Diabetes mellitus (main)
Revision as of 18:30, 11 October 2018 by Spenceemmett (talk | contribs)
Background
- Growing in worldwide prevalence
- Results from either inability of the body to release insulin from the pancreas or a resistance against the actions of insulin
Differential Diagnosis
Hyperglycemia
Diabetic Emergencies
- Diabetic ketoacidosis (DKA)
- Diabetic ketoacidosis (peds)
- Hyperosmolar hyperglycemic state (HHS)
- Nonketotic hyperglycemia
- Euglycemic DKA (SGLT-2 inhibitors, pregnancy, fasting)
Diabetes Mellitus (New or Known)
- Type 1 diabetes mellitus (new-onset or uncontrolled)
- Type 2 diabetes mellitus (new-onset or uncontrolled)
- Medication noncompliance or insulin pump malfunction
- Gestational diabetes
- Latent autoimmune diabetes of adults (LADA)
Medication/Drug-Induced
- Corticosteroids (most common drug-induced cause)
- Thiazide diuretics
- Atypical antipsychotics (olanzapine, clozapine, quetiapine)
- Beta-blockers (especially non-selective)
- Phenytoin
- Tacrolimus, cyclosporine (transplant patients)
- Protease inhibitors (HIV antiretrovirals)
- Catecholamines (epinephrine, norepinephrine infusions)
- SGLT-2 inhibitors (paradoxical DKA with euglycemia)
- Total parenteral nutrition (TPN)
- Dextrose-containing IV fluids (iatrogenic)
- Niacin
- Pentamidine (initially hyperglycemia, then hypoglycemia from beta-cell destruction)
Physiologic Stress Response
- Sepsis / critical illness (stress hyperglycemia — very common in the ED)
- Trauma / major surgery / burns
- Acute coronary syndrome / myocardial infarction
- Stroke (especially hemorrhagic)
- Pancreatitis (both a cause and consequence)
- Shock (any etiology)
- Pain (catecholamine surge)
- Seizure (postictal)
- Physiologic stress alone rarely causes glucose >200 mg/dL in non-diabetics; glucose >200 in a "stress response" should prompt evaluation for undiagnosed diabetes or prediabetes
Endocrine
- Cushing syndrome / Cushing disease (cortisol excess)
- Pheochromocytoma (catecholamine excess)
- Hyperthyroidism / thyroid storm
- Acromegaly (growth hormone excess)
- Glucagonoma (rare)
- Somatostatinoma (rare)
Pancreatic
- Pancreatitis (acute or chronic — destruction of islet cells)
- Pancreatic malignancy (adenocarcinoma, neuroendocrine tumors)
- Post-pancreatectomy
- Cystic fibrosis-related diabetes
- Hemochromatosis (iron deposition in pancreas — "bronze diabetes")
Toxic/Overdose
- Iron toxicity (hepatic injury → impaired glucose regulation)
- Salicylate toxicity (can cause both hyper- and hypoglycemia)
- Sympathomimetic toxicity (cocaine, methamphetamine)
- Calcium channel blocker toxicity (impairs insulin secretion)
- Carbon monoxide toxicity (stress response)
Other
- Renal failure (chronic kidney disease, acute kidney injury — impaired insulin clearance AND insulin resistance)
- Cirrhosis / hepatic failure (impaired glycogenolysis regulation)
- Pregnancy (gestational diabetes, steroid administration for fetal lung maturity)
- Parenteral nutrition (TPN, dextrose-containing fluids)
- Post-transplant diabetes (immunosuppressants)
Complications of Diabetes (Not Causes of Hyperglycemia)
These are associated conditions that may be present alongside hyperglycemia but do not themselves cause elevated glucose:
- Diabetic foot infection
- Diabetic peripheral neuropathy
- Cerebral edema in DKA
- Diabetic retinopathy
- Diabetic nephropathy
- In established diabetics presenting with hyperglycemia ask about medication and dietary compliance
Evaluation
Workup based on provider level of suspicion for emergent process such as DKA, HHS, sepsis
- In asymptomatic patient may consider UA to check for ketones
- Sick patients will require CBC, BMP, blood gas, EKG, additional tests at provider discretion
Management
- May consider IV hydration or IV insulin administered in the ED
- All patients with diabetes newly diagnosed in the ED will require reliable follow-up for education and blood sugar monitoring
- May consider discharging patient with prescription for metformin, starting dose is 850 mg daily