What is the appropriate management for a 14-year-old male patient presenting with hyperglycemia, polyuria, polydipsia, nocturia, weight loss, and blurred vision, with laboratory results indicating diabetic ketoacidosis and a positive test for anti-GAD antibodies?

Ang pasyenteng ito ay may Type 1 Diabetes Mellitus na may diabetic ketoacidosis at kailangang tratuhin ng intravenous o subcutaneous insulin hanggang maresolba ang acidosis, pagkatapos ay magpatuloy ng multiple daily injection insulin therapy tulad ng ginagawa sa Type 1 diabetes—hindi dapat bigyan ng metformin dahil ang positive anti-GAD antibodies ay nagpapahiwatig ng autoimmune beta cell destruction.

Diagnosis: Type 1 Diabetes Mellitus (hindi Type 2)

Ang positive anti-GAD antibodies, mababang C-peptide (<0.3 ng/ml), at presentation na may DKA ay definitively nagpapahiwatig ng autoimmune Type 1 diabetes, kahit na ang edad at BMI ay maaaring magmukha ng Type 2. 1

Key Diagnostic Features:

• Positive anti-GAD antibodies = autoimmune beta cell destruction 1
• Very low C-peptide (<0.3 ng/ml) = minimal to absent insulin production 1
• Diabetic ketoacidosis (pH 7.28, HCO₃ 15 mEq/L, serum ketones +++, urine ketones +++) 1
• Severe hyperglycemia (FPG 290 mg/dL, HbA1c 11%) 1

Immediate Management: DKA Treatment

Magsimula ng insulin therapy kaagad upang mabilis na itama ang hyperglycemia at metabolic derangement. 1

DKA Protocol:

• Intravenous insulin infusion hanggang maresolba ang acidosis (pH >7.3, HCO₃ >15 mEq/L, anion gap normal) 1
  • Alternative: Subcutaneous rapid-acting insulin every 2 hours kung mild-to-moderate DKA at walang hemodynamic instability 1
• Fluid resuscitation para sa dehydration 1
• Potassium monitoring at replacement dahil hypokalaemia ay common (50%) at severe hypokalaemia (<2.5 mEq/L) ay associated sa increased mortality 1
• Monitor blood glucose every 1-2 hours habang nasa IV insulin 1

Critical Pitfall:

Huwag magbigay ng metformin sa pasyenteng ito. Ang positive pancreatic autoantibodies ay nangangahulugang ito ay Type 1 diabetes, at ang guideline ay malinaw: "Continue or initiate MDI insulin or pump therapy, as for type 1 diabetes. Discontinue metformin." 1

Long-Term Management: Multiple Daily Injection (MDI) Insulin Regimen

Pagkatapos maresolba ang DKA, transition sa subcutaneous basal-bolus insulin regimen na ginagamit para sa Type 1 diabetes. 1

Insulin Regimen Structure:

• Basal insulin (long-acting): Magsimula sa 0.5 units/kg/day, titrate every 2-3 days based on blood glucose monitoring 1
• Prandial insulin (rapid-acting): Bigyan bago kumain para sa meal coverage 1
• Correction insulin: Para sa elevated blood glucose readings 1
• Total daily dose: Maaaring umabot ng >1 unit/kg/day depende sa pangangailangan 1

Transition from IV to Subcutaneous:

Kapag stable na (normal anion gap, resolved acidosis, hemodynamically stable), estimate ang subcutaneous insulin requirement mula sa average ng IV insulin infusion rate sa nakaraang 12 hours. Halimbawa: kung 1.5 units/hour average = 36 units/24 hours total daily dose. 1

Multidisciplinary Team Approach

Kailangan ng diabetes team na may physician, diabetes care and education specialist, registered dietitian nutritionist, at psychologist o social worker. 1

Essential Components:

• Diabetes self-management education tungkol sa glucose monitoring, insulin administration, carbohydrate counting, hypoglycemia recognition 1
• Blood glucose monitoring 4-6 times daily (pre-meals at bedtime) 1
• Consider continuous glucose monitoring (CGM) para sa better glycemic control 1
• Lifestyle management: nutrition therapy, physical activity 1

Glycemic Targets

Target A1C <7% para sa pediatric Type 1 diabetes (mas mababa kaysa sa Type 2 diabetes dahil sa mas mataas na risk ng microvascular complications sa long-term) 1

Blood Glucose Goals:

• Pre-meal: <7.8 mmol/L (140 mg/dL) 1
• Random: <10.0 mmol/L (180 mg/dL) 1
• Individualize based on hypoglycemia risk 1

Monitoring for Complications

Short-term:

• Hypoglycemia: Turuan ang pasyente at pamilya ng signs/symptoms at treatment 1
• Recurrent DKA: Monitor para sa infection, insulin non-compliance 1

Long-term:

• Microvascular complications: Annual screening para sa retinopathy, nephropathy, neuropathy 1
• Cardiovascular risk factors: Monitor blood pressure, lipids 1
• Thyroid function: Dahil sa history ng recent viral URI at autoimmune diabetes, consider screening para sa other autoimmune conditions 2

Why NOT Metformin or Type 2 Diabetes Treatment?

Ang algorithm ay malinaw: kung positive ang pancreatic autoantibodies, ito ay Type 1 diabetes at dapat tratuhin accordingly. 1

Evidence Against Type 2 Treatment:

• Positive anti-GAD = autoimmune beta cell destruction, hindi insulin resistance 1, 3, 2
• Very low C-peptide = walang significant endogenous insulin production 1
• Metformin ay para sa Type 2 diabetes na may preserved beta cell function 1
• Ang guideline explicitly states: "Discontinue metformin" kung positive ang autoantibodies 1

Common Pitfall:

Huwag malito sa presentation—kahit na ang edad (14 years old) at BMI (19 kg/m²) ay pwedeng Type 2, ang positive anti-GAD antibodies ay definitive para sa Type 1 diabetes. Ang LADA (Latent Autoimmune Diabetes in Adults) ay maaaring mag-present na may DKA kahit na adult age, at ang pediatric Type 1 ay maaaring mag-present na may normal BMI. 3, 2