30-12-2024
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her 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 patient's clinical problems with collective current best evidence based inputs.
PPM 1 - OPD right now:
19F type 1 diabetes since November 2023
On mixtard from her nearest government PHC thrice daily!
Occasional nocturia once or twice a week.
An interesting natural history of different innovations in insulin dose and interval delivery that happens in the third world @PPM2 @PPM3 that most of the first world educated physicians remain oblivious of!
Being a rural medicine pharmer has it's advantage in that one gets a ringside view of innovations that often don't percolate into the siloed world of evidence based guideline driven medicine although it's a fantastic opportunity for data driven medicine to check if patient outcomes are actually better even if due to system errors (that often remain invisible below the iceberg)!
PPM 2 - Agree. I was initially pitching for NPH in Type 1 as well. It is neck and neck with Detemir and Glargine but has rebound hyperglycemia too often.
Some form of Insulin is better than none at all!
PPM 1 - And what about its thrice daily schedule as implemented by the PHC and patient accidentally due to lack of information continuity?
PPM 2 - Well spontaneous order is generating new ideas and discoveries! Let's see how this plays out.
PPM 1 - 👍
PPM 3 - FBS 218, Hba1c 7.1
PPM 1 - Can they get admitted to see if mixtard thrice can be optimised?
PPM 3 - No sir they r not willing to
But they have glucometer at home sir.
PPM 1 - Alright ask them to share their blood sugars FBS, and two hours ppbs after every meal and prepare their PaJR groups after obtaining signed informed consent.
I guess they will find it difficult to get anything other than mixtard from the government PHC?
PPM 2 - Thanks. That HbA1c looks suspect. Is it HPLC based?
PPM 1 - No it's our latex agglutination as usual.
PPM 3 - She didn’t take her insulin today.
PPM 1 - 👍
What dose does she usually take?
PPM 3 - 6 4 6
PPM 1 - Let's ask her to share her sugars after taking the insulin in the same dose from whenever she can take her next dose.
PPM 3 - Yes sir counselled her regarding that
She will share her predinner sugars today.
PPM 1 - 👍
02-01-2025
PPM 3 - @PA did the patient check her sugars today?
03-01-2025
PA - Morning 55mg/dl
PPM 3 - 55???
PPM 1 - Not surprising given that she's on mixtard thrice daily?
Asymptomatic hypoglycemia or hypoglycemia unawareness?
https://userdrivenhealthcare.blogspot.com/2024/09/udlco-dyadic-asymptomatic-hypoglycemia.html?m=1
@PPM4 @PA of another diabetes group added you to another similar patient PaJR group being managed by @PPM3.
Hope it's not very confusing and we are all able to learn and help each other's journey using this hyperlocal strategy.
This patient is on mixtard thrice daily as a serendipitous innovation by the Telangana healthcare system that doesn't give actrapid insulin in their delivery systems and the patient has inadvertently started using this long acting and short acting insulin combination thrice daily for quite sometime (similar to another of our patients who also thrives on the same government insulin supply as documented in his case report by @case reporter ) and we wanted to investigate if this could be a valid strategy to achieve good control if one can optimize the dose using our hyperlocal strategy.
PPM 3 - I told to take twice daily sir
8 u morning and 6 units night.
PPM 1 - But do we know what actually she has taken? And we needed to have seen what were the results of her previous dosing that she has been following on her own since last many months.
PPM 3 - @PA what was the dosage of insulin yesterday night.
PA - 67mg/dl.
PPM 1 - @PPM3 any idea what dose of insulin was administered yesterday and today?
PPM 3 - Yesterday night 6 units
Today morning 8units
PPM 1 - And yesterday morning 8U of mixtard?
Should reduce both by 2U asap.
PPM 3 - Yes sir.
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