56FMigraine,Insomnia,Hypothyroidism 2000,Diabetes2018,Vertigo tinnitus 2019 Telangana PaJR.html.
August 12 2024
This is an online E Log book to discuss our patients de-identified health data shared after taking her signed informed consent. Here we discuss our patients problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
To begin with the 56yr old is a homemaker suffering from migraine since 28yrs. For 2yrs she did not know that it was migraine. But after proper consultation she was confirmed migraine and was prescribed Flunarin10mg daily before dinner and Zerodol p 500mg for pain. At first the patient was intolerant to milk products, some dry fruits like almond, cashew etc. She had triggers with loud noises, sunlight, going out after taking headbath, untimely food, sleep etc. Oversleep and disturbed sleep also caused headache. Later the neurologist changed the medicine Flunarin to Migranyl and Naprodom500 for pain. Meanwhile she tried Ayurveda and homeo also. But only temporary relief. She did not use Migranyl for much time as it was very powerful and caused discomfort. The physician prescribed Sibelium 10mg. 6yrs back the physician replaced sibelium with Amytriptyline 10mg. 3yrs back she was advised Betacap TR 60. After using this medicine the severity, frequency and intolerance to milk products and dry fruits has reduced. Now the patient is having mild headaches which are controlled with Dolo 650. Later in 2018 she was diagnosed with Diabetes for which she is taking Metformin SR 500mg. Her HBA1C is 6.1 and FS and PLBS are in control. In 2019 she had vertigo tinnitus and was asked by the ENT to reduce salt intake and not to get stressed. Due to stress she suffered insomnia also.
The PHR Patient journey record pajr transcripts below reflect the therapeutic uncertainties around the patient and their resolution through team based learning.
12-08-2024
PAJR PHR MODERATOR- Very well shared history of28yrs. Can you share if there have been any changes to the daily hourly routine of this patient from 28yrs because of her headache? When was the last episode the patient experienced? At what time of the day did it start on that day? What activity was she doing at that time and did the headache make her forced to stop all her activities for that day?
PATIENT ADVOCATE- Definitely it has affected her daily routine. She took painkillers. The last episode was 2 days back. It started in the morning at 10-11am when she was drying clothes and cooking. It continued till the next day evening. She took dolo650, but of no use, then Sumatriptan she had some relief.
PPM 1- Thanks that was useful. Would it be possible to share her hourly routine here?
PA-
6.30-7 am- wake up time
7.30am coffee
8am-9am- yoga and pranayama
9.15am Ragi with buttermilk
10am cooking
10.30am Puja
11am lunch
11.30am Paper reading, sudoku
12.30am Browse phone, nap for 1/2 -1hr
2.30pm Tea sometimes snacks
3-5pm Busy with arranging Cupboards, Folding clothes
5-6 pm Phone with relatives , walking
6 pm Fresh up and Puja
7 pm Dinner , pista, guava , banana with curd.
7.30pm Watch TV
10-11m Go to bed. If lucky she Sleeps.
PPM 1- How many days of the week is she lucky with her sleep?
PA- Almost every alternate day.
PPM 1- Does she experience various thoughts during the time 10-3am.
PA- Yes
PPM 1- Are the content of those thoughts similar every day? Can she remember what thoughts she had yesterday night? She doesn't need to share them in detail if not comfortable.
PA- Yes almost. Someone says something about her which is not right and she cannot reply back immediately and starts thinking over and over again.
PPM 1- Has your patient tried writing it down? Perhaps once she writes it down she need not change it again in her thoughts.
PA- No
PPM 1- Would she like to try it out tonight and share tomorrow how it influenced her sleep tonight?
PA- Sure. Today anyhow she will sleep as she did not sleep yesterday.
PPM 1- Alright this pattern of alternate day sleep is quite constant?
PA- Yes.
PPM 1- What is the duration of the small nap? Is taken on those afternoons that follow the nights where the patient slept at 2-3am?
PA- Half an hour to one hour. Sometimes no nap
13-08-2024
PA- Good morning Doctor. The patient had a good sleep yesterday night. No routine thoughts. Some relief. Her daily medication is as follows.
Thyronorm 125mcg since 2000
Metformin SR 500mg daily once since 2018
Betacap 40mg daily once
Fasting sugar is not more than 125 and PLBS is not more than 180. Today FS is 98. In 2019 diagnosed with vertigo tinnitus.
PPM 1- Thanks for making us a part of patients journey. We hope to support her at each and every step of her life whenever she needs us.
PA- Thank you Doctor.
14-08-2024
PA- Good morning Doctor. Yesterday night also the patient slept well. Thanks to you.
She felt relieved and happy after talking to
you about her health issues. In her past she missed some care and attention which she deserved. She wants to come out of all her past and forget everything.
PPM 1- Feels good here at our end too. Now imagine how much more your joy multiplies if you can share your ears by listening to many more people who like your patient also need attention and care. And for the ears I guess they need to be checked for wax before one can attribute the tinnitus to other causes.
PA- Good morning Doctor. Yesterday night also the patient had a good sleep.
PPM 1- 👍
PA-
7.30am coffee
2.30pm Tea
17-08-2024
PA- Good morning Doctor. Yesterday the patient was busy with Puja at her brother's place and her routine got disturbed. Due to late lunch she had headache in the noon and took sumatriptan. Skipped dinner had one banana and curd. Went to bed by 11pm. Slept well. Relief from headache.
PPM 3- Is sumatriptan helping relieve headache?
PA- Sometimes, depending on the severity.
PPM 2- If it is not relieving better not to take.
PA- Then what is the alternative medicine?
PPM 2- No medicine.
PA- It is impossible to bear the pain..
PPM 2- We will get to the root cause soon and fix it. Long term medication is not good, can lead to more problems.
PA- Sometimes the pain is so severe that she has nausea and becomes so weak to talk or even may faint.
PPM 2- OK it is really bad. Has the patient observed what triggers her pain or under what situation she gets pain.
PPM 1- Did the sumatriptan relieve the patients headache yesterday? If yes then after how much time did she find relief?
PA- yes definitely there was some relief. After 1hr she felt relief but if the patient takes rest in calm atmosphere her headache will be relieved completely.
PPM 1- Can you please share for how long from 2000 ever since the patient has shared that she had symptoms and did not take any medicine?
PA- For almost 2yrs she did not know it was migraine and took no medicine. After confirmation she was prescribed Zerodol P.
PPM 1- How long after taking the Zerodol p did the patient find relief? In what way has the relief from Sumatriptan been different for the patient?
PA- After one and half hour. Zerodol p for severe headache. Sumatriptan for mild headaches.
PPM 1- On the given day of headache, on an average how many Zerodol p did the patient had to consume in 24hrs?
PA- Only one.
PPM 1- Would the patient call yesterday's headache mild?
PA- No.
PPM 1- Was it severe?.
PA- Yes still she feels heavy in the head region.
PPM 1- Zerodol p is the combination of 2 medicines and we can't be sure which of these is actually working in your patient for severe headache. Ideally she could have taken just the paracetamol. Can you check the MG?
PA- 500MG.
PPM 1- Then ask your patient to take just paracetamol 650 next time. She can stop Sumatriptan. Let's switch the patient back to dolo 650 as and when she requires and is she still under Betacap 40mg twice daily?
PA- Betacap 40mg only once daily. The physician advised her to reduce Betacap 40 to 20 for 1 month and switch to Amytriptyline 10mg.
PPM 1- I agree with your patient's physician that this would be a better strategy.
PA- Due to late lunch had headache and took dolo650. Now okay. Skipped dinner had buttermilk.
PPM 1- So there were quite a few changes today from her regular routine earlier posted.
PA
18-08-2024
PA- The patient could not sleep till 1.30am. She took dolo at 11.30pm. She felt heaviness in the head region.
PPM 1- I feel Amytriptyline 10mg one hour before dinner would be a better migraine prophylactic for this patient. What do you say @PPM 3?
PPM 3- Amytriptyline is shown to be beneficial in migraine prevention on [19].
It may be more effective than propranolol in mixed migraine-tension types of headaches. Response to treatment can be seen in upto 4 weeks and is more rapid than with beta blockers. The daily dosing is 25 to 150mg. Sir how about we start with 25mg? Please maintain a log diary for your patient headache. Let's see the progress @PA.
You can also provide the data in the above link to @1313555002 to compare it's performance with yours.
META AI- Iam happy to help! However I need more information to provide evidence in the PICO format. Please provide me with the following details.
.P : Population (who is the study about?)
.I : Intervention (what is being studied?)
.C: Comparison (what is the Intervention being compared to?)
. O: Outcome (what is the outcome being measured?)
Once I have this information, I can provide you with evidence in the PICO format, including absolute numbers. If you also share the link, I can compare the data and provide a more comprehensive response.
19-08-2024
PPM 1- Went through the text but couldn't find the reference or evidence around which this author made the above statement of Amytriptyline's superiority over propranolol! This was the previous age analogue of current age AI, LLM hallucinations and I can't decide which is worse!
20-08-2024
PPM 1- Yes let her continue Betacap 20mg and add Amytriptyline 10mg one hour before dinner.
This is the patient's log diary (patient's journey aka Pajr) of all her events (energy outputs aka activities) as well as energy inputs (migraine or any other problem triggers)
PA- What is the medication for the patient?
PPM 1- Let her continue Betacap 20mg and add Amytriptyline 10mg one hour before dinner.
PA- How long should she continue?
PPM 1- Let's see how the patient responds to Amytriptyline till which time the Betacap 20mg can also continue. Once we are sure the Amytriptyline is working well, we can make the Betacap 20mg on alternate days for 2 weeks and then stop.
Pa- Okay doctor.
7 pm Dinner
21-08-2024
PA- The ENT has prescribed Magnium tabs for 3 months and said it helps in controlling migraine. After 1month he will review and treat tinnitus.
PPM 1- Better not buy it. Doesn't appear to be evidence based. We are more interested in his evaluation of the patients external ear canal and middle ear. Did he say why he was asking your patient to take the Magnesium tablets? Did he explain in what way it would benefit? Did he share any evidence for it's efficacy? I guess you could ask him these questions on the next visit.
@Meta AI, can you share any studies that demonstrate superior efficacy of Magnesium tablets over placebo for migraine? Please share their data in the PICO format and mention the absolute values in the Outcomes Comparison and avoid using percentages.
Meta AI- Here are some studies demonstrating the efficacy of Magnesium tab for migraine prophylaxis.
Study 1: ""Magnesium citrate as a Preventive treatment for migraines "(2011)
P (Population): Patients with migraine (n=60)
I (Intervention): Magnesium citrate (600 mg/day)
C (Comparison): Placebo
O (Outcomes):
Migraine frequency:- 2.7/ Month
(Magnesium) Vs- 1.3/Month (placebo)
Migraine severity:- 1.4/10
(Magnesium) Vs, -0.6/10(placebo)
Migraine duration:- 4.5 hrs
(Magnesium) Vs- 1.8hrs(placebo)
Reference: Tarighat Esfanjani et.aI (2011)
Magnesium citrate as a Preventive treatment for migraines. Magnesium Research, 24(2), 85-88.
Study 2: "Oral Magnesium oxide in migraine prophylaxis (1996)
P (Population): Patients with migraine (n=40)
I (Intervention): " Magnesium oxide (500mg/day)
C (Comparison): Placebo
O (Outcomes) :
Migraine frequency:- 3.5/Month
(Magnesium) Vs. -1.9/ Month (placebo)
Migraine severity:- 2.1/10
(Magnesium) Vs:- 1.1/10(placebo)
Migraine duration:-6.2 hrs
(Magnesium) Vs:- 2.9hrs (placebo)
Reference: Peikert et aI (1996). Oral Magnesium oxide in migraine prophylaxis Cephalalgia, 16(4), 277-280
Study 3: "Magnesium for migraine prophylaxis " (2012)
P(Population): Patients with migraine (n=70)
I (Intervention): Magnesium glycinate (400 mg/day)
C(Comparison): Placebo
O(Outcomes):
Migraine frequency:- 2.2/Month
(Magnesium) Vs. -1.1/Month (placebo)
Migraine severity:- 1.7/10
(Magnesium) Vs. -0.8/10(placebo)
Migraine duration:- 3.8 hrs
(Magnesium) Vs. -1.6hrs(placebo)
Reference: Gant et aI (2012) Magnesium for migraine prophylaxis. Journal of Neural Transmission, 119(4) 427-432. Please note that the results are presented as absolute values avoiding relative values in the form of percentages. Would you like more information or further assistance?
PA: Switched to Amytriptyline 10mg one hour before dinner and Betacap 20mg in the morning for alternate days.
22-08-2024
PA- Good morning Doctor. Yesterday the patient was out from 10am to 5pm. Had idly breakfast and lunch at 3.30pm. Back home by 5pm. No headache and went to bed by 9pm and had a good sleep till 6.30am.
PPM 1- 👏
23-08-2024
PA- Good morning Doctor. Yesterday the patient went out at 11am after lunch and was back by 3.30pm. Went to bed by 9.30pm and woke up at 6.30am with headache.
PPM 1- Is it still paining? Can your patient hold back paracetamol? Any identifiable triggers that may have influenced her headache while she was out?
PA- The patient has not taken any paracetamol. Applied amrutanjan and avoided paracetamol for this episode.
PPM 1- 👍
PPM 2- Good progress.
24-08-2024
PA- Good morning Doctor. The patient couldn't sleep till 12am woke up at 7.30am. No headache.
PPM 1- 👍
29-08-2024
PA- Good morning Doctor. Yesterday night the patient had mild headache with nausea for 3-4 hrs. Couldn't sleep till 1am. Did not take any paracetamol. Subsided by 1am and slept well. Overall she is fine. The patient feels that daytime TV viewing is one of her triggers. So she avoided.
PPM 1- So for this particular episode of headache the patient wasn't at home the whole day?
PA- Only upto 3pm
PPM 1- Can we hear about her activities from morning till evening before she started TV viewing just to understand other potential triggers of the day?
PA- Yesterday she woke up at 6am, had coffee, got freshed up, did puja, then had idly breakfast and left to the function by 10am by car and reached by 11am. Constantly chatting with relatives, and had lunch by 1pm and was back by 3pm. After coming home had bath and tea, relaxing for some time browsing mobile, then spoke to her mother, made dinner, then TV viewing. Meanwhile she had a video call with her son and grandson for 15min and later spoke to her relatives. Her TV viewing was disrupted. By 9.30pm went to bed. To be more clear the patient gets excited talking to her children and feels some discomfort in her head region.
PPM 1- The patient has information audio video cognitive triggers.
PA- Okay doctor then what is the remedy?
PPM 1- To reduce these cognitive triggers one may need cognitive control perhaps through meditation.
PA- Okay doctor.
30-08-2024
PA- The patient had triggers suddenly for no reason. It was severe and had to take paracetamol
31-08-2024
PA- The patient had developed a sebaceous cyst and got done excision procedure.
02-09-2024
PA- The patient went out for family ceremony without breakfast and had lunch by 2 pm. She had headache and pain for the procedure done and took dolo650.
04-09-2024
PA- Good morning Doctor. Now a days the patient is sleeping well. Meditating morning and evening for 15min.
PPM 1- 👍
09-09-2024
PA- Good morning Doctor. Yesterday night the patient could not sleep at all with various thoughts. But she feels there is lot of improvement with her insomnia and migraine as the episodes have reduced. She is continuing with her meditation morning and evening for 15min.
PPM 1- So the current challenge for this patient is how to be rid of thoughts that prevent sleep which by the way in it's initial stages is a state of our surrendering our thoughts, where we are led by the imagery of dreams that are also generated by whatever thoughts of the past that have accumulated in our memories. After the dream like state one gets into the deeper planes of sleep where there is complete darkness and the mind totally surrenders into a shut down stand by mode followed by gradual recovery again through the dream state back to consciousness.
11-09-2024
PA- The patient had Idly wada and Upma for breakfast and skipped lunch. She went out in the hot sun walking to nearby place and had severe headache which lasted till the next day evening. Her last episode was on 2nd September. Till now her headache has not subsided.
12-09-2024
PA- Doctor can you suggest some painkiller of one single dose for severe headache because inspite of taking dolo650 for every 6hrs there was no relief.
PPM 1- How much dose of Amytriptyline was taken 1hr before dinner yesterday? How many tablets of dolo650 did your patient consume in the last 24hrs?
PA- Amytriptyline 10mg and dolo650 for every 6hrs.
PPM 1- What is the brand name of the ergot tablet she used earlier? When did she take that last?
PA- Naprodom500 mg,almost one month back.
PPM 1- How many times a day and after taking it did the pain subside completely?
PA- Only one tablet per day and after one and half hour it subsided completely.
PPM 1- We could try this again.
PA- Yes Doctor. Naprodom500 taken on empty stomach causes acidity and hence the patient takes pan40 alongwith it.
14-09-2024
PA- The patient went out at 8am and was back by 4.30pm. She had prasdams at the temples. Had coffee at home by 5pm. Had mild headache and took dolo650. Skipped dinner.
16-09-2024
PA- Good morning Doctor. Should the patient continue with Betacap 20mg and Amytriptyline 10mg and for pain Naprodom500. The patient has been using the above medicines from 21st August.
PPM 1- I guess Betacap 20mg is from earlier and Amytriptyline was suggested by us for your local Doctor on 21st? Naprodom500 was taken only recently by your patient when 6hourly paracetamol did not work for severe headache.
PA- Yes Doctor, 2 yrs back I used Amytriptyline 10mg also and Betacap TR 40mg earlier.
PPM 1- Yes absolutely right. So when we recently in August suggested the patient to begin Amytriptyline 10mg she also restarted her previous Betacap on her own?
PA- No the physician advised and you asked me to take Betacap 20mg and Amytriptyline 10mg.
PPM 1- Alright I guess both Betacap and Amytriptyline may not be harmful as prophylaxis even when they are combined although we may not know which of them are working.
Yes we agreed upon an overlap while tapering off one drug over the other and it wasn't a combination therapy plan as I currently wondered. 👍
So in this plan the patient is supposed to reduce the Betacap 20mg dose by taking it on alternate days for a few weeks and stop. She can also now increase her Amytriptyline dose from 10mg to 25mg one hour before dinner.
PA- Is this combination therapy not advisable, because the patient feels both the medicines are working for her but not sure.
PPM 1- Good question!
Let's ask @ Meta AI to look for studies that have looked at the efficacy of combining two migraine prophylactic Amytriptyline and propranolol over either of them alone. Request META AI to share the data in the studies in a PICO format avoiding the complete list of references such that it becomes easier for our team to search and verify their validity.
Meta AI- I have searched for studies on the efficacy of combining Amytriptyline and propranolol for migraine prophylaxis. Here are the results in PICO format.
P (Population): Patients with migraine
I (Intervention): Combination of Amytriptyline and Propranolol.
C (Comparison): Amytriptyline or Propranolol
O (Outcome): Migraine frequency
Migraine severity
Quality of life.
Here are the study results.
1 Study: "Combination of Amytriptyline and Propranolol for migraine (2018)
. Migraine frequency:- 2.5 days/
Month(combination) vs:- 1.8 days/
Month(Amytriptyline) vs:- 1.5 days/
Month (propranolol)
. Migraine severity:- 23.1%
(Combination vs-17.1%(Amytriptyline)
Vs.- 12.5 %(propranolol)
. Quality of life:- +15.6(combination)
Vs. +10.3(Amytriptyline) vs.
+7.2(propranolol)
- Reference : Choi et aI. (2018)
Combination of Amytriptyline and Propranolol for migraine prophylaxis Journal of Clinical Neuroscience, 55,73-76.
2 Study: " Amytriptyline and propranolol in Migraine Prophylaxis "(2015)
. Migraine frequency:- 3.1 days/
Month (combination) vs- 2.2 days/
Month (Amytriptyline) vs 1.9 days/
Month ( propranolol)
. Migraine severity:- 25.9
(Combination) vs- 19.2 (Amytriptyline)
Vs.- 14.5 (propranolol)
Quality of life:+ 18.2 (combination)
Vs. + 12.5 (Amytriptyline) vs. +9.1
(Propranolol)
. Reference: Misra et aI (2015)
Amytriptyline and propranolol in Migraine Prophylaxis Journal of Pain Research,
8,727-735.
3. Study: Efficacy of combination therapy with Amytriptyline and Propranolol for migraine prevention (2020)
. Migraine frequency:- 2.8 days/
Month (combination) vs. - 2.1 days/
Month (Amytriptyline) vs. - 1.7 days/
Month (propranolol)
. Migraine severity:- 22.5
(Combination) vs. - 16.3 (Amytriptyline)
Vs.- 11.9 (Propranolol)
. Quality of life:+16.3(combination) vs
+11.4(Amytriptyline) vs, + 8.3
(Propranolol)
Reference: Kumar et aI (2020)
Efficacy of combination therapy with Amytriptyline and Propranolol for migraine prevention Journal of Clinical and Diagnostic Research 14(9), 15-18.
Please note that the results are presented as absolute values, avoiding relative values in the form of percentages. The references provided are complete and should allow your team to search and verify their validity. Please let me know if you need any further assistance!
PPM 1- @PPM 3 Can you please verify the validity of these references and also clarify what these numbers mean?
18-09-2024
PA- Good morning Doctor. Should the patient continue with amitriptyline 10mg and Betacap 20mg or any change in the medication?
PPM 1- This is the earlier mentioned plan (In this plan the patient is supposed to reduce Betacap 20mg by taking it on alternate days for 2 weeks and Amytriptyline 25mg daily one hour before dinner) Regarding stoppage of Betacap and increment of Amytriptyline.
PA- Yes Doctor. As you said Betacap 20mg on alternate days and Amytriptyline 25mg one hour before dinner.
The patient is having mild headache and body pains took dolo650.
PPM 1- 👍
19-09-2024
PA- Wake up time has changed to 5am
as the patient is practising Yoga from 6am to 7am.
PPM 1- 👍
PA- Good morning Doctor, Yesterday night the patient could not sleep till 1.30am but controlled her thoughts to a large extent by praying.
PPM 1- 🙏
21-09-2024
PA- The patient had some onion pakoda and samosa in the kitty party. Skipped dinner had buttermilk.
PPM 1- 👍
22-09-2024
PA- The patient switched to Amytriptyline 25mg and Betacap 20mg on alternate days. By 9.30pm she felt very sleepy. Is it because of increment of Amytriptyline dose?
PPM 1- Yes. What is your patient's normal sleep time? If it's 9.30pm then I guess it's good.
PA- Usually she sleeps by 10.30 to 11.30pm
PPM 1- Sounds good. As the patient skipped her dinner the Amytriptyline worked more and there was nothing to delay it's absorption. Can try half of 25mg today an hour before dinner.
PA- Doctor if it is harmful to take 25mg then will definitely reduce. But when the patient is having a good sleep why not?
PPM 1- Yes if the early sleepiness (which is just a harmless side effect) doesn't bother the patient why not!
23-09-2024
PPM 1- Too many Pistachios? Perhaps a variety of dry fruits into the plate would be better.
PA- Okay doctor.
25-09-2024
PA: Good morning Doctor. Yesterday morning, from the time patient woke up, she felt very weak and did not feel to do anything. But did yoga from 6am to 7am forcibly. Sweating was more yesterday. Had mild headache, did not take paracetamol. Her BP was 130/80, random sugar 93 and post dinner 115. She experienced these kind of episodes since she was diagnosed with migraine. Now she is okay but little weak and mild headache.
PPM 1- Very good description of the patient's day yesterday forwarded by the advocate. Ask her not to worry. The sweating was also due to weather yesterday, with many patients (including Doctors) coming to our casualty thinking they have had a heart attack. Nothing to worry about. Ask her to keep working as she has been doing because staying active inspite of our body's confusing fearful signals is the best way to tackle these problems.
PA- Okay doctor. Should I consult the ENT Doctor as he asked me to come after 1 Month. And what should I say when he asks about the Magnesium tablets he prescribed as we agreed upon not to take. He ruled out mieneyers.
PPM 1- Okay when you go for consultation ask him about the Magnesium tablets efficacy.
2.30pm Tea with muruku.
7 pm Dinner, banana with curd.
26-09-2024
7.30am coffee
27-09-2024
PPM 1- Some vegetables and fruits would be a nice addition.
PA- Yes Doctor.
Today afternoon the patient switched on the TV to know about the cricket score just for 10 min. In a few minutes she felt heaviness in the head region and slowly triggered headache. Being mild headache she got relief with Dolo 650.
PPM 1- 👍
28-09-2024
29-09-2024
PA- Good morning Doctor. Yesterday couldn't sleep the whole night.
PPM 1- Can you share your patient's hourly activities yesterday from morning till going to sleep.
PA- Woke up at 5.15 am. Got fresh and Yoga from 6am to 7am. Had coffee by 7.15 am. Bath by 9 am and by 9.30am Puja and meditation. At 10 am newspaper and sudoku. As it was ekadashi the patient had fruit diet of guava, banana and papaya. After that some writing work for one and half hour. Then had a small nap. Spoke to her brother and elder son for 15min on phone.
Had coffee by 2.15pm and again some writing work. At 4 pm attended to her son's video call for more than half an hour. Then went to get vegetables nearby.
By 6 pm got freshed up and Puja, then arranged utensils in the cabinets, cleaned the vegetables and arranged in the fridge. By 7 pm had fruits for dinner and was watching movie. At 9pm again the patient had a group video call with her children for 15min. By 9.30pm she went to bed , but could not sleep at all. Now she is having headache and took dolo650.
30-09-2024
01-10-2024
02-10-2024
PA- Doctor , today the patient consulted the ENT. The doctor said there is no problem with her ears and everything is normal according to her previous reports. He also said there is no problem with her outer and middle ear, the tinnitus is because of Fluid retention or some blockage in the internal ear. He asked if she experienced any giddiness. The patient did not have any giddiness after 2019. Then he suggested not to worry about the tinnitus and if it is troubling more then we can go for tinnitus refraining therapy. He also said it may be for many reasons and will have to do more and deeper investigation to know the cause. For tinnitus he prescribed the below medicines.
Should I take the above medicines? Please advise.
PPM1- The steps to know if the medications have any efficacy to reduce our problem is to
Step 1- Understand what are the scientific names of the medication by goggling the trade names written in the prescription.
Step 2- Type the scientific name and the word efficacy in Google and check out the papers and critically appraise them @PPM 4. Looking forward to step 1.
PPM 4- Tab Tinnex->Caroverine
Tab Otolanz->PV->Piracetam
Ginkgo Dry Extract and Vinpocetine.
A study of the efficacy of Caroverine in the treatment of tinnitus.
"THI Score post treatment with Caroverine showed statistically significant reduction in the immediate and 1st week post infusion period with
P value = 0.002. The study showed 63.3%
responded to caroverine therapy immediately after infusion.
Our study looked at the effectiveness of Caroverine in a selected placebo controlled group of patients. This study revealed that THI score post treatment with single infusion of Caroverine had significant improvement in tinnitus severity immediately and at the first week, but no improvement in the fourth week and at 6 Month follow up. Caroverine helps in reducing tinnitus in the immediate and first week post treatment. Caroverine is effective as a modality of treatment in suppressing tinnitus on short term basis."
PPM 1- Well done 👏 👏
@Meta AI Please share studies around the efficacy of oral caroverine in comparison to caroverine infusion and placebo and share the data in PICO format taking care to mention absolute values and not percentages.
Here are the studies on the efficacy of oral caroverine compared to caroverine infusion to placebo.
Study 1:- "Oral caroverine vs infusion in migraine treatment 2018)
P (Population): Patients with acute migraine (n=120)
I (Intervention): Oral caroverine (120mg), caroverine infusion (100mg) placebo
C (Comparison): Caroverine infusion placebo
O (Outcomes): Pain relief at 2hrs: 7.2/10(oral), 8.1/10(infusion)
3.5/10(placebo)
. Headache severity reduction:- 3.5(oral)
-4.2(infusion), - 1.8(placebo)
. Rescue medication use:- 1.5(oral),
6(infusion), 30(placebo)
Reference: Abraham et al. (2018).
Oral caroverine vs infusion in migraine treatment. Journal of Clinical Neuroscience, 53, 106-109.
Study 2:- "Caroverine in migraine prophylaxis- oral vs infusion (2020)
P (Population): Patients with episodic migraine (n=150)
I (Intervention): Oral caroverine (120mg/ day), caroverine infusion (100mg/month)
placebo.
C (Comparison): Caroverine infusion placebo.
O (Outcomes):
Migraine frequency reduction:- 2.1/Month (oral), -2.5/month(infusion), -0.8/month(placebo)
Quality of life improvement:- +12.5(oral)
+15.1(infusion), + 4.2(placebo)
Reference: Wang et aI (2020). Caroverine in migraine prophylaxis, oral vs infusion
Journal of headache and pain, 21(1), 1-9.
Study 3:- " Efficacy and safety of oral caroverine in migraine treatment " (2015)
P (Population): Patients with acute migraine (n=90).
I (Intervention): Oral caroverine (120mg)
placebo.
C (Comparison): Placebo
O (Outcomes) :
Pain relief at 2hrs, 7.5/10(caroverine),
3.8/10(placebo)
. Headache severity reduction:- 3.8(caroverine), -1.9(placebo)
. Rescue medication use: 12(caroverine)
28( placebo)
Reference: Zhang et aI (2015). Efficacy and safety of oral caroverine in migraine treatment. Journal of Clinical Neuroscience, 22 (11), 1627-1630.
Please note that the results are presented as absolute values.
PPM 1- Pease check if the references are searchable in Google?
9-10-2024
PA- Doctor, the patient has increased the Amytriptyline dose from 10 to 25mg and Betacap 20mg on alternate days from 22nd September. Should the patient continue Betacap 20mg? If so until when?
PPM 1- Can you ask your patient to take Betacap 10mg on alternate days for a few weeks?
PA- Okay doctor, then should the Amytriptyline dosage be increased?
10-10-2024
PPM 1- 25mg can continue for a few weeks till we can assess the patient's response in terms of the decrement in the frequency of her headache.
PA- okay doctor.
Went out at 11am and back by 3pm.
With the onset of headache had to take Naprodom500 mg alongwith Pan 40.
PPM 1- How does the patient advocate decide when to take naproxen vs when to take paracetamol? I guess we may have already discussed this earlier but need to refresh the memory.
PA- When the patient requested the doctor for a single dose of painkiller rather than 4 paracetamol tabs for every 6 hrs, then he advised the patient to take Naprodom500mg as it is effective with a single dose.
11-10-2024
PPM 1- How sweet is the kheer? Can this patient share herblood sugars once in a month?
In Fasting
2 hrs after breakfast
2hrs after lunch
2hrs after dinner.
PA-
PA- Yes, just now. Today had double lunch
as the patient had to attend a function.
PPM 1- First lunch at 11am and second at 2pm?
PA- Yes
PPM 1- Would have been interesting to know the blood sugar at 1 pm, two hours after kheer.
PA- Even in 2 pm lunch had kheer and another sweet also.
PPM 1- 👍
PA- For every three months the patient checks her blood sugars, Thyroid and creatinine also.
PPM 1- Glucometer sugars atleast once a month Fasting and thrice two hours after every meal on one day. HBA1C once in 3 months.
PA- Yes Doctor.
12-10-2024
PA -
PPM 1- Blood sugars are under ideal control. 👏👏.
When was your patient's last HBA1C?
PA- July 7th, 2024.
PPM 1- Would it be possible for you to share the values of each HBA1C done on your patient since the last many trimesters that the patient may have preserved in her records?
PA- October 2023
HBA1C - 6.3
January 2024 - 6.1
April 2024 - 7
July 2024
FS- 116
PLBS- 139
HBA1C- 6.4.
PA- Good morning Doctor. Yesterday night the patient could not sleep at all. She felt some vibrating sensation in her whole body including head region. This episode she experienced in July 2023, when the Betacap 6o mg was stopped on the advice of her physician. At that time she had severe dry cough for almost 3 months and her physician felt that was because of the stoppage of Betacap dosage. But later it was diagnosed that the reason was because of the plants in her house, which had small insects that caused allergy and was detected with Asthma for which she was given proper medication and got completely cured and was advised to remove the plants. Then the physician reduced the dosage of Betacap 60mg to 40mg.
Yesterday the patient could not sleep in a single position even for a minute. Was restles and unstable.
PPM 1- Is your patient still on alternate day Betacap?
PA- Yes, 10mg on alternate days, since yesterday.
PPM 1- Let's get back to the previous dose before it was reduced to 10mg.
PA- Okay doctor.
15-10-2024
17-10-2024
PPM 1 - Thyroid and Diabetes look good.
18-10-2024
PA- Good morning Doctor. The patient is taking 125mcg Thyronorm. Should she continue?
PPM 1 - Since when? Since 200 your patient has done well on it till date. That's good reason to continue it at the same dose. Would have been great if we had the PaJR earlier to see the TFT trends since 2000.
PA - My physician advised me to reduce to 87.5mcg.
PPM 1 - That would be a drastic reduction going by the above TFTs. I feel we need our endocrinologist PPM 4's opinion here.
PA - It was his opinion doctor.
PPM 1 - Alright I shall share some thoughts about the report with him. For example even if the TSH appears low which may indicate that there's a subclinical increased activity of T3 and T4, the reports still show that the active T3 is still lower than normal while the precursor T4 is higher.
Can you share her last few other TFTs from 2023-24?
PA - Unfortunately she doesn't have the previous reports. Since 2000 she was on 200mcg for 8-9 yrs in the beginning and was reduced to 150mcg for almost 10-13 yrs. And now she is on 125.
PPM 1 - Has she experienced any symptoms of hyperthyroidism?
@Meta AI Please list the symptoms of hypothyroidism, also mentioning their frequency in a given population of patients on thyroxine or even just hyperthyroidism.
Please use absolute values and not percentage and also share the references for any statement.
Meta AI- Here are symptoms of hyperthyroidism and hypothyroidism alongwith their frequency in patients.
Hyperthyroidism:
1. Weight loss(79,000/100000 patients)[1]
2. Palpitations (64000/100000 patients)[1]
3. Tremors (56000/100000 pts)[1]
4. Anxiety (54000/100000 pts)[1]
5. Fatigue (46000/100000)[1]
6. Heat intolerance (44000/1L pts)[1]
7. Increased sweating (42000/1L pts)[1]
8. Hair loss(36000/1L pts)[1]
9. Muscle weakness (34000/1L pts)[1]
10. Changes in menstrual cycle (28000/
100000 pts)[1]
Hypothyroidism:
1. Fatigue (93000/1L pts on Thyroxine)[2]
2. Weight gain(74000/1L pts on Thyroxine)
[2]
3. Cold intolerance (64000/100000 pts
on Thyroxine)[2]
4. Dry skin(59000/1L pts on Thyroxine)[2]
5. Hair loss(54000/1L pts on Thyroxine)[2]
6. Constipation (49000/100000 pts on
Thyroxine)[2]
7. Depression (44000/100000 pts on
Thyroxine)[2]
8. Memory impairment (41000/100000
pts on Thyroxine)[2]
9. Muscle weakness (38000/100000 pts
on Thyroxine)[2]
10. Heavy or irregular menstrual periods
(34000/100000 pts on Thyroxine)[2]
References:
[1] "Hyperthyroidism Symptoms and Diagnosis "- American Thyroid Association
(ATA)- 2019.
[2] "Hypothyroidism Symptoms and Diagnosis " -(ATA) 2020.
Population Studies :-
• Hyperthyroidism symptoms frequency based Ona study of 1,455 patients [1]
• Hypothyroidism symptoms frequency based on a study of 2,414 patients on Thyroxine [2]
Note : - The frequencies mentioned above are approximate and based on specific studies. Symptoms may vary in individual patients and if frequencies may differ in different populations.
PA - Main symptoms of thyroid for the patient was weight gain , anxiety, cold intolerance, Fatigue, heavy menstrual periods, mood swings and tremors.
But when she practised Yoga there was some relief from these problems. Main worry is weight gain.
PPM 1 - Yes , but these are symptoms of hypothyroidism and we are currently debating if your patient is becoming hyperthyroidism due to 125mcg Thyronorm she's taking.
PPM 1 - 👍
PA - The physician advised 100mcg Thyronorm. The patient is taking Betacap 10mg and Amytriptyline 25mg. She has not increased Betacap dosage as mentioned earlier with withdrawal symptoms. Now she is fine. Any change in medication?
PPM 1 - Let's go with this plan.
PA - Okay doctor.
20-10-2024
PA - The mild nagging headache did not subside till now. Taken dolo650 twice. Yesterday night and today morning.
21-10-2024
PA - The patient's headache subsided now after lunch. Friday night headache started and subsided today(Monday).
24-10-2024
PA - Afternoon had sudden headache and took Naprodom500.
27-10-2024
PA - Doctor, from August 20th the patient started the dosage of Amytriptyline 10mg daily one hour before dinner and Betacap 20mg on alternate days. Since September 23rd Amytriptyline was increased to 25mg. From October 13th Betacap reduced to 10mg on alternate days. To be precise the patient's migraine episodes, frequency, severity and duration have increased than when she used Betacap 60mg. Recently on 18th evening she had headache and with onset she took dolo650 for every 6hrs, but to no effect. And the episode lasted for 2 complete days, till Monday the 21st morning. Again she had headache on 24th Thursday. Sudden triggers and took Naprodom500. And today 27th, Sunday again it started in the noon time. But the good news is the patient is having a good sleep. Please advise.
PPM 3 - Is the headache migraine headache everytime the patient experienced? Or different character and
intensity. All these times did she figure out what is the trigger? Because for migraine the best medicine is to avoid triggers.
PA - Doctor, the patient is suffering with this headache since 28yrs. The triggers are also changing with time to time and with change in medication. Very few particular triggers the patient is definitely avoiding. It is definitely migraine because of the throbbing and nagging pain.
PPM 3 - 👍
PPM 1 - Let's not stop the Betacap. But again slowly increase the dose also keeping the current dose of Amytriptyline.
The patient can get back to Betacap 20mg daily rather than alternate days.
PPM 3 - From my previous experiences, she did best on Betacap 60mg with minimal side effects.
PPM 1 - I guess she did have some issues because of which we had to change will be clearer on reviewing her case report in the description box.
PPM 3 - I remember it was flower pot pollen driven Asthma which needed tapering of Betacap. I remember they have now removed those plants from their home.
PPM 1 - 👍 Also? I guess Insomnia was an issue that was addressed by Amytriptyline.
PPM 3 - She did have Tachycardia and tremor with Amytriptyline. Perhaps Melatonin for sleep with Betacap would be a good combination.
PPM 1 - 😯 Oh we didn't know that. She's still predominantly on Amytriptyline .
PPM 3 - Yes only recently. However I remember the patient was able to handle all the stress of her younger son's wedding with very minimal headache days(and intensity) when on Betacap 60mg. It was the home plants which precipitated quite a troublesome Asthma which needed tapering of Beta blockers. From whatever data I have she had best benefit profile with Betacap 60mg and perhaps we could recommend something for sleep with Betacap. Also photosensitive was significantly lower with Betacap when compared to Amytriptyline.
PPM 1 - Let's slowly taper Amytriptyline to 10mg.
PPM 3 - Yes Sir I would agree. Also did not have such adverse effect with Betacap on diabetes either.
PPM 1 - Her diabetes from what little has been shared appears to be well controlled.
PPM 3 - Yes recent HBA1C is 6.5
PPM 1 - 👍
29-10-2024
PA - Good morning Doctor, from today should the patient take Betacap 20mg and Amytriptyline 10mg? But as she bought 25mg Amytriptyline can she take half tablet until they are finished?
PPM 1 - Yes 👍.
PA - Thank you.
02-11-2024
Coffee at 7.30am
Ragi at 9.30am
PA - Should the patient increase Betacap dosage from 20 to 40mg?
PPM 1 - Let's see how the headache frequency is at the lower dose?
PA - The severity has reduced, frequency and duration is the same for now. After Sunday(27-10-24) headache episode again on Thursday(31-10-24) it began and lasted till today (2-11-24) morning.
PPM 1 - We can gradually try and increase the dose every four weeks to see how the dose increments may reduce the frequency and duration.
PA - Okay doctor.
PPM 1 - 👍 Wasn't this patient having insomnia initially?
PA - Was having but now she is fine 🙂
PPM 1 - We hope to remove every disease from this patient's title.
PA - Yes Doctor.
12-11-2024
PPM 1 - 👍
Calorifically this lunch appears to be heavier than the other days shared above?
@PPM5 can you use your diet image to calorie value AI tools to validate this?
PPM 5 -
PPM 1 - How much in the below plate @PPM5?
PPM 1 - Good comments by the app about your patient's plate @PA.
16-11-2024
Fasting - 108
2 hrs after breakfast (Ragi) - 102
2 hrs after lunch (Apple and pista) 121
2 hrs after dinner(Rice, leafy dal, Raw banana curry, Brinjal tomato chutney and curd) - 170.
27-11-2024
@PPM2 this patient comes closest among all our PaJR patients in exemplifying this study in her meal timings 👇
"Participants (n = 26) were classified as Later Eaters (LE) if ≥45% daily calories were consumed after 5 pm and Early Eaters (EE) if not, based on daily caloric intake assessed over 2-wk. EE and LE did not differ in anthropometrics or daily energy intake, but LE consumed more carbohydrates (p = 0.038) and fats (p = 0.039) after 5 pm. Fasting glucose, insulin, and C-peptide did not differ between groups but LE exhibited higher glucose concentrations after an oral glucose tolerance test (p = 0.001), even after adjusting for body weight, fat mass, energy intake and diet composition (p < 0.05)"
Unquote
https://www.nature.com/articles/s41387-024-00347-6
28-11-2024
PPM 2 - I am amazed that you are quoting such a poorly designed and wasteful trial @PPM1 sir?
PPM 1 - It has a shock value. Who would have thought of this hypothesis that all calories are best consumed in the morning and early evening hours! The added plus is the long gap in between that becomes classified as intermittent fasting!
@Meta AI please thematically analyse the paper below and
PA - Lunch.
10-12-2024
also share the results in the PICO format taking care to mention absolute values and avoid percentages:
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Brief Communication
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Published: 25 October 2024
Late eating is associated with poor glucose tolerance, independent of body weight, fat mass, energy intake and diet composition in prediabetes or early onset type 2 diabetes
Diana A. Díaz-Rizzolo, Leinys S. Santos Baez, …Blandine Laferrère Show authors
Nutrition & Diabetes volume 14, Article number: 90 (2024) Cite this article
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Abstract
This study investigates the impact of habitual late calorie intake on glucose metabolism in adults with overweight or obesity and diet or metformin-controlled prediabetes or type 2 diabetes independently of body weight, fat mass, energy intake or diet composition. Participants (n = 26) were classified as Later Eaters (LE) if ≥45% daily calories were consumed after 5 pm and Early Eaters (EE) if not, based on daily caloric intake assessed over 2-wk. EE and LE did not differ in anthropometrics or daily energy intake, but LE consumed more carbohydrates (p = 0.038) and fats (p = 0.039) after 5 pm. Fasting glucose, insulin, and C-peptide did not differ between groups but LE exhibited higher glucose concentrations after an oral glucose tolerance test (p = 0.001), even after adjusting for body weight, fat mass, energy intake and diet composition (p < 0.05). Glucose results remained when participants with T2D were excluded (p = 0.031). After diabetes status adjustment, differences in glucose concentrations were higher in LE for time 30 (p = 0.028) and 60 min (p = 0.036). LE, compared to EE, had poorer glucose tolerance, independent of body weight, fat mass, daily energy intake and diet composition. ClinicalTrials.gov: NCT04465721.
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Introduction
Dietary interventions are the cornerstone of the prevention and treatment of type 2 diabetes (T2D). Total energy intake and meal composition are determinants of daily glucose excursions. Meal timing may also be important due to diurnal variation of glucose tolerance [1]. Previous studies consistently demonstrated that late eating is linked to poorer glucose metabolism, in association with higher BMI, increased body fat, as a result of greater energy intake [2] and highly processed food consumption [3]. The distribution of energy intake later in the day may also prolong overnight postprandial glucose excursions and result in circadian misalignment both contributing to impaired glucose metabolism [2].
Our goal was to test the hypothesis that the associations of habitual later mealtime and worse glucose metabolism are independent of body weight, fat mass, daily energy intake, or diet composition in adults with overweight and obesity and diet or metformin-controlled prediabetes or T2D.
Methods
A total of 26 adults (50–75 years old) with overweight or obesity, diet or metformin-controlled prediabetes or T2D, HbA1c of 5.7–7.5%, a ≥ 14-h eating window, ≥6 h of sleep, stable weight, and no history of bariatric surgery, were enrolled at Columbia University Irving Medical Center (New York City). Data were collected during a 14-day free-living assessment from the NY-TREAT parent trial (June 2021–December 2022) [4].
Food intake and meal timing were assessed using five Automated Self-Administered 24-h (ASA24®) recalls, and mealtimes validated by time-stamped photos taken in real-time with the myCircadianClock app.
Participants were categorized into Later Eaters (LE) if ≥45% daily calories were consumed after 5 pm or Early Eaters (EE).
Measurements included triplicate assessments of blood pressure, body weight, height, BMI, waist circumference, and fat mass. A 75 g 2-h oral glucose tolerance test (OGTT) was conducted after a 10-h fast, with biomarkers analyzed at 0, 15, 30, 60, 90, and 120 min.
Statistical analyses
Data are presented as mean (SD) and figures as mean (SEM). Group comparisons used Student’s t-test, Mann-Whitney U test, and Chi-square test. Linear mixed models with OGTT-derived glucose variables as outcome, were performed with group (EE or LE) and time as fixed effects, with and after excluding patients with T2D. General linear models assessed glucose with groups as fixed factors, and diabetes status, body weight, fat mass, dietary intake and composition as covariates. Significance was set at p < 0.05. Analyses used IBM SPSS Statistics software version 29.0.0.0. Please see Supplementary Methods file for details.
Results
Twenty-six participants, 17 women, 3 with T2D and 4 on metformin, aged 60 (7) years, systolic blood pressure 121.9 (12.6) mmHg, diastolic blood pressure 78.5 (10.2) mmHg, waist circumference 107.5 (14.3) cm, weight 90.9 (20.2) kg, BMI 32.5 (5.3) kg/m2, fat mass 37.4 (12.1) kg, fat-free mass 53.5 (14.5) kg, were studied.
EE (n = 13) and LE (n = 13) did not differ in age, sex, anthropometrics, and body composition. Participants with T2D (n = 3) were all in the LE group (Supplementary Table 1).
Total daily energy intake and macronutrients composition did not differ between groups (Supplementary Table 2). Compared to EE, LE consumed almost twice as many calories after 5 pm, with higher amounts of fat and carbohydrates consumption, and a trend toward higher protein and sugar consumption (Supplementary Table 3).
Fasting glucose, insulin, and C-peptide did not differ between groups (Table 1). Glucose concentrations increased more over time after an oral glucose load in LE, compared to EE (p = 0.010). LE had greater mean glucose during OGTT, greater total glucose area under the curve (tAUC), with greater glucose concentrations at time 30 and 60 min (Table 1) (Fig. 1) (Supplementary Table 4). Analysis excluding participants with diabetes showed similar results: the OGTT glucose concentrations increased more in LE (n = 10) compared to EE (n = 13) (p = 0.031), with greater concentrations at 30 and 60 min (Supplementary Table 5). The significant difference in glucose outcomes between LE and EE persisted after adjusting either separately for body weight, fat mass, energy intake and diet composition or for all covariates combined (p < 0.005) (Supplementary Table 6). When adjustment was made with combined covariates including diabetes status, only a trend for differences in glucose at 30 and 60 min persisted (p = 0.082 and p = 0.074, respectively) (Supplementary Table 7).
Table 1 Metabolic parameters between EE and LE.
Full size table
Fig. 1: OGTT glucose curves in EE (gray) and LE (black).
figure 1
Mean and SEM. P-value: * <0.05, **<0.01, if a value does not appear, it is because is ≥1 and is not considered a trend or statistical significance. EE Early Eaters, LE Later Eaters.
Full size image
Discussion
The main finding of this study is that greater energy intake after 5 pm is associated with poorer glucose tolerance in adults with obesity and diet or metformin-controlled prediabetes or T2D, independently of higher body weight or fat mass, diet composition or greater energy intake.
Our data confirm the association of late eating with worse glucose tolerance shown in previous studies in individuals without obesity [1]. Adding to previous findings on the detrimental effect of late eating on BMI and metabolism [2] and its association with poorer diet [2, 3], we now observed that the association of LE with poorer glucose tolerance is independent of greater body weight, fat mass, calorie amount, or poorer diet composition.
In previous studies associating eating late with poorer glucose metabolism, later eaters had higher BMI, higher body fat [5, 6], as well as lower satiety and greater hunger [7, 8] which may have explained their greater daily calorie intake. Food consumed in the evening, compared to morning, is typically higher in energy density resulting in an overall higher total energy intake [2], which may explain why late eating is associated with greater body weight and fat mass. Therefore, the glucose benefits observed when energy intake is distributed earlier in the day may be explained by a lower body weight. However, even in individuals reporting to consume the same total daily calorie amount, late eaters can present higher BMI/fat mass and poorer glucose metabolism, highlighting the potential role of meal timing per se, independently of calorie amount, on poorer metabolism [9,10,11,12].
Our study shows that older individuals with prediabetes or early T2D who are habitual later eaters have poorer glucose tolerance, independently of body weight or fat mass and energy intake. This is in agreement with short-term intervention trials (1–14 days) in healthy volunteer. Participants consuming an isocaloric diet aiming at weight stability showed worse glucose tolerance and lower resting-energy expenditure when calories were consumed later in the day [13, 14]. This may be related to previously reported higher postprandial glucose response after dinner compared to breakfast [14,15,16]. The importance of late eating on glucose was also shown in a prospective observational epidemiological study of 2642 women at risk of T2D: eating after 9 pm was associated with 1.5 times higher 5-year risk of developing T2D [17].
A combined intervention of caloric restriction with AM versus PM distribution of daily calories glucose and HbA1C decreased more, and insulin response was higher when calories were consumed in the morning compared to the evening [18, 19], highlighting the importance of meal timing on glucose metabolism in individuals with T2D. However, another weight loss study in 23 individuals with obesity and prediabetes or T2D, showed no differences in weight or metabolism when 50% of the total daily calories were consumed in the morning versus the evening [20].
Diet composition is also a well-established determinant of T2D risk. Observational studies have shown that late eaters tend to select highly processed high-carbohydrates and/or fats meals in the evening [2, 3]. Our study supports those findings. LE consumed more carbohydrates and fats after 5 pm compared to EE. This behavior has previously been associated with worse overnight glucose metabolism and may result in desynchronization of the peripheral circadian system [2] that can lead to even worse glucose tolerance.
Bias and limitations include the inclusion criteria of the NY-TREAT study [4], focusing on individuals with a prolonged ≥14-h eating window, introduces a potential bias. However, given the prevalence of such eating patterns in the general population, the data may still be representative. Despite real-time data collection via a smartphone app, there remains an element of self-reporting as participants need to remember to photograph their meals, though validations suggest a minimal 10% error rate [3]. The study’s small sample size is a limitation but, for pilot studies such as this one, former power calculation is not always possible. However, caution is advised in generalizing findings, as the cohort specifically targets individuals with prediabetes or T2D and obesity. Replicating the study in more diverse populations and age groups would enhance external validity, contributing to a broader understanding of the results’ applicability beyond the studied demographic.
Conclusion
This exploratory study aligns with previous literature showing that late consumption of calories is associated with worse glucose tolerance. Late eating is associated with greater consumption of calories mostly from carbohydrates and fats and may lead to prolonged evening postprandial glucose excursions contributing to worse glucose tolerance. Our findings, that late eating is associated with poorer glucose metabolism, is neither explained by a higher BMI or body fat, nor by larger amount and worse daily diet composition, will need confirmation in future studies. Further research is warranted to explore the effect of both the composition and the timing of the last eating occasion on overnight glucose and glucose tolerance.
Research in context
What is already known about this subject?
Eating late has been associated with increased fatness and poorer glucose metabolism, in part due to eating unhealthy and calorie-dense food later in the day.
What is the key question?
Does eating late contribute to poor glucose tolerance without depending on increased body weight, fat mass, daily energy intake or diet composition?
What are the new findings?
Later eaters exhibit poorer glucose tolerance compared to earlier eaters. This was independent of body weight, fat mass, calories and diet composition and highlights the novelty of our findings.
How might this impact on clinical practice in the foreseeable future?
Late eating independently contributes to poorer glucose tolerance. Addressing meal timing may have implications for managing glycemic control in diet or metformin-controlled prediabetes or type 2 diabetes.
Data availability
The datasets generated during and/or analyzed during the current study are not publicly available due to being part of an active parent grant with not already published results but are available from the corresponding author upon reasonable request.
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Acknowledgements
The study was funded by the NIA R01AG065569. D.D.R. was supported by a grant from Fundación Alfonso Martin Escudero and the Russ Berrie Fellowship. L.S.B. was supported by a supplement to R01AG065569 and a Russ Berrie Fellowship. C.J.P. is supported by R01NR018916 and K99HL163474. This publication was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant Number UL1TR001873. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Author information
Authors and Affiliations
Division of Endocrinology, Nutrition Obesity Research Center, Diabetes Research Center Columbia University Irving Medical Center, New York, NY, USA
Diana A. Díaz-Rizzolo, Leinys S. Santos Baez, Rabiah Borhan, Ana Sordi-Guth & Blandine Laferrère
Health Science Faculty, Universitat Oberta de Catalunya, Barcelona, Spain
Diana A. Díaz-Rizzolo
Department of Population Health, New York Langone Health Grossman School of Medicine, New York, NY, USA
Collin J. Popp
Salk Institute for Biological Studies, Regulatory Biology Laboratory, La Jolla, CA, USA
Emily N. C. Manoogian & Satchidananda Panda
Department of Biostatistics, Columbia University Irving Medical Center, New York, NY, USA
Bin Cheng
Contributions
B.L. designed the parent grant, obtained funding, supervised data acquisition, and edited the manuscript. D.D.R., L.S.S.B., R.B., and A.S.G. participated in data acquisition. D.D.R. conceived the hypotheses and drafted the paper. D.D.R. and B.C. performed statistical analyses. All authors critically reviewed manuscript drafts and approved the final manuscript. B.L. had primary responsibility for the final content. B.L. is the guarantor of this work and, as such, has full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Corresponding author
Correspondence to Blandine Laferrère.
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Díaz-Rizzolo, D.A., Santos Baez, L.S., Popp, C.J. et al. Late eating is associated with poor glucose tolerance, independent of body weight, fat mass, energy intake and diet composition in prediabetes or early onset type 2 diabetes. Nutr. Diabetes 14, 90 (2024). https://doi.org/10.1038/s41387-024-00347-6
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Received
19 February 2024
Revised
15 October 2024
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17 October 2024
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25 October 2024
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Here is a thematic analysis of the paper in the PICO format:
P (Population): Adults with overweight or obesity and diet or metformin-controlled prediabetes or type 2 diabetes.
I (Intervention): Habitual late eating (consuming ≥45% of daily calories after 5 pm).
C (Comparison): Early eating (consuming <45% of daily calories after 5 pm).
O (Outcome): Poorer glucose tolerance, including higher glucose concentrations after an oral glucose tolerance test, greater total glucose area under the curve, and higher glucose concentrations at 30 and 60 minutes.
Absolute values:
- 26 participants were included in the study.
- 13 participants were classified as Later Eaters (LE) and 13 as Early Eaters (EE).
- LE consumed an average of 573 ± 103 calories after 5 pm, while EE consumed an average of 243 ± 76 calories after 5 pm.
- Fasting glucose, insulin, and C-peptide did not differ significantly between LE and EE.
- LE had a significantly higher mean glucose concentration during the oral glucose tolerance test (173.8 ± 10.4 mg/dL) compared to EE (147.1 ± 8.3 mg/dL).
PPM 2 - The counter regulatory hormonal role play, the leptin adiponection levels etc, hypothetically all favor early eating anyway.
But this trial investigators have done an OGTT and do not particularly suggest on this.
PPM 1 - 👍
PPM 2 - Not one mention of OGTT in this analysis!
Oh it did! Blimey. My apologies to Meta AI
PPM 1 - You picked up "blimey" from the UK!
PPM 2 - Colonialisation of my brain!
PPM 1 - 😂
29-11-2024
PA -
PPM 1 - 👍
30-11-2024
PA - The patient is suffering with severe cold and sore throat. Travelling to Somnath and Dwaraka trip. Taking Dolo 650 every6 hrs for body pains and headache.
02-12-2024
PA - The patient is feeling little better from cold and body pains.
04-12-2024
PA - The patient is suffering with headache and took Sumatriptan and had relief.
09-12-2024
PPM 1 - 👍
PPM 1 - 👍
PA - The patient is suffering with headache and took sumatriptan.
11-12-2024
PPm 1- Has the coughing frequency and duration reduced albeit it's persistence?
PA - No doctor.
PPM 1 - So it's the same as it was 10 days back?
PA - Yes.
PPM 1 - Can take a syrup benadryl sos for a few days.
PA - Okay, thank you doctor.
12-12-2024
PA - 
PA - Monthly sugar monitoring
PA - Good morning doctor. On the advice of @PPM5, the patient increased the dosage of Betacap 20 to 40 to 60. Should she stop Amytriptyline 10mg or continue? At present the severity, frequency and duration have reduced to some extent. Patient is taking Sumatriptan 50mg for pain relief, Not having the necessity of Naprodom 500.
PPM 1 - Let's stop the Amytriptyline to check if the 10mg had any effect. If it had then the symptoms may return.
PA - Okay doctor.
13-12-2024
PPM 1 - 👍
Fasting 121
Post breakfast (Ragi) 119
Post lunch 140
Post dinner 141
PPM 1 - 👍 👏
14-12-2024
PA -
PPM 1 - 👍
17-12-2024
PA - The patient had late dinner yesterday night and woke up with headache. At first she took dolo 650 thinking that headache is mild but did not find relief and took sumatriptan after 6 hrs. Then she had relief.
18-12-2024
PA - Due to late lunch the patient had headache in the evening and got relief with sumatriptan.
19-12-2024
PPM 1 - I guess the patient had stopped amitriptyline completely.
PA - Yes doctor. Discontinued amitriptyline from last 15 days.
PA - The patient had headache in the night and had to take sumatriptan.
PA - The patient had to attend a marriage function. As the lunch and sleep time was delayed, she had headache and took sumatriptan.
The next day also had to take sumatriptan.
27-12-2024
PA - After discontinuing amitriptyline, the frequency of headache has increased. On the advise of @PPM2, the patient restarted the dosage of 10mg amitriptyline again.
31-12-2024
PA - The patient had headache and took sumatriptan. Headache continued till 1st January, the next day.
07-01-2025
PA - The patient is suffering with migraine headache since afternoon. took sumatriptan.
11-01-2025
PA - The patient is having headache and took sumatriptan.
Ragi at 8.26am
12-01-2025
PA - Coffee at 7.10am.
PPM 1 - 👍
Ragi at 8.26am
PPM 1 - 👍
PA - Lunch at 10.14am.
PA - Dinner at 6.23pm.
15-01-2025
PPM 1 - 👍
PA - Tea at 3.32pm
PPM 1 - 👍
PPM 1 - 👍
PA - Monthly sugar monitoring
Fasting sugar - 107mg/dl
Post breakfast - 113mg/dl
Post lunch - 146mg/dl
Post dinner - 151mg/dl
PPM 2 - 👍
13-01-2025
PPM 1 - 👏
15-01-2025
PA - The patient had headache as she had late lunch and was out for long as she was on tour to Tirupati. She took sumatriptan for pain and had relief.
18-01-2025
PA - Diabetes and Thyroid profile.
PPM 1 - Perfect lab results 👏👏
PA - But migraine is not leaving the patient doctor. Had severe headache and nausea. Forcibly vomitted and now some relief.
PPM 1 - Has the patient experienced this after a long time because she never shared it here earlier.
It would be important to know her regular events and at what time the headache makes it's appearance.
PA - Headache was not so severe all these days. Patient had relief with Sumatriptan and no nausea. But from 2-3 episodes the patient is experiencing nausea and today it was worst. All the episodes are being updated in the case report.
Today the onset of headache was sudden triggers. And the patient is aware that it will be severe.
Today the patient was at home with desk work. Normal daily routine activities.
PPM 1 - When did she last take Sumatriptan? If a patient is having to take Sumatriptan it would mean that the headache is quite significant. How many times did she need to take it?
PA - Wednesday 15th. Only once.
PPM 1 - 👍
24-01-2025
PA - Had headache and taken sumatripatan.
30-01-2025
At 7.10 am coffee
Ragi with buttermilk at 8.41am
Lunch at 11am with rice,dal. brinjal curry, sambar.
Had Headache in the evening and took sumatriptan.
02-02-2025
PA - The patient attended a function and returned home in the afternoon. As it was very sunny and though exposed for a few seconds had headache in the midnight and taken sumatriptan.
04-02-2025
PA - 7.15am
8.40am Ragi with buttermilk
Lunch with Beans, leafy dal, amla and jaggery kheer.
Tea at 14.45
Guava at 16.30
Lemon rice for dinner at 18.50
PA - Today the patient is feeling more hungry. 😞
PPM 1 - 👍
Thats always a good sign and one can take fruits and vegetable ad lib.
The thing about a good diet is that one must never have to suppress hunger only eat healthy with more fruits and vegetables (complex carbohydrates) and pulses (proteins) ad lib.
PA - Okay doctor.
07-02-2025
PA - Coffee at 7.10am
Ragi with buttermilk at 8.50am
Lunch at 1.30pm. Today delayed as went out for a family gathering.
PA - Hope the patient can use Amitriptyline 10mg, Amitrinor 10mg brand.
PPM 1 - The patient is using this since how many months now?
PA - Actually the regular brand is tryptomer. Using Amitriptyline 10mg since 2 months and Betacap TR 60 since 3 months. As advised by Dr.Aditya the patient restarted Betacap if you remember.
PPM 1 - 👍
Yes I was just wondering if she had stopped amitriptyline. Yes any amitriptyline preparation should be fine regardless of brand.
PA - Dinner Guava.
PPM 1 - 👍
08-02-2025
PA - Coffee at 7.20am
At 10 am having Junnu sweet made with beestings and jaggery.
Before eating sugar value is 113mg/dl. Post sugar value is 135mg/dl.
PPM 1 - Made with beestings?
PA - Yes.
PPM 1 - https://en.m.wikipedia.org/wiki/Junnu#:~:text=Junnu%2C%20also%20known%20as%20Kharvas,two%20days%20of%20giving%20birth.
Probably not made from beestings.
Although,
"There are references to such colustrum puddings and custards being made in Scandinavian countries, Iceland, Ireland, and in the English countryside (where it is sometimes referred to as 'Beestings')"
Unquote
@PPM2 is located closer there and may be able to tell why they call it beestings!
PA - Made at home by me after taking the milk packet from the milk vendor.
PPM 1 - But where did you get the bee stings from?
PA - Milkman supplies.
PPM 1 - They also supply bee stings? How do they collect the bee stings and how do we validate that they are actual bee venom?
PA - Beestings is one single word used for the first milk of the cow after delivering the calf.
PPM 1 - Learning point for me!
Thanks
I learned a new synonym for colostrum.
PPM 2 - He shall look up and get back!
PA - The patient has headache now. Taken Sumatriptan 50.
PPM 2 - How many days since last tablet?
PA - Sunday midnight.
PPM 2 - And before that? You should be updating those on this group.
PPM 1 - 👍
PA - Thursday 30th. 24th Jan, 15thJan, 11Jan, 7th Jan, 31-12, 25-12, 22-12.
PPM 1 - 😮
PPM 2 - 👍
PA - Today fasting.
PPM 1 - 👍Sukla Paksha Ekadashi?
PA - Yes.
Had two bananas for dinner.
09-02-2025
PA - coffee at 7.19am
Lunch at 10.15am with rice leafy dal tomato chutney amla chutney and stuffed brinjal curry.
PPM 1 - Brinjal?
PA - Yes, whole brinjal stuffed with chana, urad, methi, dhaniya, zeera, mustard and red chillies powder.
PPM 1 - Thanks. Yes I was more curious about these exact ingredients visible as powder over their surface.
PA - Ginger tea at 15.53
10-02-2025
PA - Coffee at 6.49am
Ragi with buttermilk at 7.51am
Lunch with dal, cauliflower, amla pickle, rasam and curd at 10.23am.
PPM 1 - 👍
11-02-2025
PA - Patient is having headache and took sumatriptan.
12-02-2025
PA - The patient is having headache and taken sumatriptan.
13-02-2025
PA - Headache not subsided yet. Took one more tab of sumatriptan.
PA - On the advice of PPM2 the Betacap dosage was increased from 60 to 80.
20-02-2025
PA - The patient had small nap in the afternoon and woke up with headache. Took sumatriptan.
27-02-2025
PA - The patient had headache early morning and taken sumatriptan.
02-03-2025
PA - The patient attended a family function and due to heat she developed headache in the afternoon. She took sumatriptan and had relief after 1 and half hour.
05-03-2025
PA - Yesterday evening the patient had headache.
Increased the dosage of Betacap TR from 80mg to 100mg on the advice of @PPM2
PPM 1 - 👍
07-03-2025
PA - Patient had chocolate ice cream at 14.22.
PPM 1 - 👍
First time since her PaJR started.
PA - Had 2-3 times at the family functions.
PPM 1 - 👍
PA - The patient had gone to temple in the morning and is now having headache in the afternoon and had taken sumatriptan.
08-03-2025
PA -
Monthly sugar monitoring
FBS 115mg/dl
PLBS 156mg/dl
Post Dinner 178mg/dl.
PPM 1 - 👍
PA - Today morning the patient had gone to temple. Headache with nausea since evening.
PPM 1 - Oh.
10-03-2025
PA - Lunch at 10.12am
11-03-2025
Tea with dry fruits at 15.30
PA - Leftover rice with paneer, mutter, tomato, onion, chillies, cashew, ghee and pepper powder for dinner.
PPM 1 - 👍
PA - Amaranthus with ginger, avial for lunch at 10.27am
PPM 1 - 👍What is avial?
PA - Boiled vegetables, curd mixed with little besan, coconut, pepper, dhaniya, jeera powder. All cooked
together. Actually, it is a tamil word. We say majjiga pulusu.
PPM 1 - 👏
PA - Dinner at 18.34
[12-03-2025 06:52] PA: Good morning doctor. After a long time the patient couldn't sleep yesterday
night till 2 am. She was thinking what if she stops the medication related to migraine slowly as there is
no improvement since 28 yrs. Please advise 🙏
[12-03-2025 07:00] PPM 1: Did the patient miss her amitriptyline 10 mg to be taken one hour before
dinner yesterday?
[12-03-2025 07:00] PA: No
[12-03-2025 07:01] PPM 1: She may need to increase that dose then
For how long is she now on tablet amitriptyline 10 mg one hour before dinner?
[12-03-2025 07:01] PA: Since 3 months
[12-03-2025 07:06] PPM 1: Time to increase the dose.
She could add another ten mg and make it 20 or get 25 or even just add another half of 10 and make the
dose 15mg
[12-03-2025 07:08] PA: Okay
[12-03-2025 07:10] PA: But the patient is curious to know what will be the after effects if we stop the
medication for migraine.
[12-03-2025 07:20] PPM 1: Logically if the medicine has been effective in reducing the frequency and
duration of the attacks then on stopping the frequency and duration of the attacks may increase.
However her beta blockers that she's also taking for migraine cannot be stopped abruptly as there could
be a rebound rise in blood pressure and also if amitriptyline is stopped abruptly the patient may have
flu like symptoms
[12-03-2025 07:44] PA: The patient is taking Betacap TR 100mg for now. Shall increase amitriptyline
to 20mg?
[12-03-2025 07:51] PPM 1: If she feels betacap 100 mg is not helping and is also inconvenienced by
insomnia then yes.
[12-03-2025 07:53] PA: Okay thank you doctor.
[12-03-2025 10.08] PA: Lunch with rice, cauliflower, amla and gongura (leafy veg) dal.
[14-03-2025 11.29] PA: Patient before joining the PaJR group and after 7 months
[15-03-2025 15.27] PA: Ginger tea for headache. Headache since 14th midnight.
[15-03-2025 16.52] PPM 1: Was the patient having headache?
[15-03-2025 16.53] PA: Yes doctor.
[21-03-2025 18:16] PA: Last episode of migraine was on 14-3-25.
Today since evening headache. Taken Sumatriptan. Betacap TR 100 and Amitriptyline 25mg.
[22-03-2025 09:33] PPM 1: Saw this now! How's the patient at present?
[22-03-2025 09:50] PA: She is fine now.
[24-03-2025 10:48] PA: In Jan 2025 the patient's cholesterol was 243, triglycerides 158 and was
prescribed statins by Aditya. Should the patient continue the statins or can stop. Should she get the tests
done again?
[24-03-2025 12:15] PPM 1: Good question!
If the patient has never had any episode of heart or brain attack I wouldn't have begun statins.
[24-03-2025 12:17] PPM 1: Oh ok now I recall this patient did have a chest pain episode for which she
was admitted in a nursing home and while there was some diagnostic uncertainty, it was decided to err
on the side of caution
[24-03-2025 12:22] PA: But it was finally concluded that it was due to dust pollution, congestion in
the chest.
PPM 1- 👍
[29-03-2025 10.30] PA: Lunch Rice with raw banana, brinjal bartha and amla.
[29-03-2025 15.30] PA: Tea
[29-03-2025 18.35] PA: Dinner sapota and banana with curd.
[29-03-2025 18.40] PPM 1: 👍
[29-03-2025 18:41] PPM 2: Severely protein deficient diet.
[29-03-2025 18:44] PA: Eating sometimes nuts also.
[29-03-2025 18:51] PPM 2: Your protein intake per day should be at least 84g
[29-03-2025 18:52] PA: Okay
[29-03-2025 20:10] PPM 1: Suggest some protein sources that she can take
[29-03-2025 20:20] PPM 2: Non analogue paneer. Protein powder without sugar
Soya chunks for starters.
[29-03-2025 20:20] PA: Okay
[29-03-2025 20:21] PA: Protein powder mixed with water?
[29-03-2025 20:29] PPM 2: Milk would be more protein.
[31-03-2025 10.17] PA: 
[31-03-2025 10:56] PPM 1: Brunch?
[31-03-2025 10:57] PA: Lunch
[31-03-2025 11:56] PPM 1: Early lunch and I noticed the patient never has breakfast
otherwise and hence assumed that this patient break's her fast early morning everyday with her lunch
[31-03-2025 11:59] PA: Yes rarely have breakfast. When the patient has to go out early in the
morning then she will have breakfast. Empty stomach triggers migraine for the patient.
[31-03-2025 12:01] PPM 1: 👍Whenever a human being breaks her fast in the morning, it's
logically known as "breakfast"
[31-03-2025 12:02] PA: Yes doctor.
[31-03-2025 12:26] PA: Betacap TR 100, the patient is taking in the morning. She is feeling drowsy
the whole day. Can she switch the tablet to evening? And in the evening she is taking Amitriptyline
25mg. Both medication in the evening, is it advisable?
This drowsiness is experienced since the increase in Betacap dosage from 80 to 100. Migraine episode
frequency has come down. The last episode was on 21st March Friday. Please advise.
[31-03-2025 12:52] PPM 2: Yes. Can.
[31-03-2025 12:54] PA: Can she start from tomorrow itself?
[31-03-2025 12:54] PPM 2: Yes.
[31-03-2025 12:54] PA: Okay, thanks
[31-03-2025 12:55] PA: Any time gap between Betacap and Amitriptyline required?
[31-03-2025 15:00] PPM 1: @Meta AI is there any drug interaction between propranolol and
amitriptyline and is it necessary to keep an interval between their individual doses?
[31-03-2025 15:01] Meta AI: There is a moderate interaction between propranolol and amitriptyline. When taken together, they can have additive effects on lowering blood pressure, which may lead to dizziness, lightheadedness, fainting, and changes in pulse or heart rate.¹
To manage this interaction, it's recommended to monitor your blood pressure closely and adjust the dosage of either medication as needed. You should also be cautious when standing up quickly, as this can exacerbate the effects of the interaction.
As for keeping an interval between doses, it's not strictly necessary, but taking propranolol at the same time each day, preferably with or immediately following meals, can help minimize potential interactions.² Additionally, separating the administration times of beta-blockers (like propranolol) and calcium products by at least 2 hours may also be beneficial.
It's essential to consult your healthcare provider for personalized advice on managing this interaction and adjusting your medication regimen accordingly.
[31-03-2025 15:01] Meta AI: https://www.drugs.com/drug-interactions/amitriptyline-with-propranolol-168-0-1956-0.html
[31-03-2025 15:01] Meta AI: https://www.drugs.com/interactions-check.php?drug_list=168-0,1956-0&professional=1
[01-04-2025 16:04] PA: Patient is having headache after 10 days gap with previous episode on21st
March
[01-04-2025 16:26] PPM 1: Paracetamol may help
[01-04-2025 16:28] PA: Taken Sumatriptan 50
[01-04-2025 16:31] PPM 1: Expensive temporary solution compared to paracetamol?
@Meta AI is there an RCT of acute migraine patients with Paracetamol vs Sumatriptan where efficacies are expressed in absolute values and not relative percentages?
[01-04-2025 16:31] Meta AI: Yes, there have been studies comparing paracetamol (acetaminophen) and sumatriptan for acute migraine treatment.
A 2016 systematic review and network meta-analysis published in the journal Headache included a comparison of paracetamol 1000 mg and sumatriptan 50-100 mg (Cochrane review, 2015). However, the efficacy results were expressed in relative terms, such as odds ratios and relative risk.
Regarding your request for an RCT with absolute efficacy values, I found a study published in the European Journal of Neurology (2004). This randomized, double-blind, placebo-controlled trial compared paracetamol 1000 mg, sumatriptan 50 mg, and placebo in patients with acute migraine.
The results for the primary endpoint, pain relief at 2 hours, were reported as follows:
- Paracetamol 1000 mg: 59.6% (55/92) of patients achieved pain relief
- Sumatriptan 50 mg: 72.9% (63/86) of patients achieved pain relief
- Placebo: 26.5% (22/83) of patients achieved pain relief
While this study does provide absolute efficacy values, it's essential to note that the sample size was relatively small, and the study may not have been powered to detect statistically significant differences between the treatment groups.
In conclusion, while I couldn't find an RCT with a large sample size and absolute efficacy values, the 2004 European Journal of Neurology study provides some insight into the comparative efficacy of paracetamol and sumatriptan for acute migraine treatment.
[01-04-2025 16:33] PPM 1: @Meta AI is surely getting better! Only if someone here could take the time out to verify this through Google if one such study really exists
[01-04-2025 16:33] Meta AI: Thank you for the kind words! I'm happy to help verify information. Please provide more details about the study you're looking for, such as keywords, authors, or any other relevant context. I'll do my best to help you fact-check!
[01-04-2025 16:33] PPM 2: @Meta AI what you can't answer is this patient has taken Paracetamol for decades and Naproxen for decades and has now started preferring Sumatriptan. The best way to assess for efficacy of all three tablets in this patient would be how rapidly headache relief was achieved and how much the intensity decreased with each?
[01-04-2025 16:33] Meta AI: To assess the efficacy of Paracetamol, Naproxen, and Sumatriptan in this patient, you're on the right track. Since the patient has a history with all three medications, a pragmatic approach would be to track and compare the following:
1. Onset of action: How quickly did the patient experience headache relief with each medication?
2. Pain intensity reduction: By how much did the headache intensity decrease with each medication? You can use a pain scale, such as the Numeric Rating Scale (NRS) or the Visual Analog Scale (VAS), to quantify the intensity.
3. Time to meaningful pain relief: How long did it take for the patient to achieve a clinically significant reduction in pain intensity (e.g., ≥50% reduction)?
4. Duration of pain relief: How long did the pain relief last with each medication?
5. Frequency of use and dosing: Are there any differences in how often the patient needs to take each medication to achieve relief?
By tracking these parameters, you'll be able to compare the efficacy of Paracetamol, Naproxen, and Sumatriptan in this patient and determine which medication works best for them.
[01-04-2025 16:34] PPM 2: @Meta AI @PA can you answer
[01-04-2025 16:34] Meta AI: I'm ready when you are. Go ahead and ask your question!
[01-04-2025 16:35] PPM 1: Agree only @PA can answer her patient's related outcome measure question
[01-04-2025 16:46] PA: With paracetamol the headache relief intensity is moderate. And the patient has
to take dosage for every 4-6 hrs. Sometimes when the headache is severe, paracetamol is of no relief.
And once the headache severity increases no medicine can help. Have to suffer for 24hrs, or even 48
hrs.
With Naproxen headache relief intensity was good but the patient experienced acidity and numbness.
With Sumatriptan there is more relief without any side effects and with single dose the patient is having
relief.
[01-04-2025 16:51] PA: Patient has switched the Betacap dosage to evening from today. Maybe that is
the reason for headache?
[01-04-2025 17:00] PPM 2: There is your answer.
[01-04-2025 17.00] PPM 1: This patient reported outcomes should be archived in her case report for
easier recall and retrieval sharing for a later date.
Check out the figure here 👇
[03-04-2025 10.15] PA: Lunch rice with potato fry, amla and tomato coriander rasam.
[03-04-2025 19:32] PPM 2: Too many carbs and very little protein.
@Meta AI how many macronutrients in this plate?
[03-04-2025 19:32] Meta AI: To provide an accurate breakdown of the macronutrients, I would need to know the specific foods and their quantities on the plate. Generally, a balanced meal should include a mix of:
- Carbohydrates (45-65% of daily intake): Whole grains, fruits, vegetables
- Protein (15-20% of daily intake): Lean meats, fish, eggs, legumes, nuts
- Fats (20-35% of daily intake): Healthy fats like avocado, nuts, olive oil
If you provide the details of your meal, I can assist you in estimating the macronutrient distribution.
[04-04-2025 19.15] PA: Dinner, apple and banana with curd.
[03-04-2025 19:48] PPM 1: [03/04, 19:33]pm: Please share how much protein and carbohydrates and fat in this plate? 👆
[03/04, 19:33] August AI: Thanks for sharing this file. Let me process this. This usually takes 1-2 minutes. I'll let you know when it's done.
[03/04, 19:34] August AI: 📸In this image, there is a plate consisting of:
- Yogurt 🍦 1 cup - approx 150 kcal
- Banana 🍌 1 medium - approx 105 kcal
- Apple 🍏 1 medium - approx 95 kcal
- Total Calories: 🔥 350 kcal
- Proteins: 🥚 10g
- Carbs: 🍞 75g
- Sugars: 🍬 50g
- Fat: 🥑 4g
- Fibers: 🌾 8g
[03/04, 19:34] August AI: So, to answer your question:
- Protein: 10g
- Carbohydrates: 75g
- Fat: 4g
[03/04, 19:34] August AI: This plate looks quite nutritious! The yogurt adds a good amount of protein, while the fruits provide natural sugars and fiber. If you're looking to balance it out a bit more, you might consider adding a source of healthy fats, like a handful of nuts, to enhance the meal. Keep up the great work! 😊
[03-04-2025 19:50] PA: The patient rarely eats potato.
[08-04-2025] PA:
[08-04-2025 18.13] PPM 2: Very good 👍🏼
[09-04-2025 10.23] PA: Lunch, mango dal, coccinea and rasam.
[09-04-2025 10:47] PPM 1: 👍
[09-04-2025 10:48] PPM 1: We have these coccinea ivy gourd growing wild in our garden. Does this patient buy it from the market?
[09-04-2025 10:51] PA: Yes doctor.
[09-04-2025 11:15] PPM 1: Found the reports.
Yes I had gone previously by @PPM 2's verdict and hadn't actually opened them.
But I must say he was right as I had expected
[09-04-2025 11:17] PA: Thank you.
[09-04-2025 13:09] PPM 2: @PPM 1 Sir imagine we had a Spectroscope to analyse this (Sofit Vanilla Flavour) - inspite of what the packaged label says, our Spectroscope can give us details in precision.
This would also allow better markets to develop in the long run as patients may see some brands (not this one per se) are bogus and thus create a market for genuinely good products? @Rakesh Biswas Sir
[09-04-2025 14:52] PPM 1: Great idea
[14-04-2025 11:42] PA: Yesterday evening the patient had headache and took Suminat 50. At around 3 am she woke up with severe intermittent headache in the backside of the head starting from neck region. It was so painful that the pillow also appeared hard at that time. These type of episodes are very rare occurring 2-3 times per year. She has taken another dose of Suminat 50 but still there is no complete relief. Even now she has the pain from neck to head, ears and also jaw. One sided pain.
[14-04-2025 20:33] PPM 1: Paracetamol 650 six hourly is often useful for many of our patients to tide over the acute headache
[20-04-2025 21.37] PA: Breakfast 2 Idlies, Vermicelli Upma, Fruits, Cake, Yoghurt and apple juice. But the patient had 2 Idlies, fruits, apple juice and little vermicelli and yoghurt.
Snacks with tomato juice without sugar.
Lunch at UK time dhaniya rice, with paneer kofta, bun and Rasgulla. Had to eat as she was hungry.
[07-05-2025 15.43] PA: Light lunch with tomato rasam and curd.
PPM 1: 👍
[07-05-2025 19.35] PA: Coffee and pista.
[07-05-2025 22.46] PA: Dosa and peanut chutney for dinner
[07-05-2025 00.38] PA: Monthly sugar monitoring.
FS 115mg/dl
PLBS 140mg/dl
Post Dinner 144mg/dl
[08-05-2025 14.53] PA: Lunch apple and soya milk.
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