Diabetes Management

ADA 2024 · EASD 2022 · NICE NG28 · IDF Atlas 2021

537M
Adults with diabetes globally
33M
Estimated in Pakistan (2024)
50%
Undiagnosed worldwide
1.5M
Deaths attributed annually

Diabetes: A Comorbidity-Driven Treatment Era

The ADA/EASD 2022 paradigm shift: stop choosing drugs based only on HbA1c — choose based on comorbidities. Established CVD → GLP-1 RA or SGLT2i. CKD or HF → SGLT2i first. Obesity → GLP-1 RA. This patient-centred approach has revolutionised outcomes.

CV Death ↓26% (EMPA-REG)HHF ↓35% (DAPA-HF)CKD Progression ↓ (CREDENCE)Weight ↓15% (STEP)

Correct classification is critical — wrong diagnosis leads to wrong treatment. T1DM misdiagnosed as T2DM can be fatal.

Type 1 Diabetes (T1DM)Typically <30 years (can be any age)

Autoimmune destruction of pancreatic β-cells → absolute insulin deficiency

Key Features

  • Abrupt onset, often with DKA
  • Low/undetectable C-peptide
  • Positive islet autoantibodies (GAD, IA-2)
  • BMI usually normal or low
  • Always requires insulin

Lab Workup

GAD65 Ab, IA-2 Ab, ZnT8 Ab, Fasting C-peptide (<0.2 nmol/L)

Type 2 Diabetes (T2DM)Usually >40 years (increasingly younger due to obesity)

Insulin resistance + progressive β-cell dysfunction → relative insulin deficiency

Key Features

  • Gradual insidious onset
  • Often incidentally detected
  • Strong family history
  • Associated with obesity/metabolic syndrome
  • May be managed without insulin initially

Lab Workup

FBG, HbA1c, Lipids, ALT, eGFR, UACR

Gestational Diabetes (GDM)2nd–3rd trimester of pregnancy

Placental hormones cause insulin resistance; β-cell compensation insufficient

Key Features

  • Screen all at 24–28 weeks (75g OGTT)
  • Risk: obesity, prior GDM, PCOS, family history
  • Macrosomia, stillbirth, pre-eclampsia risk
  • 50% develop T2DM within 10 years
  • Treat with diet → Metformin → Insulin

Lab Workup

75g OGTT: FBG ≥5.1, 1-hr ≥10.0, 2-hr ≥8.5 mmol/L (WHO criteria)

MODY (Monogenic)Usually <25 years, autosomal dominant

Single gene mutations affecting β-cell function (MODY 1–6)

Key Features

  • Strong family history (3 generations)
  • Negative islet antibodies
  • Normal C-peptide
  • MODY2 (GCK): mild stable hyperglycemia, no treatment needed
  • MODY3 (HNF1A): responsive to sulfonylurea

Lab Workup

Genetic testing for GCK, HNF1A, HNF4A mutations

Hypertension

BP management module

Algorithms

Clinical decision flowcharts

Lab Reference

HbA1c, glucose, renal panels

Drug Database

Full dosing reference

Based on ADA Standards of Care 2024, EASD/ADA Consensus 2022, NICE NG28, IDF Guidelines. Always individualise management. Refer complex cases.