What is the appropriate diagnosis and treatment for a 12-year-old female patient presenting with morning tachycardia (elevated heart rate), dizziness, hyperglycemia (elevated blood glucose), elevated liver enzymes, hyperuricemia (elevated uric acid), normal c-peptide levels, and hyperlipidemia (elevated lipids)?

Diagnosis: Type 2 Diabetes Mellitus with Severe Hyperglycemia and Metabolic Syndrome

This 12-year-old requires immediate dual therapy with basal insulin (0.5 units/kg/day) plus metformin (500 mg twice daily with meals), given the severe hyperglycemia (blood glucose 20-30 mmol/L or approximately 360-540 mg/dL) with symptomatic presentation (tachycardia, dizziness). 1, 2

Diagnostic Reasoning

The clinical presentation strongly indicates type 2 diabetes mellitus rather than type 1 diabetes based on:

• Normal C-peptide levels indicate preserved pancreatic beta-cell function and endogenous insulin production, distinguishing this from type 1 diabetes where C-peptide would be low or absent 1
• Metabolic syndrome features including hyperlipidemia, elevated liver enzymes, and hyperuricemia are characteristic of insulin resistance-driven type 2 diabetes 1, 3
• Severe hyperglycemia with symptoms (tachycardia and dizziness from marked hyperglycemia) without mention of ketoacidosis suggests type 2 diabetes with decompensation 1

Critical diagnostic step: Check for ketosis/ketoacidosis immediately with urine ketones, serum bicarbonate, and pH to rule out diabetic ketoacidosis, as approximately 6% of youth with type 2 diabetes present with DKA 1, 4. If ketoacidosis is present, this requires intravenous insulin until acidosis resolves before transitioning to subcutaneous insulin plus metformin 1, 4.

Immediate Treatment Protocol

Initial Pharmacologic Management

Basal insulin initiation:

• Start at 0.5 units/kg/day subcutaneously, given once daily (typically at bedtime) 2
• Titrate every 2-3 days based on fasting blood glucose monitoring 2
• Target fasting glucose 90-130 mg/dL (5.0-7.2 mmol/L) 1

Concurrent metformin initiation:

• Start 500 mg orally twice daily with meals 2
• Increase to 1000 mg twice daily (maximum effective dose 2000 mg/day) over 2-4 weeks as gastrointestinal tolerance allows 1, 2
• Verify normal renal function before starting - metformin is contraindicated if eGFR <30 mL/min/1.73 m² and should not be initiated if eGFR <45 mL/min/1.73 m² 5

Rationale for Dual Therapy

The American Diabetes Association guidelines specify that youth with blood glucose ≥250 mg/dL (13.9 mmol/L) and symptomatic hyperglycemia require initial basal insulin therapy while metformin is simultaneously initiated and titrated 1. This patient's blood glucose of 20-30 mmol/L (360-540 mg/dL) with symptoms (tachycardia, dizziness) clearly meets these criteria 1, 2.

Metformin monotherapy would be insufficient for this degree of hyperglycemia and would prolong poor glycemic control, increasing risk of complications 2.

Insulin Tapering Strategy

Once glycemic targets are achieved (typically 2-6 weeks):

• Monitor home blood glucose 4 times daily (fasting and before meals) 1
• When fasting glucose consistently 90-130 mg/dL, begin tapering insulin by 10-30% every few days 1, 4
• Continue metformin throughout taper and indefinitely 1, 4
• If A1C remains <7% (53 mmol/mol) on metformin alone, insulin can be discontinued 1, 4

Management of Associated Metabolic Abnormalities

Hyperlipidemia Management

Lifestyle intervention first:

• Weight reduction of 7-10% excess weight through comprehensive lifestyle program 1
• Fat-, cholesterol-, and simple carbohydrate-restricted diet 1
• 30-60 minutes moderate-to-vigorous physical activity at least 5 days per week 1

Pharmacologic lipid management:

• If lifestyle modifications plus improved glycemic control fail to normalize lipids, consider statin therapy 1
• Critical contraindication: Statins are absolutely contraindicated in females of childbearing potential unless highly effective contraception is used and extensive counseling provided 1
• For this 12-year-old, defer statin therapy until after puberty and reassess lipids after achieving glycemic control and weight reduction 1

Elevated Liver Enzymes

• Likely represents non-alcoholic fatty liver disease (NAFLD) associated with insulin resistance 1, 3
• Weight reduction and improved glycemic control typically improve transaminases 1, 3
• Monitor liver enzymes every 3 months initially 1

Hyperuricemia

• Associated with insulin resistance and metabolic syndrome 1, 6
• Usually improves with weight loss and improved glycemic control 1
• No specific uric acid-lowering therapy indicated unless symptomatic gout develops 6

Monitoring Protocol

Initial phase (first 3 months):

• Home blood glucose monitoring 4 times daily (fasting and before meals) 1
• Weekly phone contact to adjust insulin doses 1
• A1C measurement every 3 months 1, 4
• Liver enzymes, lipid panel, uric acid every 3 months 1

Target A1C: <7% (53 mmol/mol) for most youth with type 2 diabetes on oral agents, with consideration of <6.5% (48 mmol/mol) if achievable without hypoglycemia 1, 4

Critical Pitfalls to Avoid

Do not use metformin monotherapy in patients with blood glucose ≥250 mg/dL or symptomatic hyperglycemia - this delays adequate glycemic control and increases complication risk 2

Do not delay insulin therapy while attempting lifestyle modification alone in severely hyperglycemic patients - immediate pharmacologic intervention is mandatory 1, 2

Do not miss ketoacidosis - always check for ketones in patients with marked hyperglycemia, as treatment algorithm differs significantly if DKA is present 1, 4

Do not start metformin without verifying renal function - the low muscle mass in children can result in falsely reassuring creatinine levels despite impaired renal function 5

Do not prescribe statins to adolescent females without addressing contraception and providing extensive counseling about teratogenicity 1

Monitor for vitamin B12 deficiency with long-term metformin use, as this is a common overlooked complication 2

Comprehensive Diabetes Education

Provide immediate diabetes self-management education covering:

• Blood glucose monitoring technique and interpretation 1
• Insulin injection technique and storage 1
• Recognition and treatment of hypoglycemia 1
• Sick day management 1
• Nutritional counseling focusing on reduced simple carbohydrates and increased fruits/vegetables 1
• Physical activity goals 1

This education should be developmentally appropriate, culturally competent, and involve the entire family 1.