Diabetes without Ketoacidosis (new onset Type 1 Diabetes)
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Treatment guideline for newly diagnosed diabetics who present without ketoacidosis. For patients with ketoacidosis see diabetic ketoacidosis guideline
Diabetes mellitus (ADA criteria) is the presence of symptoms (polyuria, polydipsia, weight loss) and a random plasma glucose concentration >11.1 mmol/L: due to an absolute/relative deficiency of insulin. If acidotic do not use this guide, see DKA guideline
- The majority of newly diagnosed Type 1 Diabetes Mellitus are quite well, and present without ketoacidosis (pH is >7.3 and HCO3 is normal), they are only mildly dehydrated, though may have had a lot of weight loss, they are not vomiting or systemically unwell).
- They often have a trace or more of urinary ketones, but are not acidotic.
- This is not a medical emergency BUT insulin therapy needs to be instituted to prevent decompensation to DKA.
- Type 1 diabetes can present in any racial group and independent of BMI, so obese children are still most likely to have type 1 diabetes.
Differential Diagnosis includes:
- Stress induced hyperglycaemia
- Type 2 Diabetes Mellitus
- Other: see Classification of Diabetes Mellitus below
(Risk factors for type 2 Diabetes include: BMI >+4 SD, Acanthosis nigricans, Family history of Type 2 diabetes, History of Gestational diabetes in mother and being of a High risk ethnic group- Maori, Pacific Island or Asian. If symptomatic then will normally be started on insulin, discuss with on call endocrinologist).
Laboratory Values for New Diabetics without Ketoacidosis.
- Blood glucose >11 mmol/l
- Severe Ketoacidosis not present (pH>7.25, HCO3 >15 mmol/l)
- Ketonuria usually present.
Marked hyperglycaemia may require individualized therapy even if not in DKA (Blood Glucose >40 mmol/l), discuss all cases with Endocrinologist on call.
Essential for all cases:
- Blood glucose, urea, electrolytes, LFT
- Capillary or venous blood gas (arterial blood gas rarely required)
- Urine - ketones, glucose and routine culture
- HbA1c (measure of 3 months glycaemia) - must be in purple top tube
- Pre type 1 diabetes antibodies (GAD & IA2) - plain tube. Write 'pre-type 1 diabetes'.
- Random blood lipids, TFTs, thyroid autoantibodies and coeliac antibodies.
- Check for precipitating cause eg. infection (urine, FBC, blood cultures; consider CXR).
- Paired glucose/insulin level plus C-peptide if considering Type 2 diabetes
Principles of Management
- To stabilise blood sugar and institute appropriate education for the family.
- All patients are initially admitted to stabilise and to start education. They will have a 3-5 day admission.
- Further education is then at the Greenlane Clinical Centre (GCC) diabetes centre over the ensuing weeks.
- Most are managed with insulin by a syringe (mixing long and short) 2-3 times daily, or by insulin pens. Insulin pumps are not started during this phase of diabetes.
Management for Type 1 Diabetes (no ketoacidosis)
Please discuss with Paediatric Endocrinologist on call before starting insulin
Aim to start subcutaneous insulin before next meal if well.
Estimate total daily requirement of insulin (guide only).
Pre pubertal: 0.8 Units/kg/24 hours (may vary if minimal symptoms and mild hyperglycaemia)
Pubertal: up to 1 - 1.5 Units/kg/24 hours
- 1/3 Fast acting insulin ( Novorapid or Actrapid)
- 2/3 long acting insulin ( Protaphane)
- 2/3 Total daily dose given before breakfast
- 1/3 Total daily dose given before dinner
In the initial stages of treatment additional short acting insulin may be given as a sliding scale.
The majority can be managed with oral fluids.
Blood glucose monitoring before meals and 4 hourly overnight (if ketotic), with sliding scale if appropriate (normally reduced to 4x day and once overnight when stable, checking for hypoglycaemia).
Diabetes Care 2004, 27 Suppl:S5
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- Date last published: 26 January 2017
- Document type: Clinical Guideline
- Services responsible: Paediatric Endocrinology
- Author(s): Craig Jefferies
- Editor: Greg Williams
- Review frequency: 2 years
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