Diabetes mellitus (DM) is a chronic illness that leads to significant morbidity and death in the U.S.

Disease Complications

• Acute
  • Diabetic ketoacidosis - Type 1 DM
  • Hyperosmolar nonketotic coma - Type 2 DM
• Long-term (Types 1 and 2 DM)
  • Cardiac - coronary artery disease
  • Immunologic - recurrent infections
  • Neurologic - neuropathy
  • Ophthalmic - retinopathy
  • Renal - proteinuria with renal failure
  • Vascular - small vessel disease with extremity loss
• A large body of evidence supports that structured care with appropriate clinical interventions may prevent acute complications and improve long-term outcomes in DM patients

Diagnosis

• Disease Monitoring

• Laboratory Testing
  • Glycemic control
    • 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: <7% of glycated hemoglobin
      • Laboratory testing recommendations 
        • 2 measurements per year for patients meeting goal of <7%
          • If patient is not hypoglycemic, goal should be <6%
        • More frequent monitoring in patients with HbA1c greater than or equal to 7%; however not more often than every 3 months
        • Do not use for diagnosis for diabetes
    • 1-5-Anhydroglucitol
      • 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
      • Laboratory testing recommendations
        • Not recommended as a standard test for monitoring DM
      • May be useful for identifying post-prandial hyperglycemia and assessing glycemic control in patients with moderately controlled diabetes
    • 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 gestational DM; not recommended as a standard to use 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 gestational DM; not recommended as a standard to use 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 diabetes
      • Testing recommendations
        • Not recommended as a standard test 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 as a standard test for monitoring DM
        • May be useful for assessing endogenous insulin production to confirm need for insulin therapy
  • Dyslipidemia
    • Lipid panel
      • Premise of testing
        • Patients with diabetes have an increased incidence of lipid abnormalities
        • Lipid lowering therapies have been demonstrated to reduce macrovascular disease
    • Target goal: LDL <70 mg/dL (particularly if there is evidence or risk of CVD); HDL >40 mg/dL, triglycerides <150 mg/dL
      • Recommended laboratory testing
        • Initial evaluation and every year if goals are met
          • More often if goals are not met
        • Treat aggressively with statins if goals not met
  • Hepatic function
    • Liver function tests (SGOT, SGPT, alkaline phosphatase, bilirubin)
      • Premise of testing
        • Patients with DM are at-risk for steatohepatitis
        • Recommend testing - initial and annually thereafter if values are normal on initial testing
  • Renal function
    • Creatinine 
      • Premise of testing
        • Many drugs will 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
          • 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
        • Recommended laboratory testing
          • Serum creatinine and eGFR (calculated) annually
  • Microalbumin (urine)
    • Premise of testing
      • Diabetic nephropathy occurs in 20-40% of patients with diabetes and is the single leading cause of end stage renal disease
      • Microalbuminuria (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
        • Recommended laboratory testing
          • 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
        • Recommend testing initially and, if normal, every 3 years thereafter