Type 1 Diabetes Pathophysiology

Type 1 diabetes (T1D) is a chronic autoimmune disorder that occurs in genetically susceptible individuals and that may be precipitated by environmental factors. In a susceptible individual, the immune system is triggered to develop an autoimmune response against altered pancreatic beta cell antigens, or molecules in beta cells that resemble a viral protein.

Diabetes and Cancer

Epidemiologic data have demonstrated significant increases of various cancers in people with obesity and diabetes. Recently, concern has emerged that antihyperglycemic medications may also be associated with an increased prevalence of multiple cancers; however, available data are limited and conflicting.1,2

Screening and Monitoring of Prediabetes

Screening for Prediabetes

AACE recommends that individuals who meet any of the clinical risk criteria noted below should be screened for prediabetes or type 2 diabetes (T2D) (1).

Management of Prediabetes

The primary goal of prediabetes management is to normalize glucose levels and prevent or delay progression to diabetes and associated microvascular complications.

The Burden of Type 1 Diabetes


Overall, type 1 diabetes (T1D) accounts for approximately 5% of diabetes and affects about 20 million individuals worldwide. Among those younger than 20 years of age, T1D accounts for the majority of T1D cases (1,2). The current U.S. prevalence estimate of 1-3 million T1D patients may triple by 2050 due to a rising incidence of T1D (3).

Type 1 Diabetes Diagnosis

Patients with type 1 diabetes (T1D) require exogenous insulin for survival and should be identified as soon as possible to avoid high morbidity due to a delay in insulin treatment.

The Burden of Diabetes


Diabetes affects 9.4% of the population of the United States, or approximately 30.3 million people. Of these, 7.2 million have not been diagnosed. Approximately 90% of all diabetes cases are type 2 diabetes.1

Clinical Presentation of Type 2 Diabetes Mellitus

Risk Factors

The risk factors for the development of both prediabetes and type 2 diabetes mellitus (T2DM) are as follows:1

Diagnosis of Type 2 Diabetes Mellitus

There is a continuum of risk for poor patient outcomes as glucose tolerance progresses from normal to overt type 2 diabetes. AACE-defined glucose tolerance categories are listed in Table 1.1

Table 1. Glucose Testing and Interpretation1


Management of Common Comorbidities of Diabetes

As may be expected with a chronic disease that primarily affects middle-aged and older individuals, type 2 diabetes is usually complicated by other medical conditions.

Identification, Screening, and Diagnosis of Diabetes in Pregnancy

Management of Pregnancy Complicated by Diabetes

Preconception Care

Clinical Evidence for Glucose Control in the Inpatient Setting

Key Points

  • Epidemiologic studies show that glucose control in hospitals is woefully inadequate.

    • Approximately 30% of hospitalized patients have blood glucose values >180 mg/dL.

Mechanisms of Adverse Effects of Hyperglycemia in Acute Illness: A Review of the Basic Science

Key Points

  • Hyperglycemia and insulin regulation play both a direct and indirect role in the cellular mechanisms underlying inflammation and oxidative stress.

  • Free fatty acids generated by hyperglycemia and insulin deficiency also result in endothelial dysfunction and the generation of reactive oxygen species.

Financial Impact of Inpatient Glycemic Control: Opportunities for Clinical and Financial Improvement

Key Points

  • Diabetes is an increasingly prevalent diagnosis among hospitalized patients.

    • Many patients have unrecognized diabetes.

  • Diabetes contributes to greater lengths of stay and increased costs among hospitalized patients.

  • Identifying and treating diabetes:

Management of Hyperglycemia in the Critical Care Setting

Key Points

  • Hyperglycemia is common in critically ill patients, both with and without diabetes.

  • Hyperglycemia is a predictor of adverse outcomes, including mortality.

Management of Hyperglycemia in the Noncritical Care Setting

Key Points

  • Hyperglycemia is associated with poor outcomes in noncritically ill patients.

  • Glycemic goals for noncritically ill patients

    • Premeal blood glucose: <140 mg/dL

    • Random blood glucose: <180 mg/dL

Diagnosis and Management of Hyperglycemic Crises: Diabetic Ketoacidosis and the Hyperglycemic Hyperosmolar State

Key Points

  • DKA and HHS are life-threatening emergencies.

  • Management involves

    • Attention to precipitating cause

    • Fluid and electrolyte management

    • Insulin therapy

    • Patient monitoring

    • Prevention of metabolic complications during recovery

Management of Inpatient Hyperglycemia in Special Populations

Hyperglycemia is associated with adverse clinical outcomes in the hospital setting, both in critically ill and noncritically ill patients.

Avoiding Hypoglycemia in the Hospital Setting

Key Points

  • Various patient- and provider-specific factors may increase the risk of inpatient hypoglycemia

Safety Concerns With Insulin Use in the Inpatient Setting: The Pharmacist’s Role

Key Points

  • Insulin is the most appropriate agent for the majority of hospitalized patients.

  • Insulin is a “high-alert medication.”

Role of Nursing in the Continuum of Inpatient Diabetes Care

Key Points

  • Nurses are essential—and central—to successful implementation of protocols, order sets, glucose monitoring, and educational programs to support improved glycemic control.

Glycemic Control During Labor and Delivery

Key Points

  • The last 18 hours in utero have a significant impact on the infant’s metabolic responses after birth, even if maternal glucose control is adequate over the duration of gestation.

Protocols and Order Sets

The order sets provided here are only a few examples from institutions involved in the management of inpatient hyperglycemia; this is not an all-inclusive list. Posting of these protocols does not constitute endorsement of any specific protocol. We believe that each institution should consult with diabetes experts to select and implement insulin protocols.

Successful Models of Implementation

Key Points

  • Hyperglycemia in the hospital affects quality of care, patient safety, length of stay, and cost; hence, addressing hyperglycemia in hospitalized patients can unite professionals in a common quest.

  • Models for implementation of improved control of hyperglycemia include:

Glucometrics: Assessing Quality in Inpatient Glycemic Management

Glucometrics is a way to measure the success of inpatient glucose management. Getting timely and accurate metrics to frontline clinical teams, which can analyze the results and look for cause and effect, will transform performance improvement into optimal outcomes.

Strategies for Effective Discharge Planning for Hospitalized Patients With Diabetes

Key Points

  • Upon admission (or as soon thereafter as possible), every patient’s need for diabetes education should be assessed.

  • During hospital stay, all patients with diabetes should receive necessary training in diabetes knowledge and self-care skills.

Type 2 Diabetes Glucose Management Goals

Optimal management of type 2 diabetes requires treatment of the “ABCs” of diabetes: A1C, blood pressure, and cholesterol (ie, dyslipidemia).

Treatment of Type 1 Diabetes


The treatment goals for patients with type 1 diabetes (T1D) are the same as those for patients with type 2 diabetes (T2D), as outlined in Table 1 (1).

Table 1. Glucose goals for patients with diabetes (1).

Team Approach to Type 2 Diabetes Management

Comprehensive care of patients with diabetes requires a team of healthcare professionals. Working with different healthcare providers allows the patient to learn in-depth information regarding their health and well-being. It also ensures that the patient’s needs are cared for and addressed.