DM

Dx Criteria and Goals

• Criteria
  • FBG ≥ 126 mg/dL
  • A1C ≥ 6.5%
  • Randomg BG > 200
  • 2hr PPBG ≥ 200 during OGTT w/ 75g load
• Goals
  • FBG < 120
  • A1C
    • ADA: ≤ 7%
    • AACE ≤ 6.5%
  • Alb:SCr < 30 mcg/mg
  • BP < 130/80 $\overline{eBG} = 28.6 \times A1C - 46.7$

SSx

• High BG
• Polyuria
• Polydypsia
• Infection
• Blurred vision
• Ketoacidosis

Treatment

Basal-Bolus insuling for T1DM See Hypoglycemics for Therapy Dosing and SEs

1. Initiate lifestyle modifications and metformin
2. Add second drug after 3mo
3. Add third drug after additional 3mo
4. Add insulin at any point if necessary
5. Switch to basal-bolus or basal & GLP-1 for tightest control
6. PP Hyperglycemi is best treated with GLP-1s, DPP-4 inhibitors, amylin analogs, or &alph;-glucosidase inhibitors

Monitoring

• Screen all pts ≥ 45yo or overweight individuals
  • Repeat q3yr if normal

DKA / HHS

DDx

• HHS is commonly caused by dehydration
• DKA is commonly caused by an absolute lack of insulin
• Calculate corrected Na before correcting, preferably fix underlying BG problem before correcting at all
  • Corrected Na = $ \text{Na} + 0.16 \times (\text{BG}-100) $

Lab	Normal	Mild DKA	Moderate DKA	Severe DKA	HHS
BG	90-130	> 250	> 250	> 250	> 600
apH	7.35-7.45	7.25-7.3	7-7.25	< 7	> 7.3
Bicarb	22-26	15-18	< 15	< 10	> 18
Urine Ketones	-	+	+	+	Small
Serum Ketones	-	+	+	+	Small
Osm	275-300	Variable	Variable	Variable	> 320
Anion Gap	7-9	> 10	> 12	> 12	Variable
Mental Status	Alert	Alert	Drowsy	Stupor / Coma	Stupor / Coma
Na	135-145	Mild Decrease	Mild Decrease	Mild Decrease	Normal
K	3.5-5	Normal or High	Normal or High	Normal or High	Normal or Low
SCr	0.6-1.3	Slightly High	Slightly High	Slightly High	Moderately High
BUN	6-20	High	High	High	High
Amylase	23-85	High	High	High	High
Lipase	0-160	High	High	High	High
WBC	4.5-10	High	High	High	High

Treatment

• Insulin 0.1 U/kg bolus then 0.1 U/kg/hr OR 0.14 U/kg/hr w/ no bolus
• Decrease rate to 0.02-0.05 U/kg/hr once BG controlled
  • ≤ 200 in DKA or ≤ 300 in HHS
• Do not initiate insulin if K < 3.3 mEq/L, replete to &approx; 5 w/ 20 mEq/L containing fluids
• Replete Phos if < 1 or if exhibiting organ dysfunction by protocol (usually 20-30 mEq added to 1L of fluid)
• Bicarb may not be efficacious, consider LR or other balanced salt solution alternated or in place of NS in order to help correct acidosis
  • Use will drive K down farther
• Transition to SubQ insulin when pt is eating and hyperglycemic crisis has resolved
  • Overlap SubQ w/ IV infusion for 1-2hrs

Monitoring

• Hypoglycemia
• Hypokalemia
• Gradually increase Na to avoid cerebral edema

  Resolution Criteria

• DKA
  • BG < 200 and 2 of the following
    • Bicarb ≥ 15
    • vpH > 7.3
    • Anion Gap ≤ 12
• HHS
  • BG < 300
  • Normal Osm
  • Normal Mental Status
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