Exclusive series: 'Difficult diabetes- The diagnosis is important': Dr. Sanjay Kalra
M3 India Newsdesk Aug 20, 2020
Dr. Sanjay Kalra in his first article- part of a new exclusive series for M3 India, shares key practice points and treatment approaches for differential diagnosis of diabetes in adults, children, and adolescents.
Diabetes can be a difficult disease to manage. The vast spectrum of clinical presentations and aetio-pathophysiologic mechanisms, coupled with an ever-increasing array of investigations and treatment modalities, make diabetes care a daunting task.
Good clinical sense
Diabetes management, however, is a fulfilling career. Once we understand the basics of aetio-pathogenesis, and pharmacotherapeutics, it becomes easy to manage the varied presentations of diabetes, its complications and comorbidities. Good clinical sense encourages a systematic approach to patient care: history taking and physical examination, leading to a provisional diagnosis, followed by pragmatic prescription and rational interpretation of investigations. Such a system is followed in acute care, and should not be missed in Diabetology.
A person presenting with uncontrolled diabetes should be evaluated and assessed before being prescribed glucose-lowering medication in a knee jerk reaction. The cause (type) of diabetes, cause of poor control, barriers to good control (both past and present), and facilitators or motivators for good control (present and future) must be explored while planning treatment. The goal or target that is appropriate for a particular patient, the strategy or technique to achieve it, and the drugs or tools that should be preferred, will be based upon this information.
Diagnosis of type of diabetes
Many medical students view diabetes classification as a binary construct, assuming that all adult diabetes is type 2, and childhood diabetes, type 1. This heuristic is simplistic, and misclassification may lead to inappropriate therapy. While type 2 diabetes is certainly the most common of dysglycaemia in adults, there are other forms of diabetes as well.
LADA (late inset autoimmune diabetes of adults) is an autoimmune disorder which may respond to oral glucose lowering drugs for some time. Within a relatively short period, however, glucose control deteriorates. This is because of premature destruction of beta cell. In northwest India, we have observed the persons with LADA are relatively leaner, fair complexioned, less hirsute, with light coloured skin and eyes. They may exhibit stigmata of autoimmune disease such as goitre, skin rash vitiligo and arthritis. Insulin is the drug of choice, and either premixed or basal bolus regimens may be used.
Pancreatic diabetes presents with a history of severe abdominal pain in the past. Such episodes may be repeated. Imaging of the abdomen may reveal calcification. Symptoms of malabsorption, and signs of malnutrition can be seen. Diabetes control is achieved with small frequent doses of insulin, administered as a subcutaneous basal bolus regimen. Pancreatic diabetes is characterised by destruction of both alpha and beta cells, and this may predispose the patient to hypoglycaemia. Modern analogues, therefore, are the preferred preparation of insulin.
Glucocorticoid-induced diabetes is becoming more and more frequent in practice. Such patients usually exhibit a glycaemic peak post-lunch or pre-dinner based upon the duration of action and dose of the glucocorticoid being taken. Insulin sensitisers such as metformin can be used in relatively higher doses. Pioglitazone or/and SGLT2I inhibitors may be added provided they are well tolerated. Premixed insulin, prescribed twice daily with breakfast and dinner, usually does not suffice. A basal bolus regimen, or a three-dose regimen of rapid-rapid-premixed coformulation is more effective in such cases.
Diabetes associated with obesity presents a special challenge. On one hand, high doses of insulin are required to counteract insulin resistance. At the same time, over-insulinisation may promote weight gain. Use of moderate doses of insulin, coupled with strict lifestyle modification, GLP1RA, SGLT2i, and metformin helps in achieving good glucose control with weight loss or minimal weight gain. The patient may be started on medical grade formula MNT (medical nutrition therapy), as meal/snack replacement, to assist in weight loss.
Diabetes in children and adolescents
Children and adolescents with diabetes may also pose a diagnostic and therapeutic challenge.
- Monogenic diabetes and type 2 diabetes are differential diagnosis of type 1 diabetes, and should be identified
- Neonatal diabetes (which presents in infancy) may be treated with secretagogues
- MODY (maturity onset diabetes of young) is usually characterised by a relatively milder course and usually presents in early adulthood, with ‘mild’ hyperglycaemia and a strong family history of early onset diabetes
- Type 2 diabetes in children and adolescents is characterised by evidence of stigmata of insulin resistance, including obesity, central obesity, acanthosis nigricans, and xanthelasmae
It may be difficult to pinpoint the type of diabetes in one clinical consultation. In such cases, it is prudent to inform the child and family that the diagnosis will become clear after longitudinal follow up. The choice of insulin or non-insulin therapy should be based on the metabolic status. While a stable adolescent may be prescribed GLP1RA or metformin, a patient with evidence of ketosis, or at risk of ketosis, should be prescribed insulin.
Disclaimer- The views and opinions expressed in the article and videos are those of the speakers and do not necessarily reflect the official policy or position of M3 India.
The author, Dr. Sanjay Kalra is a leading Endocrinologist and the current President of the Endocrine Society of India.
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