prenatal visit
  • If initial screen is positive, follow up with OGTT
  • If initial screen is negative but patient is high risk, follow up with OGTT at 24-28 weeks gestation
• Repeat screening 6-12 weeks postpartum only as followup for positive result during pregnancy
• Comparison of Diagnostic Testing Recommendations for GDM

  Comparison of Diagnostic Testing Recommendations for GDM
  Guidelines	Glucose Load	Diagnostic Threshold (mg/dL)
  American Diabetes Association (2007)	100 g, 3-hour glucose tolerance test (two abnormal values) OR Fasting or casual glucose	F ≥95, 1 hr ≥180, 2 hr ≥155, 3 hr ≥140 [Carpenter and Coustan (CC), O’Sullivan and Mahan (OM)] F >126 or casual glucose >200 (CC, OM)
  Joslin Diabetes Center (2005)	100 g, 3-hour or 75 g, 2-hour1 glucose tolerance test (two abnormal values)	F>105, 1 hr >190, 2 hr >165, 3 hr  >145 [National Diabetes Data Group (NDDG)]
  International Diabetes Center (2003)	100 g, 3-hour glucose tolerance test (two abnormal values)	F ≥95, 1 hr  ≥180, 2 hr  ≥155, 3 hr  ≥140 (CC, OM)
  U.S. Preventative Services Task Force (2003)2	Initial testing: 50 g, 1-hour glucose tolerance test; if abnormal (130-140 mg/dL), proceed to 100 g, 3-hour glucose tolerance test (two abnormal values)	F ≥95, 1 hr  ≥180, 2 hr  ≥155, 3 hr  ≥140 (CC, OM)
  American College of Obstetricians and Gynecologists  (2001)	100 g, 3-hour glucose tolerance test (two abnormal values)	F ≥95, 1 hr ≥180, 2 hr ≥155, 3 hr ≥140  [(OM) and (CC)] F ≥105, 1 hr ≥190, 2 hr ≥165, 3 hr ≥145 (NDDG)
  World Health Organization (1999)	75 g, 2-hour glucose tolerance test	F ≥126 or 2 hr ≥200
  National Diabetes Data Group (1979)	100 g, 3-hour glucose tolerance test	F >105; 1 hr >190; 2 hr >165; 3h >145
  175 g load is not as well validated by studies but is acceptable for use in diagnosis 2Updated 2008 – evidence is insufficient to recommend for or against routine screening for GDM

Recommendations for physical examination (Diabetes Care; Standards of Medical Care in Diabetes, 2010)

• Blood pressure – every week, including orthostatic measurements when indicated (goal <130/80 mmHg)
• Weight – every visit (goal is BMI <25 kg/m²)
• Funduscopic examination and dilated eye exam by expert (if first exam is normal, then every 2-3 years)
• Thyroid palpation
• Skin examination (for acanthosis nigricans and insulin injection sites)
• Neurological/foot examination
  • Inspection of feet for lesions
  • Palpation of dorsalis pedis (DP) and posterior tibial (PT) artery pulses
  • Presence/absence of patellar and Achilles reflexes
  • Determination of proprioception, vibration and monofilament sensation

Laboratory Testing

• Glycemic control

  Glycemic Control

  HbA1c Premise of testing Glycation of hemoglobin is non-linear over time and occurs over the whole lifespan of the red blood cell Correlates with risk of long-term complications and with DM control over previous 2-3 months Target goal – <7% of glycated hemoglobin Laboratory testing recommendations  2 measurements per year for patients meeting goal of <7% (ADA 2008), ≤6.5% (ACE/AACE) If patient is not hypoglycemic, goal should be <6.5% More frequent monitoring in patients with HbA1c ≥7%; however, not more often than every 3 months 1,5-Anhydroglucitol (GlycoMark®) Premise of testing Renal reabsorption of 1.5-anhydroglucitol is competitively inhibited by glucose and is excreted in the urine when the concentration of plasma glucose exceeds its renal threshold (~180 mg/dL) Poor glycemic control leads to decreased concentrations of plasma 1,5-anhydroglucitol Less sensitive to small changes in glycemic control at high HbA1c levels 1.5-AG reflects postprandial glycemic changes better than other glycemic indicators and measurements may be useful for assessing postprandial hyperglycemia Laboratory testing recommendations Not recommended for monitoring DM May be useful for identifying postprandial hyperglycemia and assessing glycemic control in patients with moderately controlled diabetes In patients with normal 1.5-AG (HbA1c 6.1-7.9%), treatment should be aimed at normalizing fasting blood glucose In patients with low 1.5-AG, treatment should be aimed at normalizing postprandial glucose Fructosamine Premise of testing Intermediate marker of glycemia Carbonyl group of glucose reacts with an amino group of a protein Provides glycemia index over 20-day period Laboratory testing recommendations May be useful in monitoring GDM; not recommended for other types of DM May be used in patients with shortened red cell survival (eg, sickle cell disease) Albumin, glycated Premise of testing Intermediate marker of glycemia Measures glycation of serum albumin Provides glycemia index over 20-day period Laboratory testing recommendations May be useful in monitoring GDM; not recommended for other types of DM May be used in patients with shortened red cell survival (eg, sickle cell disease) Control in patients with moderately controlled diabetes Insulin Premise of testing Circulating levels of insulin may be prognostic for likelihood of progression to insulin dependence in DM Laboratory testing recommendations Not recommended for monitoring DM C-peptide Premise of testing C-peptide connects the A & B chains of proinsulin Released in equimolar concentrations with insulin Reflects endogenous insulin production Laboratory testing recommendations Not recommended for monitoring or diagnosis of DM May be useful for assessing endogenous insulin production to confirm need for insulin therapy or to aid in confirmation of DM type 1

• Dyslipidemia
  • Lipid panel
    • Premise of testing
      • Patients with DM have an increased incidence of lipid abnormalities
      • Lipid-lowering therapies have been demonstrated to reduce macrovascular disease
    • Target goal – LDL <100 mg/dL (moderate risk patient); LDL <70 mg/dL (high risk patient); HDL >40 mg/dL, triglycerides <150 mg/dL
    • Laboratory testing recommendations
      • Initial evaluation and annually thereafter if goals are met
        • More often if goals are not met
      • Treat aggressively with statins if goals not met
• Hepatic function
  • Premise of testing
    • Patients with DM are at risk for steatohepatitis
  • Laboratory testing recommendations
    • Liver function tests –  AST, ALT, alkaline phosphatase and bilirubin
    • Initial evaluation and annually thereafter if values are normal on initial testing
• Renal function
  • Creatinine 
    • Premise of testing
      • Many drugs require adjusted dosing based on creatinine, creatinine clearance or estimated glomerular filtration rates (eGFR)
      • Absolute creatinine values do not reflect glomerular filtration rates in many patients
        • Diabetic nephropathy diminishes creatinine clearance
        • Renal function thereby diminishes clearance and glomerular filtration rate
      • Creatinine and eGFR are broad measures of renal function
    • Target goal
      • Normal ranges
        • Males – 97-113 mL/min
        • Females – 88-128 mL/min
    • Laboratory testing recommendations
      • Serum creatinine and eGFR (calculated) annually
• Microalbumin (urine)
  • Premise of testing
    • Diabetic nephropathy occurs in 20-40% of patients with DM and is the single leading cause of end-stage renal disease
    • Microalbuminuria or persistent albuminuria (range 30-299 mg/g creatinine, 30-299 mg/24 hours) signifies the earliest stage of diabetic nephropathy
  • Target goal
    • <30 mg/g creatinine, <30 mg/24 hour urine
  • Laboratory testing recommendations
    • Spot urine or 24-hour urine for microalbumin annually
    • Addition of angiotensin converting enzyme inhibitors to diabetes regimen is renoprotective if microalbuminuria is present
• Thyroid function
  • TSH
    • Premise of testing
      • Autoimmune thyroid disease occurs more frequently in patients with DM type 1
    • Laboratory testing recommendations
      • Initial evaluation and, if normal, every 3 years thereafter

Tests generally appear in the order most useful for common clinical situations

Guidelines

• Consensus statement on the worldwide standardization of the hemoglobin A1C measurement: the American Diabetes Association, European Association for the Study of Diabetes, International Federation of Clinical Chemistry and Laboratory Medicine, and the International Diabetes Federation. Diabetes Care. 2007; 30 (9) :2399-2400.PubMed
• Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycemia. Version 2006, World Health Organization. Geneva: Switzerland [Accessed: 31 Oct 2011] 
• Diabetes Care January 2010, Volume 33, Supplement 1. American Diabetes Association. [Accessed: 3 May 2010] 
• Executive summary: standards of medical care in diabetes--2011. Diabetes Care. 2011; 34 Suppl 1 :S4-10.PubMed
• Handelsman Y, Mechanick JI, Blonde L, Grunberger G, Bloomgarden ZT, Bray GA, gogo-Jack S, Davidson JA, Einhorn D, Ganda O, Garber AJ, Hirsch IB, Horton ES, Ismail-Beigi F, Jellinger PS, Jones KL, Jovanovic L, Lebovitz H, Levy P, Moghissi ES, Orzeck EA, Vinik AI, Wyne KL. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011; 17 Suppl 2 :1-53.PubMed
• Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, Damm P, Dyer AR, Leiva A, Hod M, Kitzmiler JL, Lowe LP, McIntyre HD, Oats JJ, Omori Y, Schmidt MI. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010; 33 (3) :676-682.PubMed
• Moses RG. New consensus criteria for GDM: problem solved or a pandora's box?. Diabetes Care. 2010; 33 (3) :690-691.PubMed
• National Collaborating Centre for Chronic Conditions, ed. Type 2 Diabetes: National Clinical Guideline for Management in Primary and Secondary Care. Update. London: Royal College of Physicians, 2008.
• National Collaborating Centre for Women's and Children's Health, ed. Type 1 Diabetes: Diagnosis and Management of Type 1 Diabetes in Children and Young People. London: RCOG Press, 2004.
• National Collaborating Centre for Women’s and Children’s Health, ed. Management of Diabetes and Its Complications from Preconception to the Postnatal Period. London: RCOG Press, 2008.
• Phillip M, Battelino T, Rodriguez H, Danne T, Kaufman F. Use of insulin pump therapy in the pediatric age-group: consensus statement from the European Society for Paediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2007; 30 (6) :1653-1662.PubMed
• Qaseem A, Vijan S, Snow V, Cross JT, Weiss KB, Owens DK. Glycemic control and type 2 diabetes mellitus: the optimal hemoglobin A1c targets. A guidance statement from the American College of Physicians. Ann Intern Med. 2007; 147 (6) :417-422.PubMed
• Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, Lernmark A, Metzger BE, Nathan DM. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem. 2011; 57 (6) :e1-e47.PubMed
• Snow V, Aronson MD, Hornbake ER, Mottur-Pilson C, Weiss KB. Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2004; 140 (8) :644-649.PubMed
• Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of Diabetes Mellitus. Version 2011, World Health Organization. Geneva: Switzerland [Accessed: 31 Oct 2011] 

General

• Adi S. Type 1 diabetes mellitus in adolescents. Adolesc Med State Art Rev. 2010; 21 (1) :86-102, ix.PubMed
• Aroda VR, Ratner R. Approach to the patient with prediabetes. J Clin Endocrinol Metab. 2008; 93 (9) :3259-3265.PubMed
• Cheng YW, Caughey AB. Gestational diabetes: diagnosis and management. J Perinatol. 2008; 28 (10) :657-664.PubMed
• Dungan KM. 1,5-anhydroglucitol (GlycoMark) as a marker of short-term glycemic control and glycemic excursions. Expert Rev Mol Diagn. 2008; 8 (1) :9-19.PubMed
• Kirk JK, Namak S. Diabetes: Rethinking risk and the Dx that fits. J Fam Pract. 2009; 58 (5) :248-256.PubMed
• Little RR, Sacks DB. HbA1c: how do we measure it and what does it mean?. Curr Opin Endocrinol Diabetes Obes. 2009; 16 (2) :113-118.PubMed
• Mohamadi A, Cooke DW. Type 2 diabetes mellitus in children and adolescents. Adolesc Med State Art Rev. 2010; 21 (1) :103-19, x.PubMed
• National Kidney Disease Education Program: Health Professionals. National Kidney Disease Education Program. Bethesda: Maryland [Last Reviewed: 11 Feb 2009; Accessed: 16 Apr 2009] 
• Phillips PJ, Phillipov G. Diabetes monitoring--albuminuria--frequently asked questions. Aust Fam Physician. 2007; 36 (9) :713-715.PubMed
• Rivkees SA. Why the consensus for consensus?. J Pediatr Endocrinol Metab. 2008; 21 (6) :503-505.PubMed
• Rodbard HW. Diabetes screening, diagnosis, and therapy in pediatric patients with type 2 diabetes. Medscape J Med. 2008; 10 (8) :184-.PubMed
• Russell MA, Carpenter MW, Coustan DR. Screening and diagnosis of gestational diabetes mellitus. Clin Obstet Gynecol. 2007; 50 (4) :949-958.PubMed
• Taplin CE, Barker JM. Autoantibodies in type 1 diabetes. Autoimmunity. 2008; 41 (1) :11-18.PubMed
• Theodoraki A, Baldeweg SE. Gestational diabetes mellitus. Br J Hosp Med (Lond). 2008; 69 (10) :562-567.PubMed
• Vijan S. Type 2 diabetes. Ann Intern Med. 2010; 152 (5) :ITC31-15.PubMed
• Wilson JF. In clinic. Diabetic ketoacidosis. Ann Intern Med. 2010; 152 (1) :ITC1-2, ITC1.PubMed
• Winter WE, Schatz DA. Autoimmune markers in diabetes. Clin Chem. 2011; 57 (2) :168-175.PubMed
• Zhang X, Gregg EW, Williamson DF, Barker LE, Thomas W, Bullard KM, Imperatore G, Williams DE, Albright AL. A1C level and future risk of diabetes: a systematic review. Diabetes Care. 2010; 33 (7) :1665-1673.PubMed

ARUP Institute for Clinical and Experimental Pathology®

• Anderson JL, Carlquist JF, Roberts WL, Horne BD, May HT, Schwarz EL, Pasquali M, Nielson R, Kushnir MM, Rockwood AL, Bair TL, Muhlestein JB. Asymmetric dimethylarginine, cortisol/cortisone ratio, and C-peptide: markers for diabetes and cardiovascular risk?. Am Heart J. 2007; 153 (1) :67-73.PubMed
• Owen WE, Roberts WL. Cross-reactivity of three recombinant insulin analogs with five commercial insulin immunoassays. Clin Chem. 2004; 50 (1) :257-259.PubMed
• Owen WE, Roberts WL. Performance characteristics of an HPLC assay for urinary albumin. Am J Clin Pathol. 2005; 124 (2) :219-225.PubMed
• Roberts WL. Hemoglobin constant spring can interfere with glycated hemoglobin measurements by boronate affinity chromatography. Clin Chem. 2007; 53 (1) :142-143.PubMed

Acromegaly
Actinomyces and Nocardia Species
Adrenal Hyperfunction
Autoimmune Thyroid Disease
Electrolyte Abnormalities, Life Threatening
Glucagonoma
Heart Failure
Hemochromatosis
Hyperinsulinemic Hypoglycemia
Ischemic Heart Disease
Metabolic Acidosis
Metabolic Syndrome
Narcolepsy
Osteomyelitis
Polycystic Ovarian Syndrome
Renal Function Markers