Diabetes Mellitus

Diagnosis/Definition

Diabetes mellitus is a chronic metabolic disorder with inappropriate hyperglycemia due either to an absolute deficiency of insulin secretion or a reduction in the biologic effectiveness of insulin (or both). Most diabetics are classified into one of two major types depending on the pathogenesis. Type 1 diabetes result from beta cell destruction with total or near total insulin deficiency. Type 2 diabetes results from a combination of insulin resistance and inefficient insulin secretion.

Initial Diagnosis and Management

• Fasting plasma glucose concentration ≥ 126 mg/dl on at least two separate occasions.
• Random glucose ≥ 200 with symptoms of diabetes (i.e. polyuria, polydipsia, rapid unintentional weight loss).
• A glucose ≥ 200 at 2 hours during an oral glucose tolerance test.
• Type 1 patients may present with diabetic ketoacidosis (DKA) and require hospitalization for the institution of insulin therapy and diabetic education.
• Type 2 patients can usually be treated as an outpatient with a step therapy approach, depending on glucose levels at diagnosis.
  Ongoing Management and Objectives
• Glycemic Control: The goals of therapy are individualized but generally efforts are made to bring the average glucose and hemoglobin A1c levels as near to normal as possible without causing an excessive risk of hypoglycemia. Target preprandial glucose readings are 80-140 mg/dl. Target bedtime glucose levels are 100-140 mg/dl.
• Both Type 1 and Type 2 Diabetes: Eye, kidney, foot, lipid and cardiovascular problems are particularly common and require ongoing evaluation and management.
• Follow the VA/DoD Diabetes Mellitus Clinical Practice Guideline.

Indications for Specialty Care Referral

All newly diagnosed diabetics should be referred to the Diabetes Care Center (DCC) for education.

Diabetics who need a refresher course should be referred to the DCC.

Diabetics requiring intensive management (i.e. poorly controlled diabetics and those requiring one-on-one review for fine-tuning of medications, carbohydrate understanding, insulin start-up, pump therapy, and medication adjustment) should be referred to the DCC for case management.

Patients with stable diabetes should be managed by their primary care manager who has an interest and training in the management of diabetic patients. Referral to the Endocrinology Clinic should be for specific problems in diabetes management.

Insulin pump patients will be followed on a routine basis in the Endocrinology Clinic to meet Centers for Medicare & Medicaid Services (CMS) criteria for continued pump management.

Criteria for Return to Primary Care

Patients should return to their primary care provider when:

The specifically requested educational or treatment goals have been achieved.

The patient has reached the point of maximum benefit from the services provided by the Endocrinology Clinic.