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FIRST CONSULT

Diabetes overview
Current contributors
Leann Olansky, MD, Paul Levinson, MD, Mary Gillam, MD
Revised: July 29, 2013
Copyright Elsevier BV. All rights reserved.

Key points

Diabetes mellitus is a metabolic disorder caused by a relative or complete lack of

insulin or a defect in the normal action of insulin, resulting in hyperglycemia and
disturbances of carbohydrate, fat, and protein metabolism

Diabetes is one of the most common chronic diseases, with increasing incidence
worldwide

Some patients present with acute symptoms, whereas other cases remain undiagnosed
owing to the subclinical phase of the disease, particularly in patients with type 2 diabetes

Patients with diabetes are at increased risk for cardiovascular disease, peripheral
vascular disease , and stroke , as well as specific complications, including diabetic
retinopathy , diabetic nephropathy , and diabetic neuropathy

Diabetic emergencies that require urgent treatment include the following:

Diabetic ketoacidosis , which is a life-threatening acute complication requiring

urgent inpatient treatment that occurs most commonly in patients with type 1 diabetes;
patients may present with polyuria, thirst, weakness, lethargy, vomiting, abdominal pain, and
reduced consciousness, and absolute or relative insulin deficiency, electrolyte disturbances,
dehydration, ketosis, and metabolic acidosis are present
o

Hyperosmolar hyperglycemic state, which usually affects patients with type 2

diabetes, especially elderly patients, and is characterized by a high plasma osmolarity with no
significant ketonemia or acidosis; the condition is associated with a high mortality rate, and
treatment in an intensive care unit is usually necessary
Hypoglycemia , which is an acute complication that occurs when the plasma

glucose level decreases below normal in patients receiving glucose-lowering medications; the
threshold for symptoms and signs of hypoglycemia, which include palpitations, tremor,
anxiety, and sweating, as well as headache, abnormal behavior, altered consciousness, and
eventually coma, varies for different patients, but glucose levels <70 mg/dL should be
avoided

Treatment of type 1 diabetes requires insulin replacement

Type 2 diabetes may be controlled by dietary and lifestyle adaptations, a variety of

oral or subcutaneous glucose-lowering agents, or subcutaneous insulin therapy

Long-term monitoring and diabetes care is improved when a well-organized health

care team works in partnership with the patient and caregiver

Background
Description

Disorders of glucose homeostasis can be classified as follows:

Type 1 diabetes

Type 2 diabetes

Other specific types, such as various genetic defects and syndromes,

infections, other rare immune-mediated conditions, diseases of the exocrine pancreas, and
drug- or chemical-induced disorders
Gestational diabetes

The distinction between type 1 and type 2 diabetes is not always apparent, and there
may be some overlap

Type 1 diabetes classically presents in childhood , but onset may occur at any age and
is usually rapid but can be insidious in older adults. Patients typically present with sudden
weight loss, polyuria, thirst, and elevated blood glucose levels, or the presentation may be
acute, with symptoms of diabetic ketoacidosis

Type 2 diabetes, which represents 90% of all cases of diabetes, classically occurs in
middle-aged and elderly patients, although incidence in early adulthood and childhood is
increasing. Onset is usually insidious and may be preceded by a period of impaired glucose
tolerance, which is often asymptomatic; a family history of diabetes is typical

Epidemiology
Incidence and prevalence

The number of patients with diabetes is increasing steadily, with an estimated 25.8
million adults and children affected in the U.S. (8.3% of the population) in 2010

Approximately 7 million cases remain undiagnosed, and 79 million adults over the
age of 20 have prediabetes, a condition that places them at high risk of developing diabetes

The number of cases of diabetes in adults worldwide was estimated to be 347 million
in 2008 and is estimated to be 438 million in 2030

The prevalence of diabetes in all age groups worldwide was estimated to be 11.8% in
men and 10.8% in women in 2010

Demographics
Age:

Type 1 diabetes classically presents in childhood, but onset can occur at any age

Type 2 diabetes classically occurs in middle-aged and elderly patients, although more
recently there has been an increase in incidence in early adulthood and childhood

The prevalence of type 2 diabetes increases with age

The increase in the number of patients over age 65 is an important factor in the
increasing prevalence of diabetes worldwide
Gender:

The ratio of prevalence of diabetes in male patients compared to female patients

varies markedly between populations, with little discernable trend, although impaired
glucose tolerance is generally more common in female patients

In 2010, the prevalence of diagnosed diabetes in the U.S. in patients over age 20 was
11.8% for men and 10.8% for women
Race and geography:

Type 1 diabetes is most common in Finland and least common in China, Japan, and
parts of South America

Groups of Native Americans and Australian aborigines who have adopted a more
westernized lifestyle have particularly high rates of type 2 diabetes

The worldwide estimated prevalence rates for all types of diabetes are highest in
India, China, and the U.S.

Causes and risk factors

Causes
Type 1 diabetes:

One form is thought to have an autoimmune cause; pancreatic -cell destruction is

possibly triggered by glutamic acid decarboxylase acting as an autoantigen
Genetic and environmental factors also have some influence
Another form, described as 'idiopathic,' has no known etiology, with no evidence of
autoimmunity
Type 2 diabetes:

Insulin resistance and pancreatic -cell dysfunction both occur

Can be caused predominantly by insulin resistance, with relative insulin insensitivity,

or predominantly by an insulin secretory defect, with or without insulin resistance

A mixture of genetic and environmental factors probably lead to the onset of type 2
diabetes
Risk factors

A sedentary lifestyle and obesity appear to increase the risk of insulin resistance and,
subsequently, type 2 diabetes

The risk of developing type 2 diabetes also increases with age, past history of
gestational diabetes, family history of diabetes, and presence of coexisting hypertension and
dyslipidemia

Intrauterine factors may play a role in the development of type 2 diabetes

Associated disorders

Impaired glucose tolerance without overt diabetes

Affects 15% to 20% of persons aged 45 to 74 years in the U.S.

o
o

Defined as a fasting plasma glucose level <126 mg/dL that increases to 140 to
199 mg/dL 2 hours after a 75-g glucose load

Associated with an increased risk of developing diabetes and an increased risk

of ischemic heart disease

Annual screening with measurement of fasting glucose or a 2-hour oral

glucose tolerance test (OGTT) is recommended

Other risk factors for coronary heart disease (eg, low-density lipoprotein
[LDL] cholesterol level <100 mg/dL) should be treated aggressively

A total of 50% of patients revert to normal glucose tolerance within 10 years,

25% of patients remain glucose intolerant, and 25% of patients develop type 2 diabetes

Impaired fasting glucose

A category of glucose tolerance added by the American Diabetes Association

o
(ADA)

Defined as a fasting plasma glucose level of 100 to 125 mg/dL

Patients have a higher risk of developing type 2 diabetes and also already may
be at increased risk for macrovascular complications

The ADA defines individuals with glycosylated hemoglobin (HbA1c) in the range of
5.7% to 6.4% at high risk for the development of diabetes

Metabolic syndrome

Diagnosed when a patient has coexisting hypertension, central obesity, and

dyslipidemia (high triglyceride levels and/or low high-density lipoprotein [HDL]
cholesterol levels), with or without hyperglycemia but with increased insulin resistance
Associated with an increased risk of cardiovascular disease and stroke

Autoimmune disorders associated with type 1 diabetes include hyperthyroidism , celiac

disease ,Addison disease , and megaloblastic anemia

Diagnosis
Summary approach

The ADA criteria for the diagnosis of diabetes are as follows:

Symptoms of diabetes, which classically include polyuria, polydipsia, and
unexplained weight loss, plus a casual (defined as any time of day without regard to time
since last meal) plasma glucose level 200 mg/dL
Fasting (defined as no caloric intake for at least 8 hours) blood glucose level

o
126 mg/dL
o

Two-hour postglucose load level 200 mg/dL during an OGTT, which should
be done as described by the World Health Organization (WHO) , using a glucose load
containing the equivalent of 75 g of anhydrous glucose dissolved in water

HbA1c6.5%. This test should be performed in a laboratory using a method that

is certified by the National Glycohemoglobin Standardization Program or traceable to the
Diabetes Control and Complications Trial reference assay

In the absence of unequivocal hyperglycemia, presence of any of these criteria should

be confirmed by repeat testing on a different day

Although advocated by the WHO criteria, the OGTT is not recommended for routine
clinical use; in other ways, the WHO criteria and the ADA criteria are similar

Other laboratory investigations (eg, lipid profile) will be necessary once the diagnosis
has been established

Clinical presentation
Symptoms:

Diabetes can present with symptoms of hyperglycemia and/or symptoms related to

complications of the disease
Type 1 diabetes:

The classic presentation is acute, with rapid onset of polydipsia, polyuria,

weight loss, and lethargy
Patients may present with diabetic ketoacidosis , which is an emergency

Type 2 diabetes:

Onset is classically more insidious; many patients are unaware of the

condition, which is commonly diagnosed following routine blood tests

When hyperglycemia is marked (>200 mg/dL) and sustained, typical

presenting symptoms are lethargy, polyuria, polydipsia, frequent infections, and symptoms
of complications (eg, angina, impotence)

Diabetic ketoacidosis can occur as a result of significant stress but is much

more common in patients with type 1 diabetes
Signs:

There may be no abnormalities on physical examination in the early stages of both

type 1 and 2 diabetes

Ketotic breath, signs of dehydration, and weight loss may occur, especially in patients
with type 1 diabetes

Signs of complications may be already present at the time of diagnosis in patients

with type 2 diabetes

Treatment
Summary approach

The main goals of treatment are to alleviate symptoms, minimize the development of
long-term complications, enhance the patient's quality of life, and reduce the risk of death
Immediate action is required in patients with the following:
Diabetic ketoacidosis , which is diagnosed when the blood glucose level is

>250 mg/dL in conjunction with an arterial pH <7.35, a venous pH <7.30, or a serum

bicarbonate level <15 mEq/L in the presence of ketonuria and/or ketonemia; urgent hospital
admission is appropriate, and early initiation of insulin, intravenous fluids, and electrolyte
replacement is essential
o

Hyperosmolar hyperglycemic state, which results in a blood glucose level

>600 mg/dL, an arterial pH >7.3, and a serum bicarbonate level >15 mEq/L; urgent hospital
admission is appropriate
Hypoglycemia , which occurs when the plasma glucose level decreases below

normal (ie, <70 mg/dL); depending on the patient's level of consciousness, treatment may
consist of oral glucose, intravenous dextrose, or intravenous or intramuscular glucagons

Good control of blood glucose and blood pressure; lipid-lowering treatment;

prevention, monitoring, and treatment of microvascular complications such as diabetic
nephropathy , diabetic retinopathy , and diabetic neuropathy; foot care; lifestyle measures
(eg, smoking cessation, weight control, and dietary measures); and prepregnancy counseling
and care of pregnant women with diabetes are important strategies in diabetes care to reduce
the risk of and/or delay the progression of microvascular complications

Intensive glycemic control has been shown to reduce the risk of macrovascular
complications in type 1 diabetes, but not in type 2 diabetes; individual patient
characteristics may modify the role of glycemic control in macrovascular risk reduction. In
individuals with type 2 diabetes, controlling individual cardiovascular risk factors has been
shown to be effective in preventing or slowing cardiovascular disease

Intensive glycemic control slows the onset and progression of microvascular

complications of diabetes

The ADA recommends a goal HbA1cof <7%, but treatment goals may need to
be individualized, especially in specific patient populations, such as pregnant women,
children, elderly patients, and those with a long duration of disease

Patients with type 1 diabetes require an individualized insulin regimen. Trials

of various types of insulin and insulin regimens can be considered; short- and long-acting
insulin analogs also are available. Patients need to be trained to perform injections and to
self-monitor their blood glucose levels

Continuous subcutaneous insulin infusion devices (ie, insulin pumps) may be

considered in individuals with type 1 diabetes or in selected patients with insulin-requiring
type 2 diabetes

Pancreas transplantation, usually in conjunction with simultaneous kidney

transplantation (ideally from the same donor) may be considered in certain patients with
type 1 diabetes

Patients with type 2 diabetes may be able to control their blood glucose levels
through dietary and lifestyle changes. Lifestyle modifications represent a core component of
treatment of type 2 diabetes, regardless of whether pharmacotherapy is also necessary

If dietary and lifestyle changes are unsuccessful, the medication of choice in

overweight people with type 2 diabetes is generally metformin , provided there are no
contraindications

Several classes of oral agents, such as sulfonylureas, thiazolidinediones,

meglitinides, -glucosidase inhibitors (such as acarbose ), dipeptidyl peptidase-4 inhibitors,
and sodium glucoselike transporter 2 inhibitors may be used in patients with type 2
diabetes

When monotherapy does not achieve the desired level of glycemic control,
combination therapy with agents that have differing modes of action should be used

Exenatide , an incretin mimetic that mimics the action of glucagon-like

peptide-1, a gut-derived hormone, was approved initially in May 2005 as an adjunctive

treatment for use in patients with type 2 diabetes and was approved as a first-line treatment
in 2010. A second incretin mimetic, liraglutide , also was approved in 2010, and a onceweekly, extended-release formulation of exenatide, exenatide XR, was approved in 2012.
These agents, delivered through a subcutaneous injection, can be used alone or in
combination with metformin, a thiazolidinedione, insulin, or an insulin secretagogue. The
advantages of glucagon-like peptide-1 receptor agonists are their promotion of weight loss
and low risk for hypoglycemia, except if combined with secretagogues
o

The endogenous incretin system can be augmented by a class of agents known

as dipeptidyl peptidase-4 inhibitors, which inhibit the enzyme that degrades glucagon-like
peptide-1 and another incretin hormone, gastric inhibitory polypeptide. Several dipeptidyl
peptidase-4 inhibitors are available in the U.S.: sitagliptin , saxagliptin , linagliptin ,alogliptin ,
and vildagliptin , the latter of which is only available outside the U.S.

A rapid-release form of bromocriptine has been approved for the treatment of

type 2 diabetes. In clinical trials, this agent showed a reduction in HbA1csimilar to that of
other oral agents and also resulted in an estimated 40% reduction in cardiovascular events
over 1 year

The class of agents referred to as the sodium glucoselike transporter 2

inhibitors lower blood glucose through an insulin-independent mechanism by promoting
glucosuria. One agent, canagliflozin , was approved for the treatment of type 2 diabetes in
2013

Insulin therapy may be considered in patients with type 2 diabetes whose

glycemic control remains poor despite the aforementioned noninsulin therapies. A
combination of long-acting insulin and oral or injectable hypoglycemic agents may be
adequate, but, if not, short-acting insulin analogs may be added to cover meal-related
glycemic excursions

Pramlintide , an amylinomimetic that was approved in March 2005 for the

treatment of type 1 and type 2 diabetes in conjunction with insulin, is indicated in patients
who continue to demonstrate suboptimal glycemic control, despite optimal insulin therapy.
Pramlintide is an injectable therapy and has a benefit of causing some weight loss

Medical nutritional therapy is important in all patients with diabetes; individual

therapeutic goals can be set depending on the circumstances

Tight blood pressure control has been found to reduce the incidence of microvascular
and macrovascular complications of diabetes but not the mortality rate among patients with
type 2 diabetes; multiple antihypertensive medications may be required. The ADA
recommends a blood pressure goal of <140/80 mm Hg in patients with diabetes. Lower
systolic targets, such as <130 mm Hg, may be appropriate for certain individuals, such as
younger patients, if it can be achieved without excessive treatment burden

Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers may

have benefits independent of their effect on blood pressure in certain patients with diabetes

(eg, patients with impaired left ventricular function or patients with type 2 diabetes and
microalbuminuria or established nephropathy)

Patients with type 2 diabetes have an increased prevalence of lipid abnormalities;

reducing LDL cholesterol levels, raising HDL cholesterol levels, and lowering triglyceride
levels have been shown to reduce the risk of cardiovascular events and death. The ADA
recommends the following goals in patients with diabetes: LDL cholesterol level <100
mg/dL, HDL cholesterol level >40 mg/dL in men and >50 mg/dL in women, and
triglyceride level <150 mg/dL. Statin treatment, regardless of baseline lipid levels, is
recommended in diabetes patients with any of the following characteristics:
Overt cardiovascular disease (CVD)

Without CVD, if the patient is over the age of 40 years and has one or more
other CVD risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or
albuminuria)

Lower-risk patients than the above (eg, without overt CVD and under the age
of 40 years), if LDL cholesterol remains above 100 mg/dL or in those with multiple CVD
risk factors

Aspirin therapy reduces the risk of further ischemic events in patients with established
coronary vascular disease and peripheral vascular disease and is recommended for
individuals with diabetes and a history of myocardial infarction or stroke

The effectiveness of antiplatelet therapy as a primary preventive measure is

less clear; therefore, its use in patients with diabetes for primary prevention of CVD
remains controversial. A 2010 joint position statement from the ADA, the American Heart
Association (AHA), and the American College of Cardiology Foundation recommended use
of low-dose aspirin (75-162 mg/d) for primary prevention for adults with diabetes who are
at increased CVD risk (10-year risk of CVD events over 10%) and who are not at increased
risk for bleeding. This generally includes most men over age 50 years and women over age
60 years who also have one or more of the following major risk factors: smoking,
hypertension, dyslipidemia, family history of premature CVD, and albuminuria

Aspirin is not recommended for individuals with diabetes who are at low risk
for CVD, as the low benefit is likely to be outweighed by risks of significant bleeding

Smoking is linked to both microvascular and cardiovascular complications in patients

with diabetes, and, thus, smoking cessation is recommended; nicotine replacement therapy,
bupropion, and counseling may be helpful

Other lifestyle measures, such as regular exercise, have been shown to reduce blood
glucose levels and may prevent the development of type 2 diabetes in certain patients at
high risk

Other specific therapies may be necessary if certain complications (eg, diabetic

nephropathy, diabetic retinopathy) are present

Patients with diabetes are at increased risk for some infections, and outcomes may be
worse than those in patients without diabetes. The ADA recommends that all patients over
age 6 months with diabetes receive the influenza vaccine annually and that all adults with
diabetes have at least one lifetime pneumococcal vaccination

Follow-up
Plan for review:

The patient's knowledge of the disease, medications, self-monitoring of blood

glucose, and acute and chronic complications, as well as problem-solving skills, should be
assessed initially and then annually; glucose self-monitoring training should be provided as
needed to meet treatment goals, although routine self-monitoring may not be of great value in
patients taking oral hypoglycemic agents and who are not following their food intake

HbA1cshould be measured quarterly if the treatment regimen has changed or if the

patient is not meeting management goals and then every 6 to 12 months if stable. The general
recommended target level of HbA1cfor most nonpregnant adults is <7.0%; however, the target
should be individualized. A more stringent target might be recommended for certain
individual patients, if this can be achieved without significant hypoglycemia or other adverse
effects of treatment. Appropriate patients might include those with short duration of diabetes,
long life expectancy, and no significant CVD. Less stringent HbA1cgoals may be appropriate
for patients with a history of severe hypoglycemia, limited life expectancy, advanced
microvascular or macrovascular complications, extensive comorbid conditions, and those
with long-standing diabetes

The urine albumin-to-creatinine ratio should be obtained to assess for

microalbuminuria at the time of diagnosis and then annually thereafter

Blood lipid levels should be measured at the initial visit and then annually or, in lowrisk individuals, every 2 years

Blood pressure (target: <140/80 mm Hg) should be measured at every visit

The patient's feet should be examined regularly, with a visual inspection at every visit
and annual neurologic examination and measurement of pedal pulses

A dilated retinal examination should be done by a trained expert shortly after

diagnosis and then annually thereafter

A dental examination should be done at least twice yearly

Advice, support, and counseling on smoking cessation should be provided

Screening for psychological or behavioral disorders should be considered

Complications:

Acute complications include diabetic ketoacidosis , hyperosmolar hyperglycemic state,

andhypoglycemia

Diabetes increases the risk of macrovascular atherosclerotic disease, leading to an

increased risk of developing angina , myocardial infarction , stroke , peripheral vascular
disease , and diabetic foot ulcers ; infection and poor healing of lower limb wounds may
necessitate amputation

Microvascular complications include diabetic retinopathy , diabetic nephropathy ,

diabetic neuropathy,Charcot joint , and complications of autonomic dysfunction (eg, erectile
dysfunction )

Diabetes is associated with a marked increase in the risk of premature death from
several cancers, infectious diseases, and degenerative disorders, independent of several major
risk factors

Complications of diabetes in pregnancy include an increased risk

of preeclampsia , spontaneous abortion , polyhydramnios , premature labor , congenital
malformations, macrosomia, cesarean delivery, birth asphyxia, and neonatal respiratory
distress syndrome

Psychological and behavioral complications can result in poor compliance with

therapy

Patient education
Patients should be advised of the following:

Diabetes is characterized by high levels of blood sugar (glucose) and constitutes a

significant public health threat across a broad spectrum of the population

The disease is typically classified as type 1 or type 2 based on the underlying

pathophysiologic process, although it often accompanies certain physiologic states, such as
pregnancy and the so-called 'metabolic syndrome' (high cholesterol, hypertension, obesity,
and hyperglycemia)

Severe complications, including kidney failure, worsening of arteriosclerosis with an

increased risk of heart attack and stroke, and loss of vision, may result if the disease goes
undiagnosed and untreated

Online information for patients

American Academy of Family Physicians: Diabetes Overview

American Diabetes Association:

Living with diabetes

Women's health

Centers for Disease Control and Prevention: Diabetes Public Health Resource

International Diabetes Federation

Mayo Clinic: Diabetes

National Diabetes Education Program

National Diabetes Information Clearinghouse

Resources
References
Guidelines
The ADA has produced the following:

ADA. Standards of medical care in diabetes2013. Diabetes Care. 2013;36:S11-66

ADA. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2013;36:S67-74

Haas L, Maryniuk M, Beck J, et al.; 2012 Standards Revision Task Force. National
standards for diabetes self-management education and support. Diabetes Care.
2013;36:S100-8

International Expert Committee. International Expert Committee report on the role of

the A1C assay in the diagnosis of diabetes. Diabetes Care. 2009;32:132734

ADA. Standards of medical care in diabetes2012 . Diabetes Care. 2012;35:S11-63

Bantle JP, Wylie-Rosett J, Albright AL, et al. Nutrition recommendations and

interventions for diabetes: a position statement of the American Diabetes Association. Diabetes

Care. 2008;31:S61-78

Bax JJ, Young LH, Frye RL, Bonow RO, Steinberg HO, Barrett EJ. Screening for
coronary artery disease in patients with diabetes. Diabetes Care. 2007;30:272936

Sacks DB, Arnold M, Bakris GL, et al. Guidelines and recommendations for laboratory
analysis in the diagnosis and management of diabetes mellitus. Diabetes Care. 2011;34:e61
99

Peters A, Laffel L; American Diabetes Association Transitions Working

Group. Diabetes care for emerging adults: recommendations for transition from pediatric to
adult diabetes care systems.Diabetes Care. 2011;34:247785

Pignone M, Alberts MJ, Colwell JA, et al. Aspirin for primary prevention of
cardiovascular events in people with diabetes. Diabetes Care. 2010;33:13951402

Skyler JS, Bergenstal R, Bonow RO, et al. Intensive glycemic control and the
prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes
trials. Diabetes Care. 2009;32:187-92

The ADA and the AHA have jointly produced the following:

Gardner C, Wylie-Rosett J, Gidding SS, et al. Nonnutritive sweeteners: current use and
health perspectives. Circulation. 2012;126:509-19

The ADA and the American College of Sports Medicine have jointly produced the following:

Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: American College
of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes
Care. 2010;33:e14767
The ADA and the American College of Cardiology Foundation have jointly produced the
following:

Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients with
cardiometabolic risk: consensus statement from the American Diabetes Association and the
American College of Cardiology Foundation. Diabetes Care. 2008;31:81122
The ADA and the European Association for the Study of Diabetes have jointly produced the
following:

Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2
diabetes: a patient-centered approach. Position statement of the American Diabetes
Association and the European Association for the Study of Diabetes. Diabetes Care.

2012;35:136479
The American Association of Clinical Endocrinologists has produced the following:

Garber AJ, Abrahamson MJ, Barzilay JI, et al. American Association of Clinical
Endocrinologists' comprehensive diabetes management algorithm 2013 consensus statement
executive summary . Endocr Pract. 2013;19:536-57

Jellinger PS, Smith DA, Mehta AE, et al; AACE Task Force for Management of
Dyslipidemia and Prevention of Atherosclerosis. American Association of Clinical
Endocrinologists' guidelines for management of dyslipidemia and prevention of
atherosclerosis. Endocr Pract. 2012;18:1-78

The American Dietetic Association has produced the following:

American Dietetic Association. Diabetes type 1 and 2 evidence-based nutrition

practice guideline for adults. Chicago: American Dietetic Association; 2008
The American Academy of Pediatrics has produced the following:

Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2
diabetes mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131:364-82
The American College of Physicians has produced the following:

Qaseem A, Humphrey LL, Sweet DE, Starkey M, Shekelle P. Oral pharmacologic

treatment of type 2 diabetes mellitus: a clinical practice guideline from the American College of
Physicians. Ann Intern Med. 2012;156:218-31

Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P. Use of intensive insulin

therapy for the management of glycemic control in hospitalized patients: a clinical practice
guideline from the American College of Physicians. Ann Intern Med. 2011;154:260-7
The International Diabetes Federation has produced the following:

International Diabetes Foundation. Clinical Guidelines Task Force. Global guideline for
type 2 diabetes . 2012
International Diabetes Foundation. Clinical Guidelines Task Force. Management of
postmeal glucose . 2011

The International Diabetes Federation and International Society for Pediatric and Adolescent
Diabetes have produced the following:

The global International Diabetes Federation/International Society for Pediatric and

Adolescent Diabetes guidelines for diabetes in childhood and adolescence . 2011

Further reading

Polonsky KS. 200th anniversary article: the past 200 years in diabetes. N Engl J Med.
2012;367:1332-40

Zhang X, Gregg EW, Williamson DF, et al. A1C level and future risk of diabetes: a
systematic review. Diabetes Care. 2010;33:166573

Inzucchi SE. Clinical practice: diagnosis of diabetes. N Engl J Med. 2012;367:542-50

Ismail-Beigi F. Clinical practice: glycemic management of type 2 diabetes mellitus. N

Engl J Med. 2012;366:1319-27

Sherwin R, Jastreboff AM. Year in diabetes 2012: the diabetes tsunami. J Clin
Endocrinol Metab. 2012;97:4293-301

Steenkamp DW, Alexanian SM, McDonnell ME. Adult hyperglycemic crisis: a review
and perspective. Curr Diabetes Rep. 2013;13:130-7

Wang CC, Reusch JE. Diabetes and cardiovascular disease: changing the focus from
glycemic control to improving long-term survival. Am J Cardiol. 2012;110:58B-68B

Seaquist ER, Anderson J, Childs B, et al. Hypoglycemia and diabetes: a report of a

workgroup of the American Diabetes Association and the Endocrine Society. J Clin
Endocrinol Metab. 2013;98:1845-59

Garber AJ, Abrahamson MJ, Barzilay JI, et al. AACE comprehensive diabetes
management algorithm 2013. Endocrinol Pract. 2013;19:327-36

Wheeler ML, Dunbar SA, Jaacks LM, et al. Macronutrients, food groups, and eating
patterns in the management of diabetes: a systematic review of the literature, 2010. Diabetes
Care. 2012;35:43445

Danaei G, Finucane MM, Lu Y, et al. National, regional, and global trends in fasting
plasma glucose and diabetes prevalence since 1980: systematic analysis of health
examination surveys and epidemiological studies with 370 country-years and 2.7 million
participants. Lancet. 2011;378:3140

Codes
ICD-9 codes
Diabetes mellitus type 1 (insulin dependent type) (IDDM) (juvenile type):

250.01 Type I diabetes mellitus, not stated as uncontrolled, without mention of

complication

250.03 Type I diabetes mellitus, uncontrolled, without mention of complication

250.11 Type I diabetes mellitus, not stated as uncontrolled, with ketoacidosis

250.13 Type I diabetes mellitus, uncontrolled, with ketoacidosis

250.21 Type I diabetes mellitus, not stated as uncontrolled, with hyperosmolarity

250.23 Type I diabetes mellitus, uncontrolled, with hyperosmolarity

250.31 Type I diabetes mellitus, not stated as uncontrolled, with other coma

250.33 Type I diabetes mellitus, uncontrolled, with other coma

250.41 Type I diabetes mellitus, not stated as uncontrolled, with renal manifestations

250.43 Type I diabetes mellitus, uncontrolled, with renal manifestations

250.51 Type I diabetes mellitus, not stated as uncontrolled, with ophthalmic

manifestations
250.53 Type I diabetes mellitus, uncontrolled, with ophthalmic manifestations
250.61 Type I diabetes mellitus, not stated as uncontrolled, with neurological
manifestations

250.63 Type I diabetes mellitus, uncontrolled, with neurological manifestations

250.71 Type I diabetes mellitus, not stated as uncontrolled, with peripheral circulatory
disorders

250.73 Type I diabetes mellitus, uncontrolled, with peripheral circulatory disorders

250.81 Type I diabetes mellitus, not stated as uncontrolled, with other specified
manifestations

250.83 Type I diabetes mellitus, uncontrolled, with other specified manifestations

250.90 Type I diabetes, not stated as uncontrolled, with unspecified complication

250.92 Type I diabetes mellitus, uncontrolled, with unspecified complication

Diabetes mellitus type II (noninsulin dependent type) (NIDDM) (adult-onset type) or
unspecified type:

250.00 Type II diabetes mellitus or unspecified type, not stated as uncontrolled,

without mention of complication

250.02 Type II diabetes mellitus or unspecified type, uncontrolled, without mention of

complication

250.10 Type II diabetes mellitus or unspecified type, not stated as uncontrolled, with
ketoacidosis

250.12 Type II diabetes mellitus or unspecified type, uncontrolled, with ketoacidosis

250.20 Type II diabetes mellitus or unspecified type, not stated as uncontrolled, with
hyperosmolarity, not stated as uncontrolled

250.22 Type II diabetes mellitus or unspecified type, uncontrolled, with

hyperosmolarity,

250.30 Type II diabetes mellitus or unspecified type, not stated as uncontrolled, with
other coma

250.32 Type II diabetes mellitus or unspecified type, uncontrolled, with other coma

250.40 Type II diabetes mellitus or unspecified type, not stated as uncontrolled, with
renal manifestations

250.42 Type II diabetes mellitus or unspecified type, uncontrolled, with renal

manifestations

250.50 Type II diabetes mellitus or unspecified type, not stated as uncontrolled, with
ophthalmic manifestations

250.52 Type II diabetes mellitus or unspecified type, uncontrolled, with ophthalmic

manifestations

250.60 Type II diabetes mellitus or unspecified type, not stated as uncontrolled, with
neurological manifestations

250.62 Type II diabetes mellitus or unspecified type, uncontrolled, with neurological

manifestations

250.71 Type II diabetes mellitus or unspecified type, not stated as uncontrolled, with
peripheral circulatory disorders

250.73 Type II diabetes mellitus or unspecified type, uncontrolled, with peripheral

circulatory disorders

250.80 Type II diabetes mellitus or unspecified type, not stated as uncontrolled, with
other specified manifestations

250.82 Type II diabetes mellitus or unspecified type, uncontrolled, with other

specified manifestations

250.90 Type II diabetes mellitus or unspecified type, not stated as uncontrolled, with
unspecified complication

250.92 Type II diabetes mellitus or unspecified type, uncontrolled, with unspecified

complication