22-11-2024
This is an online E Log book to discuss our patient's de-identified health data shard after taking his signed informed consent. Here we discuss our patient's 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.
The patient is a 49 year old Male with the history of Diabetes Mellitus since 12 yrs with uncontrolled sugars.
PPM 3 - Below are his sugar values and medication.
19-11-24
1 pm
366, 10 HAI, Metformin 500mg.
4 pm
237
7 pm
365, 12 HAI, 6 NPH, Metformin 500mg
10 pm
181
20-11-24
2 am 55
7 am 233, 10 HAI, 4 NPH, Metformin 500mg.
10 am 201
1 pm 202, 12 HAI, Metformin 500mg.
4 pm 159
7 pm 136, 10 HAI, Metformin 500mg.
10 pm 270
21-11-24
2 am 58
7 am 395 Glimiperide 1 mg, Metformin 500mg
10 am High
1 pm 335, 10 HAI, Metformin 500mg.
4 pm 289
7 pm 171 Glimiperide 2 mg, Metformin 500mg
10 pm 270
22-11-24
2 am 250
7 am 452 Glimiperide 2 mg, Metformin 500mg.
PPM 1 - 😮
PPM 3 - His GRBS charting since admission, he wanted to get discharged today @PPM1.
PPM 1 - Please share his lateral view of arm muscle and trunk asap.
Serum Creatinine!?
Amazing numbers.
PPM 3 - Creatinine 0.8 sir.
PPM 1 - 👍
He needs continued dose of titration. Is he trained to capture and share his blood sugars in the same way as done here?
PPM 3 - Yes sir.
PA - We will monitor sir and update every time checking GRBS.
PPM 1 - 👍
PA - Giving dose.
PPM 1 - Please don't share patient's name to protect his privacy.
PA - Ok sir. Today will you discharge the patient?
PPM 1 - 👍
PPM 4 - His premeal GRBS is now 400 sir @PPM1 Should we give 10HAI+ Tab Metformin 500mg after food sir??
PA - Can we give the patient rice or roti now?
PPM 1 - Yes ,10 HAI+Tab Metformin 500mg
23-11-2024
PA - Given 10 U before breakfast. After taking upma, GRBS is 465 sir.
PA - Morning breakfast.
PPM 1 - 👍
@PPM3 wasn't he supposed to be on tablet glimiperide and we were supposed to be increasing the dose?
PPM 4 - Yes sir we have advised him glimiperide 2 mg +tab Metformin 1000mg in the morning sir.
PPM 4 - This prescription is of July sir.
PPM 1 - 👍
PA - Afternoon sugar value.
PPM 4 - What did the patient eat?
PA - Morning he had Java and ate Upma.
PPM 4 - Now for lunch?
PA - Not yet.
He will have rice. Should he take injection? He is hungry.
PPM 4 - For today give 10 Actrapid before lunch. After 30 min of lunch give metformin 500mg.
PPM 3 - Please share the Post lunch GRBS value here.
PA - Okay
PPM 1 - At night what is the medication? But he also took 10U soluble insulin before breakfast today?
PPM 4 - Night also glimiperide 2mg +but with tab.metformin 500mg sir. Since they have taken today insulin HAI.
PPM 1 - 👍
PPM 4 - Today afternoon also advised for taking short acting 10 units sir.
PPM 1 - Let's see the post lunch after 2 hrs.
PPM 4 - Yes sir.
PA - Evening GRBS 277
PPM 4 - Post lunch GRBS??
PPM 1 - Today he may not have taken Glimiperide 2 mg in the morning?
PPM 3 - Yes sir.
PPM 1 - Why didn't he take it in the morning? Also he didn't check his fasting sugars today?
PPM 3 - @PA Didn't you check the fasting sugars in the mornng?
PPM 4 - Tomorrow please post all the values here. as follows alongwith medication.
Before breakfast (Fasting)
2 hrs after breakfast
Before lunch
After 2hrs of lunch
Before dinner
2 hrs after dinner
Midnight at 2 am
Now please give the patient glimiperide 2mg before food and tab metformin 500 mg after food.
PPM 1 - Maybe we just ask him
Fasting
And ppbs after every meal
4 times as anything more will break him.
PPM 4 - Okay sir.
Have you @PA given the tablets glimiperide 2 mg before food and metformin 500mg after food?
PA - Given mam.
PPM 4 - 👍
Please check after 2 hours.
PA - Okay
24-11-2024
PA - 2 am GRBS is 464
PPM 4 - 👍 Fasting GRBS??
PA - 473
PPM 4 - Glimiperide 2 mg before breakfast and tab. metformin 1000mg after breakfast.
PA - Is injection not necessary?
PPM 4 - Now not necessary. Will decide by the values.
PA - Sugar level is high
PPM 4 - Have you given the medication as mentioned above @PA?
PA - Given mam.
PPM 4 - @PPM1 sir previously in our ward also it happened like this.
Ppbs to be high and now should we consider short acting insulin daily?
PPM 1 - Well let's tackle the highs with short acting insulin till we can reach the maximal glimiperide dose.
Let's increase it today by 0.5mg making it 2.5mg before breakfast and dinner.
PPM 4 - 👍
He is now complaining of giddiness sir.
Now asked him to give 8 U HAI s/c only sir.
PPM 1 - 👍
PPM 4 - Before lunch should we add anything sir?
PPM 1 - Yes 4-6U of insulin at each evaluation of high blood sugars can be given safely although needs to be monitored hourly.
For adding before lunch, it depends on his sugar values before lunch.
As the sugars are currently uncontrolled we may have to at least continue the 7 point profile as you suggested earlier.
PPM 4 - Okay sir.
Please check the GRBS Before lunch @PA.
PPM 2 - Have we checked his ketones? Atleast in the Urine dip?
That body habitus doesn't scream type 2?
PPM 1 - 👍
PPM 4 - Yes sir , Negative.
PPM 2 - Okay thanks. Whyisn't gliclazide being considered instead of Glimiperide?
Any comparative trials you can fish out?
PPM 4 -
Here's a study comparing the efficacy of gliclazide and glimepiride in controlling blood sugar levels in type 2 diabetic patients ¹.
Population: 845 type 2 diabetic patients
Intervention: Gliclazide modified release (MR) 30-120 mg daily
Comparison: Glimepiride 1-6 mg daily
Outcome: HbA1c levels, fasting blood sugar (FBS), and postprandial blood sugar (PPBS) levels
The study found that both gliclazide and glimepiride significantly reduced HbA1c levels, FBS, and PPBS levels. However, gliclazide showed a slightly better safety profile, with fewer hypoglycemic episodes ¹.
Here are the absolute numbers and values:
- HbA1c reduction: Gliclazide: 2.44%, Glimepiride: 1.91% ²
- FBS reduction: Gliclazide: 52.5%, Glimepiride: 56.9% ¹
- PPBS reduction: Gliclazide: 41.3%, Glimepiride: 32.3% ¹
- Hypoglycemic episodes: Gliclazide: 3.7%, Glimepiride: 8.9% ¹
Overall, both gliclazide and glimepiride are effective in controlling blood sugar levels, but gliclazide may have a slightly better safety profile.
Yes sir I think we need to consider gliclazide here
Since PPBS and HBA1C have higher reduction in terms of percentage and alsp reduced hypoglycemic episodes when compared to glimperide.
But in this study
These were added to their previous OHA - either metformin or an alpha glucosidase inhibitor..
PPM 1 -
It's just one study and may not be representative of our entire glimiperide and gliclazide hypoglycemia universe.
Also we need more data surrounding the hypoglycemia events in the two groups to reach a meaningful conclusion about the safety of the two.
Bottom line: Oral hypoglycemic agent are meant to cause hypoglycemia and it's the art of controlling their potency that becomes important in deciding if they will cause hypoglycemia or not.
The shorter duration of action of gliclazide may be a disadvantage in terms of efficacy
PPM 4 -
Okay sir.
I think here in our patient
They got vexed by using all kinds of insulin injections and in a mind set that these sugars will be controlled only by injectables and not OHA.
And counselling them that we would give tablets and then slowly titre them accordingly seems a bit foolish for them.
And they want to use injectables sir.
How to go about this ??
PPM 2 -
Perhaps the cost consideration is the only reason stopping us?
Can you check the cost of a Ketone meter and let me know please?
PPM 4 - 👍
The cost ranges from 2.5k -9k sir
PPM 2 -
Oh boy! Would your team think getting a Ketone meter be useful?
PPM 1 -
Only when the higher dose titrations demonstrate sugar levels going down then they may think differently although there's always a chance that he may be LADA and his insulin reserve is low but then unless we go up to higher dose levels and follow up for a while it would be difficult to conclude.
We have in the past had patients with apparent secondary sulfonyl urea failure who once dose up titrated went on to develop hypoglycemia and needed dose down titration. So it's complex and time is still the greatest healer
PPM 2 -
Getting ketones would be the shortest route to better outcomes?
Ketones would confirm insulin deficiency definitively
PPM 1 -
Could have easily done that before Discharge while he was admitted
PPM 2 -
I would recommend your team to consider getting a Ketone meter from your pooled fund.
PPM 4 -
Sir urine for ketone bodies was negative sir
Blood ketones were not done
PPM 1 -
Can't take that to the patient's home once discharged
Urinary ketones are easily available in the hospital
PPM 2 -
Urine ketones are a no go. We need a quantitative assessment of blood ketones.
PPM 1 -
Oh blood ketones have never been done here
PPM 2 -
They show up much later than blood levels and are also tinkered by several drugs and even asymptomatic bacteriuria
I know sir. Which is why even a single Ketone level of >0.6 mmol should raise concern for insulin deficiency and lower threshold for insulin prescription.
PPM 1 -
Yes but we go by urine ketones and acidosis in ABG
Ketosis can happen even on a keto diet
PPM 2 -
To be applied in appropriate context *
Ideally our hospital should be arranging for it on a warfooting basis but the apathy is loud enough that it can be heard across continents!
PPM 1 - Here in this patient's context, it would be more important to know if he's going into ketoacidosis and just ketonemia may not move our decision to switch to life long insulin that easily
PPM 2 - I fully understand. The biggest difference is that - Unfortunately patients in India are invariably coerced into getting Insulin prescriptions as vials and needing to load them into syringes themselves and inject, which is tedious.
We prescribe pens here and compliance is much easier. But the cost is over the hills and far away
PPM 1 - 👍
PPM 2 - What's his last known HbA1c btw? And when was the last time he had an eye and foot check?
PPM 1 - Also that discrepancy between loading 100U vial doses into 40U syringes and vice versa.
Recently one of my patients confused me as he was using pens and i wasn't able to figure out if the same issue happens with pen cartridges too
PPM 4 - Outside hba1c done in june was 14.6
And in our hospital recent hba1c -8.5%
Fundoscopy done here
Suggestive of bilateral non proliferative diabetic retinopathy changes .
Sensory examination was normal.
PPM 1 - 👍
PPM 2 - Superb. Thanks for sharing.
I wouldn't trust our hospital HbA1c at all!
He needs to be on Insulin!!
PPM 1 - 👍
PPM 2 - Has he lost any weight recently? How's his usual appetite like?
PPM 1 - 👍
PPM 4 - Yes sir
He lost his weight when he was on mixtard along with OHA 'S from 60kg to 35-40 kgs
And then was started on
Inj.mixtard 20u in the morning.
And inj.glulisine 16u at night.
He was following this from June and now gained weight
And is now around 55kg according to him.
He has all the osmotic symptoms sir
Polyphagia polydypsia and nocturia
PPM 2 - Yes such rapid weight loss usually suggests insulin deficiency. He should be on Insulin.
What does the patient do for work? Does he drive?
PPM 4 - He was an autodriver sir
But now stays at home
And sometimes looks after his farms.
PPM 2 - 👍
What's his current opinion on taking insulin?
PPM 1 - This is the most important question
PPM 4 - He wants to take insulin sir.
He has opinion that oral tablets will not be sufficient for his sugar control .
PPM 2 - Good and why is he not on Insulin then?
PPM 1 - I guess we are the ones who wanted to test if he can do without it inspite of all the current data coming in now.
If the patient is fine with not testing his insulin reserves with OHAs and taking life long insulin we shouldn't subject him to this test
PPM 2 - Fully agree.
PPM 4 - Got a call from attenders
Saying that his sugars are high now before dinner
Asked them to give actrapid 10u s/c for now .
PPM 1 - 👍
25-11-2024
PPM 4 - What is the morning fasting GRBS? How many units insulin did you give the patient?
@PA didn't you check the GRBS?
27-11-2024
PPM 4 - Please post your patient's sugar chartings @PA.
28-11-2024
PPM 4 - @PA are the sugar levels in control? Are you giving the patient 10U HAI?
PA - Hello mam.
Since two days sugar levels around 360 to 400. Last night it was 512 and just now 501 mam.
Today he had rice quantity more. He is checking sugars regularly.
PPM 4 - Are the readings before or after food? Need to increase the insulin dosing??
Make it to 14 units 3 times a day along with metformin 500mg after food.
PA - Only today and night sugar is high. Now given insulin 12 unit.
PPM 4 - You can give 4 more units.
PA - Okay mam. Night or morning??
PPM 2 - Can he afford Flexpens or Glargine?
PPM 4 - He was not getting these pens sir?? It seems they are not available near by also
sir.
PPM 2 - Can you enquire the costs?
I used to have an allure for NPH but since I've started here - I've long grown out of it. This may sound harsh but we have to step out of the scarcity mindset and offer him the best we can within affordable means.
PPM 4 - When he was admitted we asked him about the price sir
His said it cost him around 1200-1500rs sir
PPM 2 - What costed 1200 to 1500? Insulin or the pens?
PPM 4 - Pen sir.
PPM 2 - Okay. Which pen was it?
And frankly 1200 1500 sounds reasonable. Was it okay for the patient?
29-11-2024
PPM 4 - Glargine pen sir
PPM 2 - Is he willing to take it now?
With Novorapid?
PPM 4 - Will need to find out sir.
No comments:
Post a Comment