From the Guidelines
For a 28-year-old with new-onset diabetes, the initial workup should include fasting plasma glucose, hemoglobin A1C, and antibody testing (GAD65, islet cell, insulin autoantibodies) to distinguish between type 1 and type 2 diabetes, as recommended by the most recent guidelines 1. The initial evaluation should also include C-peptide levels to assess endogenous insulin production, as well as a basic metabolic panel, urinalysis for ketones and protein, and lipid profile.
- The diagnosis of type 1 diabetes versus type 2 diabetes is crucial, as the management strategies differ significantly.
- If type 1 diabetes is confirmed, insulin therapy should be initiated immediately with a basal-bolus regimen, as this approach has been shown to improve glycemic control and reduce the risk of microvascular complications 1.
- For type 2 diabetes, metformin is the preferred initial pharmacologic agent, starting at 500mg daily with meals, gradually increasing to 1000mg twice daily as tolerated, due to its efficacy, safety, and potential cardiovascular benefits 1.
- Lifestyle modifications, including diet changes and regular exercise, are essential for both types of diabetes, and patient education on glucose monitoring, hypoglycemia recognition and management, and sick day rules should be provided.
- Early endocrinology referral is recommended, especially for type 1 diabetes, as young adults with new-onset diabetes require careful evaluation to ensure proper classification and treatment, as highlighted in the latest standards of care in diabetes 1.
From the Research
Appropriate Workup for New-Onset Diabetes Mellitus (DM)
The workup for new-onset diabetes mellitus (DM) in a 28-year-old involves several steps, including:
- Confirming the diagnosis of diabetes or hyperglycemia prior to ordering, dispensing, or administering insulin 2
- Evaluating the patient's symptoms, medical history, and physical examination to determine the type of diabetes (type 1 or type 2) and the appropriate treatment plan
Initial Treatment Options
Initial treatment options for new-onset DM may include:
- Insulin therapy for patients with type 1 diabetes mellitus (T1DM) or those with type 2 diabetes mellitus (T2DM) who have severe hyperglycemia or are symptomatic 2, 3
- Oral antidiabetic medications, such as metformin, for patients with T2DM who have mild to moderate hyperglycemia 4, 5
- Combination therapy with metformin, pioglitazone, and exenatide for patients with new-onset T2DM, which has been shown to be more effective than sequential add-on therapy in achieving glycemic control 4, 5
Role of Insulin Therapy
Insulin therapy may be considered as an initial treatment option for patients with new-onset T2DM who have:
- HbA1c levels >9% 6, 3
- Severe hyperglycemia or symptoms such as polyuria, polydipsia, and weight loss 2, 3
- Failed to achieve glycemic control with oral antidiabetic medications 2, 6
Short-Term Intensive Insulin Therapy
Short-term intensive insulin therapy (STII) may be considered as an option for patients with new-onset T2DM who have HbA1c levels >9%, as it has been shown to: