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Type 2 Diabetes Mellitus Differential Diagnoses

  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
 
Updated: Jul 07, 2016
 
 

Diagnostic Considerations

Correctly determining whether a patient has type 1 or type 2 diabetes is important because patients with type 1 diabetes require continuous exogenous insulin for survival. In contrast, treatment of type 2 diabetes consists of lifestyle measures and a variety of other medications, with insulin introduced if those prove inadequate.

As previously stated, patients with type 2 diabetes mellitus can usually be differentiated from those with type 1 disease on the basis of history and physical examination findings and through simple laboratory tests. Patients with type 2 diabetes are generally obese, and may have acanthosis nigricans and/or hirsutism in conjunction with thick necks and chubby cheeks.

A patient whose diabetes has been controlled with diet or an oral antidiabetic agent for longer than several months generally has type 2 diabetes. A lean patient who has had diabetes since childhood, who has always been dependent on insulin, or who has a history of diabetic ketoacidosis (DKA) almost certainly has type 1 diabetes.

When dealing with patients with known diabetes in the emergency department, distinguishing the type of diabetes can be difficult in 2 groups: (1) patients who are treated with insulin and are young but clinically appear to have type 2 diabetes, and (2) older patients with late-onset of diabetes who nonetheless take insulin and seem to share characteristics of patients with type 1 diabetes. (This latter group is now said to have latent autoimmune diabetes of the adult [LADA]).

When in doubt, the emergency department patient should be treated with insulin and his or her glucose levels should be closely monitored. Some adolescents or young adults, mostly Hispanic or African American patients, who present with classic DKA are subsequently found to have type 2 diabetes.

Prediabetes

Prediabetes often precedes overt type 2 diabetes. Prediabetes is defined by a fasting blood glucose level of 100-125 mg/dL or a 2-hour post-oral glucose tolerance test (post-OGTT) glucose level of 140-200 mg/dL. Persons with prediabetes are at increased risk for macrovascular disease, as well as diabetes.[1]

Often confused with prediabetes is the metabolic syndrome (also called syndrome X or the insulin-resistance syndrome). Metabolic syndrome, thought to be due to insulin resistance, can occur in patients with overtly normal glucose tolerance, prediabetes, or diabetes. It is diagnosed when a patient has at least 3 of the following 5 conditions:

  • Abdominal obesity
  • Elevated triglyceride level
  • Low level of high-density lipoprotein (HDL) cholesterol
  • Elevated blood pressure
  • Fasting glucose value of 100 mg/dL or higher

Eventually, clinically apparent insulin resistance develops. Unfortunately, insulin resistance is not possible to measure clinically, except in research settings. An elevated fasting blood glucose or triglyceride level may be the first indication of insulin resistance. Fasting insulin levels are generally increased at an earlier stage, but they are more directly related to insulin clearance than to insulin resistance. An effort to standardize insulin assays is under way and may allow for the use of fasting insulin levels to diagnose insulin resistance in the future.

 
 
Contributor Information and Disclosures
Author

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy ofSciences,and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

William L Isley, MD Senior Associate Consultant, Associate Professor of Medicine, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic of Rochester

William L Isley, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Kenneth Patrick L Ligaray, MD Fellow, Department of Endocrinology, Diabetes and Metabolism, St Louis University School of Medicine

Kenneth Patrick Ligaray, MD is a member of the following medical societies: American Association of Clinical Endocrinologists and Endocrine Society

Disclosure: Nothing to disclose.

Anne L Peters, MD, CDE Director of Clinical Diabetes Programs, Professor, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California, Los Angeles County/University of Southern California Medical Center

Anne L Peters, MD, CDE is a member of the following medical societies: American College of Physicians and American Diabetes Association

Disclosure: Amylin Honoraria Speaking and teaching; AstraZeneca Consulting fee Consulting; Lilly Consulting fee Consulting; Takeda Consulting fee Consulting; Bristol Myers Squibb Honoraria Speaking and teaching; NovoNordisk Consulting fee Consulting; Medtronic Minimed Consulting fee Consulting; Dexcom Honoraria Speaking and teaching; Roche Honoraria Speaking and teaching

David S Schade, MD Chief, Division of Endocrinology and Metabolism, Professor, Department of Internal Medicine, University of New Mexico School of Medicine and Health Sciences Center

David S Schade, MD is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, New Mexico Medical Society, New York Academy of Sciences, and Society for Experimental Biology and Medicine

Disclosure: Nothing to disclose.

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Scott R Votey, MD Director of Emergency Medicine Residency, Ronald Reagan UCLA Medical Center; Professor of Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine

Scott R Votey, MD is a member of the following medical societies: Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Simplified scheme for the pathophysiology of type 2 diabetes mellitus.
Prevalence of type 2 diabetes mellitus in various racial and ethnic groups in the United States (2007-2009 data).
Prevalence of diabetes mellitus type 2 by age in the United States (2007 estimates).
Possible physical examination findings in patients with type 2 diabetes mellitus.
Diagnostic criteria (American Diabetes Association) for diabetes mellitus type 2.
Major findings from the primary glucose study in the United Kingdom Prospective Diabetes Study (UKPDS).
Results from metformin substudy in the United Kingdom Prospective Diabetes Study (UKPDS).
Findings from the blood pressure substudy in the United Kingdom Prospective Diabetes Study (UKPDS).
Laboratory monitoring guidelines for patients with type 2 diabetes mellitus.
American Diabetes Association guidelines for low-density lipoprotein cholesterol in diabetes mellitus type 2.
Treatment of type 2 diabetes mellitus.
Types of insulin. Premixed insulins can be assumed to have a combination of the onset, peak, and duration of the individual components.
Simplified scheme for using insulin in treating patients with type 2 diabetes mellitus.
Simplified scheme of idealized blood glucose values and multiple dose insulin therapy in type 2 diabetes mellitus.
 
 
 
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