Diabetes Mellitus


Diabetes Mellitus, a term coined for its associated ‘ honey (mellitus)sweet’ urine being ‘siphoned out (diabetes)  ’, is a disease that needs no introduction. Not to be confused with diabetes insipidus (also associated with excess urination but not due to high sugar levels) there are two types of diabetes mellitus, type II, seen in adults accounts for 90% of diabetes cases, and type I or insulin dependent type is seen in the young accounting for the other 10 %. 6-12% of Americans suffer from Diabetes Mellitus.


Factors contributing to diabetes include genetics, weight gain, dietary intake and inactivity.


Diabetes slowly contributes to health decline by affecting :


-the blood vessels and cholesterol levels and increases risk for cardiovascular disease such as strokes, heart attacks, etc.


-vision  due to diabetic retinopathy.


-nerves due to diabetic neuropathy which may in turn lead to diabetic foot infections, gangrene and amputation.


-kidneys due to nephropathy.


Diagnosed after patients present with increased appetite, urination and excessive thirst associated with progressive weight loss or by incidental test results of elevated fasting (<100 is normal, >126 is diabetes) or random glucose levels (> 200 is diabetes), elevated HgA1c ( <5.7 normal, <6.5 is prediabetes, > 6.5 is diabetes) by 2hr glucose tolerance tests (>200 is diabetes) , the disease is easily monitored by primary physicians with the help of glucose monitoring tests, glycosylated hemoglobin levels HgA1c (target levels <7.0)


Diabetes is managed by primary physicians, either internal medicine or family practitioners, and in some difficult to treat cases by endocrinologists.


Most diabetes patients are advised lifestyle modifications which include


-Weight loss




-Dietary restrictions of foods with high glycemic indices, avoidance of simple carbohydrates and fatty foods. (link for foods with high glycemic index)


-avoid smoking and high alcohol intake.


If a fair trial of the above fails to show improvement in fasting glucose levels, HgA1C levels in 3 months then early institution of medications is warranted. For insulin dependent DM –I insulin is the only choice.


Metformin ( Glucophage ) is commonly used ( with additional benefit due to weight loss) unless contraindicated in patients with kidney disease with creatinine > 1.4, heart failure, liver disease or alcohol abuse.


If Metformin proves inefficacious or is contraindicated due to kidney disease, etc, either an additional oral agent such as glyburide, glipizide (sulfonylurea type meds) and repaglinide (prandin 0.5mg tid) , nateglinide (starlix 120mg tid), sitagliptin a DPP4 inhibitor(januvia), injectables such as  insulin, etc may be used. Pioglitazone may be used in those with contraindications to the use of above medications however its association with bladder cancer and heart failure risks should be weighed with the benefits of its use.


Additional medications include GLP1 Glucagon like peptide 1 agonists such as exanatide ( byetta twice daily ) injections (limited by thyroid cancer risk), once weekly exanatide extended release (bydureon) injections (limited by thyroid cancer risk), alpha glucosidase inhibitors such as acarbose  (precose) whose use is limited by flatulence and diarrhea) and DPP4 inhibitors or dipeptidyl peptidase IV enzyme inhibitors sitagliptin (januvia), saxagliptin (onglyza) , linagliptin (trajenta) especially in CKD patients.


Titration to avoid hypoglycemia and an even control of glucose levels is usually achieved with twice daily administration of insulin. Glucose level checks with finger sticks can help guide initial adjustments and later administration of supplemental regular insulin. Insulin combinations are available including humalog, novolog, etc with regular and NPH mixtures to help glycemic control.


Tips for Diabetes:


Exercise daily 30 minutes and maintain ideal body weights


Maintain a healthy diet with low carbohydrate, low salt and an American Diabetic Diet


Use sugar substitutes in moderation if you have a sweet palate. Avoid high glycemic index foods


Avoid sugary beverages and sodas, or daily sugary coffees, or shakes.


Check sugars fasting and occasionally with glucose tolerance test if recommended by your physician


Check annual urine panel for protein and creatinine content for monitoring any diabetic nephropathy


Check annual kidney functions and labs for cholesterol


Annual eye exam to check for diabetic retinopathy


Daily to every other day foot examinations for checking any foot cuts, calluses that may be present without pain due to diabetic neuropathy


 Talk to your doctor if you develop numbness in the feet or hands


Keep glucose tablets or glucagon injections handy for low glucose attacks


Talk to your doctor if you develop sweating at night due to low glucose levels if taking insulin or diabetes medications


Keep regular appointments with your primary physician and try to maintain a HgA1c of  approx 7.0