CONTINUATION OF 30F DIABETES1 10 YEARS MADHYA PRADESH CASE REPORT FROM THE PREVIOUS CASE REPORT LINK BELOW 👇
[31-05-2025 20:08] PA: 7 am drink 1/2 glass coconut water
9:20 am before breakfast sugar 150, 1/2 Glimepiride Tablet 1 Omeprazole tablet
9:25 am 2 roti with pumpkin fry 1 Metformin Tablet
11:20 am after breakfast sugar 157
11:40 am Drink 1 glass coconut water and Musk Melon
1:20 pm before lunch sugar 153
1:25 pm Salad, 2 roti with pumpkin fry
3:20 pm after lunch sugar 137
4:30 pm eat salad
6 pm eat 2 Marry gold biscuit
7:40 pm eat some roasted makhana and dry fruits.
[31-05-2025 22.23] PA: 08.50PM before dinner sugar 181mg/dl.
1/2 Glimepiride Tablet 1 Omeprazole tablet Rice with pumpkin fry and brinjal fry 1 Metformin Tablet
[01-06-2025 05:21] PA: Good morning sir
1/6/25
5:20 am fasting sugar 168
[01-06-2025 09:47] PPM 1: 👍
[01-06-2025 21:19] PA: 6 am 1/2 glass coconut water
9:15 am before breakfast sugar 143
1/2 Glimepiride Tablet 1 Omeprazole tablet 2 roti with ladyfinger fry 1 Metformin Tablet
11:20 am after breakfast sugar 164
11:35 am drink 1 glass coconut water, Musk Melon and 2 piece apple
1:20 pm before lunch sugar 126
1:25 pm Salad, 2 roti with ladyfinger fry
3:20 pm after lunch sugar 122
4 pm eat salad
7:40 pm eat long sew
9 pm before dinner sugar 145, 1/2 Glimepiride Tablet, 1 Omeprazole tablet, Rice with lentil and ladyfinger fry, 1 Metformin Tablet.
[01-06-2025 21:39] PPM 1: 👍
[02-06-2025 06:01] PA: Good morning sir
2/6/25
6 am fasting sugar 181
9:30 am before breakfast sugar 197, 1/2 Glimepiride Tablet, 1 Omeprazole tablet
9:35 am 2 roti with black gram fry
11:30 am after breakfast sugar 125
11:40 am drink 1 glass coconut water and Musk Melon & apple
1:25 pm before lunch sugar 114
1:30 pm Salad, 2 roti with black gram fry
3:30 pm after lunch sugar 150
4:30 pm eat salad
9 pm before dinner sugar 143, 1/2 Glimepiride Tablet, 1 Omeprazole tablet,Rice with black gram curry
1 Metformin Tablet
[02-06-2025 22:34] PPM 2: Can she gradually stop monitoring? @PPM1 Sir
[03-06-2025 05:49] PA: Good morning sir
3/6/25
5:50 am fasting sugar 145
[03-06-2025 08:47] PPM 1: It's her choice entirely
[03-06-2025 08:47] PPM 1: Currently the sugars look quite stable
[03-06-2025 08:51] PA: Sir, how many times should the patient check her sugar level in a day? Please tell.
[03-06-2025 08:52] PPM 1: Now you can switch to once a week in this same way
[03-06-2025 08:52] PA: Ok sir
[03-06-2025 08:53] PPM 1: Can continue sharing the food plates and daily hourly activities
[03-06-2025 08:53] PA: Yes sir
[03-06-2025 08:55] PA: Sorry sir patient is not able to update daily routine, will try to update it this week
[03-06-2025 09:23] PPM 1: Will add you to a patient's group where the daily hourly activities are updated daily just to give you the idea as to how it can be done.
[03-06-2025 20:44] PA: Ok sir
[03-06-2025 21:21] PA: 7 am drink 1/2 glass coconut water
9:20 am before breakfast sugar 134, 1/2 Glimepiride Tablet, 1 Omeprazole tablet
9:25 am, 2 roti with brinjal fry, 1 Metformin Tablet
11:20 am after breakfast sugar 160
11:40 am drink 1 glass coconut water and Musk Melon
1:25 pm Salad 2 Paratha with brinjal fry
4:30 pm eat salad
7:40 pm sugar 111 shivering problem 2 chocolate and roasted makhana
9 pm before dinner sugar 200, 1/2 Glimepiride Tablet, 1 Omeprazole tablet Rice with bitter gourd fry and spiny gourd curry, 1 Metformin Tablet
[03-06-2025 22:03] PPM 1: What time did the shivering start and what time was the sugar checked?
[03-06-2025 22:03] PA: Sir 7;15 pm
[03-06-2025 22:04] PA: Checked sugar at 7:40
[03-06-2025 22:06] PPM 1: I guess from 7:15PM to 7:40PM the sugars self corrected by compensatory release of catecholamines
[03-06-2025 22:07] PA: Ok sir
[04-06-2025 05:31] PA: Good morning sir
4/6/25
5:30 am fasting sugar 143
[04-06-2025 10:35] PPM 1: Can you share again the 4:30PM salad photo? Also why not ask the patient to take an early dinner before 7:00PM?
I myself as well as other members of our PaJR team here, finish our dinner before 7PM
[04-06-2025 13:54] PA: "Sorry sir, patient will not be able to eat. She does not reach home from office."
[04-06-2025 13:56] PA: Patient comes home from office between 7:45 and 7:55
[04-06-2025 16:29] PPM 1: Did the patient feel hungry before or after taking the salad yesterday at 4:30PM?
[04-06-2025 16:32] PA: Yes sir
[04-06-2025 22.39] PA: 6:30 am after coconut water
9:20 am before breakfast sugar 134, 1/2 Glimepiride Tablet, 1 Omeprazole tablet, 2 roti with long beans fry, 1 Metformin Tablet
1:15 pm, Salad,2 roti with long beans fry
After lunch the sugar level became 113 at 2 pm and if there is a problem of shivering then ate chocolate
Eat 1 chocolate, 3 pm eat salad, Then check sugar 128
6 pm Sorry sir patient was hungry and had nothing to eat except chocolate biscuits so she ate biscuits
7:50 pm eat some roasted peanuts and makhana
9:50 pm before dinner sugar 211, 1/2 Glimepiride Tablet, 1 Omeprazole tablet
Rice with long beans fry and lentil,1 Metformin Tablet
[05-06-2025 07:49] PA: Good morning sir
5/6/25
7:45 am fasting sugar 166
[05-06-2025 08:31] PPM 1: Did the patient have shivering at 2:00PM? Was the sugars checked as soon as she started shivering before eating the chocolate?
[05-06-2025 08:33] PPM 1: Does she carry her lunch to her office?
[05-06-2025 08:34] PPM 1: Don't take glimiperide 0.5 mg in the morning today
[05-06-2025 08:36] PA: Yes sir
[05-06-2025 08:36] PA: Yes sir
[05-06-2025 08:37] PA: Ok sir
[05-06-2025 08:38] PPM 1: So as soon as she started shivering her sugars were 113? @PPM2 perhaps the sugars increase even before compensatory catecholamine induced shivering kicks in?
[05-06-2025 08:39] PPM 1: Is the patient using a 0.5mg strength tablet?
If yes she can take half of that which is 0.25
[05-06-2025 08:39] PA: Patient carries lunch, fruits, coconut water and salad to office
[05-06-2025 08:47] PA: Sorry sir, I didn't understand strength tablet
[05-06-2025 08:49] PPM 1: What is the current strength in mg mentioned in her tablet packet?
Is it 1 mg or 0.5 mg? Can you share an image of the glimiperide tablets she's consuming?
[05-06-2025 08:57] PPM 1: This is showing 1 mg which I assume the patient is breaking in half and then taking. If the patient can buy a tablet which is 0.5 mg as shown here 👇
Then she could take half of the 0.5 mg tablet
[05-06-2025 08:59] PA: Ok sir
[05-06-2025 12:34] PPM 2: Yes and also possibly due to chronic diabetes, the autonomic system is attuned to produce symptoms at a much higher level of blood sugar?
[05-06-2025 13:04] PPM 1: Aha! Did we publish it earlier as hypoglycemia hyper-awareness syndrome here earlier?
[05-06-2025 23:29] PA: 8:30 am drink 1/2 glass coconut water
9 am Drink black tea without sugar
10 am before breakfast sugar 172
1 Omeprazole tablet
Dosa with green chutney
1 pm eat papaya and Musk Melon
2:45 pm before lunch sugar 123
2:50 pm Salad, rice with brinjal fry, bottle gourd curry and yellow lentil
6:30 pm eat biscuit
9:40 pm 1 Omeprazole
patient had gone to the market so she ate this sabudana khichdi and Manchurian rice 4-5 spoon
1 Metformin Tablet
[06-06-2025 00:01] PPM 2: I guess she can stop the monitoring and switch to once every 3 days.
[06-06-2025 08:51] PA: Ok sir
[06-06-2025 09:23] PA: Sir, should the patient take Glimepiride Tablet 1 mg in half because 0.5 tablet not able to get right now
[06-06-2025 09:41] PPM 1: Yesterday no glimiperide taken or not mentioned?
Taking half of 0.5 was meant to provide the patient with 0.25 mg of dose but if the patient takes half of 1 mg she will still get 0.5 mg and currently even that dose could be causing her shivering.
[06-06-2025 09:42] PA: Ok sir
[06-06-2025 09:45] PPM 1: Please share how much glimiperide was taken by the patient yesterday
[06-06-2025 09:46] PA: Sorry sir, Yesterday also she had problem of shivers and sugar level was 135 then she ate biscuit
[06-06-2025 09:47] PPM 1: How much glimiperide did the patient take yesterday?
[06-06-2025 09:47] PA: Sir she didn't take Glimepiride tablet yesterday
[06-06-2025 09:48] PA: Today's Fasting is 154
[06-06-2025 11:11] PPM 1 Both morning and evening?
Was the patient taking half tablet of 1 mg morning and evening?
[06-06-2025 11:12] PPM 1: At 6:30PM?
[06-06-2025 11:34] PA: Yesterday she did not take Glimepiride Tablet
[06-06-2025 11:35] PA: Yes sir morning and evening.
[06-06-2025 11:35] PA: Yes sir at 6.30pm
[06-06-2025 16:26] PA: 9 am Drink 1 glass coconut water
10 am 1 Omeprazole tablet, Breakfast 2 Paratha with Bundi raita, 1 Metformin Tablet
2:30 pm, Lunch 3 roti with bottle gourd fry, Bundi raita and papaya
[06-06-2025 16:28] PPM 1: 👍
[06-06-2025 22:44] PA: 6:30 pm eat 1 ice cream
9:30 pm before dinner sugar 153, 1 Omeprazole tablet, 2 roti with pumpkin fry and curd, 1 Metformin Tablet
[07-06-2025 07:24] PPM 1: 👍
[07-06-2025 22:12] PA: Today the patient is having body pains throughout the day
7 am drink 1 glass coconut water
8:55 am,1 Omeprazole tablet, Breakfast, 2 roti with brinjal fry, 1 Metformin Tablet
11:30 am drink 1 glass coconut water and Musk Melon
Lunch 1:25 pm, Salad, 2 roti with brinjal fry
4 pm eat salad
6 pm chocolate biscuit and some chips
9:25 pm, 1 Omeprazole tablet, Salad, rice with mix dal, 1 Metformin Tablet
[08-06-2025 07:40] PA: Sir, the patient is having severe body pains since yesterday. Can she take any medicine?
[08-06-2025 08:01] PPM 4: Maybe managing micronutrient deficiencies if any, can help with body pains.
[08-06-2025 10:20] PPM 1: What does the patient usually take for her body pains? Since when has she first noticed these body pains? Since 2015 when her illness began?
[08-06-2025 10:51] PA: Ultracet tablet
[08-06-2025 10:52] PA: Sir, last time when she took it, she was feeling very dizzy
[08-06-2025 11:38] PPM 1: Yes that's a side effect.
To avoid that the patient can even take plain paracetamol 5
650 mg every 6 hourly for one day
[08-06-2025 12:54] PA: Ok sir
[08-06-2025 23.08] PA: 7 am drink 1 glass coconut water
9:15 am 1 Omeprazole tablet, 2 roti with pointed gourd fry
11:20 am drink 1 glass coconut water and Musk Melon
1:10 pm Salad, 2 roti with pointed gourd fry
4 pm eat 2 pieces of dahi Puri and bhel
8:30 pm eat some soya sticks
10:30 pm 1 Omeprazole tablet, Rice with Tuar dal,saag fry and pointed gourd fry, 1 Metformin Tablet
1/2 Paracetamol tablet
[09-06-2025 07:04] PPM 1: 👍
[09-06-2025 22:27] PA: 9:20 am, 1 Omeprazole tablet, 2 roti with sponge gourd fry,1 Metformin Tablet
1 Paracetamol tablet
11:30 am eat Musk Melon
1:30 pm eat Chawal fry,2 roti with sponge gourd
7:30 pm eat some soya sticks
9:25 pm 1 Omeprazole tablet, Rice with sponge gourd fry and Malabar spinach curry,1 Metformin Tablet, 1 Paracetamol tablet
PPM 1: 👍
[10-06-2025 13:03] PA: Sir can the patient take this medicine GLIMEPIRIDE 0.5MG
[10-06-2025 16:46] PPM 1: Yes let's start with half of that before breakfast.
[10-06-2025 19:19] PA: Sir should the patient take it before dinner also.
[10-06-2025 19:26] PA: Sir, today patient went to AIIMS hospital because she was feeling burning and fatigue in her eyes.
[10-06-2025 21:20] PA: Breakfast
9:30 am, 1 Omeprazole tablet, 2 roti with black gram curry, 1 Metformin Tablet,1 Paracetamol tablet
12:30 pm eat dokla and chips
3:30 pm Eat black gram curry
7 pm jaamun
9 pm 1 Omeprazole tablet, Rice with boiled potato and black gram curry,1 Metformin Tablet.
[11-06-2025 06:59] PPM 1: No let's first see the effect of taking it once daily.
If the patient is starting today then she would need to share her fasting and then two hours after every meal blood sugars today
[11-06-2025 07:14] PA: Ok sir
[11-06-2025 14:23] PA: Today's Fasting sugar 187
9 am Drink 1 cup black tea without sugar
9:40 am before breakfast sugar 180,1 Omeprazole tablet, 1/2 Glimepiride Tablet 0.5 mg,2 roti with bottle gourd fry, 1 Metformin Tablet
12 pm after breakfast sugar 237
12:30 pm drink 1 glass coconut water
1 pm eat Musk Melon
2:15 pm before lunch sugar 114, Salad, Rice with bottle gourd fry, ladyfinger fry, spiny gourd fry and mix dal
[11-06-2025 20.22] PA: 6 pm after lunch sugar 207
6:15 pm eat papaya
7 pm drink 1/2 cup black tea without sugar
[11-06-2025 21:12] PPM 1: No shivering?
Can take 1/2 of 0.5 mg glimiperide before dinner
[11-06-2025 21:13] PA: No sir
[11-06-2025 21:13] PA: ok sir
[11-06-2025 22:14] PA: 9:45 pm before dinner sugar 156, 1/2 Glimepiride Tablet 0.5 mg, 1 Omeprazole tablet, Rice with bottle gourd fry, ladyfinger fry, curd raita and mix dal,1 Metformin Tablet
[12-06-2025 10:47] PPM 1: 👍
[12-06-2025 20:03] PA: Today's Fasting sugar 176
8 am drink 1/2 cup black tea without sugar
9:20 am before breakfast sugar 177, 1/2 Glimepiride Tablet, 1 Omeprazole tablet,2 roti with bottle gourd fry and curd raita, 1 Metformin Tablet
11:20 am after breakfast sugar 250
11:40 am eat Musk Melon
1:25 pm before lunch sugar 141
2 roti with bottle gourd fry and curd raita
3:25 pm after lunch sugar 164
4:10 pm eat salad
7 pm eat some roasted makhana and dry fruits
8 pm drink 1 glass coconut water
[12-06-2025 21:11] PA: 9 pm before dinner sugar 194, 1/2 Glimepiride Tablet,1 Omeprazole tablet
Rice, carrot, soya chunks curry, bottle gourd fry and curd raita, 1 Metformin Tablet
[13-06-2025 02:53] PPM 2: Looks like weight bearing exercise is completely lacking and this is certainly having an impact on her outcomes
[13-06-2025 09:18] PPM 1: Thanks
Please mention half tablet of 0.5 mg glimiperide (0.25 mg)
Also share the two hour post values after taking 0.25 mg glimiperide just for a few days as this is a new dose change in the patient
[13-06-2025 11:34] PA: Ok sir
[13-06-2025 20:13] PA: Today's Fasting 172
8 am drink 1 glass coconut water
9:10 am before breakfast sugar 193, 1/2 Glimepiride Tablet, 1 Omeprazole tablet
9:15 am 2 roti with sponge gourd fry
11:15 am after breakfast sugar 167
11:30 am drink 1 glass coconut water and Musk Melon
1 pm before lunch sugar 137, Salad, 2 roti with sponge gourd fry
3:45 pm eat salad
6:30 pm eat some roasted makhana and dry fruits
[13-06-2025 20:19] PPM 1: Today's fasting is the effect of 0.25 mg glimiperide taken yesterday
[13-06-2025 20:22] PA: Yes sir
[13-06-2025 20:28] PPM 1: And 167 is the effect of 0.25 mg of glimiperide. Better to say 0.25 mg rather than just half tablet
[13-06-2025 21:29] PA: Ok sir
[13-06-2025 21.50] PA: 8:30 pm eat bhel
9:25 pm before dinner sugar 176, 1 Omeprazole tablet, 0.25 mg Glimepiride Tablet
Rice with sponge gourd fry and arum curry, 1 Metformin Tablet
[14-06-2025 10:06] PPM 1: Two hours after night 0.25 mg and today's fasting?
[14-06-2025 11:44] PA: Sir
Today's Fasting 188
Before breakfast sugar 139
After breakfast sugar 153
[14-06-2025 17:09] PPM 1: Just fasting and two hours after every meal would be sufficient for 2 days
[14-06-2025 18:38] PA: Ok sir
[14-06-2025 20.01] PA: Today's Fasting sugar 188
9:20 am before breakfast sugar 139, 0.25 mg Glimepiride Tablet, 1 Omeprazole tablet, 2 roti with brinjal fry, 1 Metformin Tablet
11:20 am after breakfast sugar 153
11:40 am drink 1 glass coconut water and Musk Melon
1:40 pm before lunch sugar 102
Eat 3 paratha with brinjal fry and salad, one chocolate and 2 Glucon-D tablet
4 pm after lunch sugar 155
4:10 eat salad
6:40 pm eat some roasted makhana and dry fruits
8 pm eat ice cream
[14-06-2025 22:33] PA: 10 pm before dinner sugar 175
0.25 mg Glimepiride Tablet, 1 Omeprazole tablet, Rice with brinjal fry and lentil, 1 Metformin Tablet
[15-06-2025 10:38] PPM 1: 👍well done
Now you don't need to do before meals sugar
Can just do fasting alone and two hours post breakfast, lunch and dinner for 2 more days
And then once if everything is fine we can make this 4 point check once weekly
[15-06-2025 11:50] PA: Ok sir
[15-06-2025 19:37] PA: Today's Fasting sugar 161
8:45 am drink 1/2 glass coconut water
9:15 am before breakfast sugar 190, 0.25 mg Glimepiride Tablet, 1 Omeprazole tablet, Rice with potato fry, lentil and curd raita, 1 Metformin Tablet
11:20 am after breakfast sugar 131
11:40 am drink 1 glass coconut water and Musk Melon
1:25 pm before lunch sugar 102
Eat half lunch,Rice with potato fry, lentil and curd raita
3:30 pm after lunch sugar 155
4 pm eat half lunch
6:30 pm eat salad
[15-06-2025 21:24] PA: 9:20 pm before dinner sugar 129
0.25 mg Glimepiride Tablet, 1 Omeprazole tablet, Rice with curd raita and potato fry, 1 Metformin Tablet
[15-06-2025 23:03] PA: After dinner sugar 224
[16-06-2025 10:01] PPM 1: 👍
[16-06-2025 20.03] PA: Today's Fasting sugar 161
8:45 am Drink 1/2 glass coconut water
9:25 am before breakfast sugar 176, 0.25 mg Glimepiride Tablet, 1 Omeprazole tablet, 2 roti with ladyfinger fry
11:25 am after breakfast sugar 123
11:40 am drink 1 glass coconut water and Musk Melon
1:30 pm before lunch sugar 102
Eat 1 chocolate, Salad, 3 roti with ladyfinger fry and mango pickle. Then eat 1 Glucon-D tablet
3:30 pm after lunch sugar 165
4 pm eat salad
6 pm eat some roasted makhana and dry fruits
[16-06-2025 21:35] PPM 1: Why glucon d after lunch?
[17-06-2025 05:40] PA Sir, because the patient was having a problem of shivering
[17-06-2025 07:12] PPM 1: At 1:30 PM immediately after lunch?
Patient couldn't check the glucose during shivering as she was in office?
[17-06-2025 07:13] PPM 1: After how much time of taking the glucon d tablet did the shivering stop?
[17-06-2025 08:02] PA: Half an hour later
[17-06-2025 08:04] PA: Sir, I had checked my sugar and had lunch but shivering was not getting better, so I took Glucon-D tablet
[17-06-2025 08:12] PPM 1: So when did the shivering start exactly?
[17-06-2025 09:20] PA: 1:20 pm
[17-06-2025 12:14] PPM 2: A pattern of autonomic dysregulation is emerging and possibly not linked to Hypoglycemia.
[17-06-2025 14:38] PPM 1: But she did feel better after glucon d
[17-06-2025 14:39] PPM 1: It may have been 60 at 1:20 PM and it increased to 102 at 1:30PM along with the catecholamine induced shivering as well as glucose liberation
[17-06-2025 14:41] PPM 2: Placebo?
Autonomic symptoms like shivering are very commonly due to Hypos but Whipples triad does not apply when she does not have a hypo?
[17-06-2025 14:41] PPM 2: Which means this is autonomic dysfunction from something else?
[17-06-2025 14:43] PPM 1: She didn't check in time to detect the hypo
[17-06-2025 15:36] PPM 2: Understandable but this is a hypothesis as well. If this continues, she will perhaps need a CGM to correlate with symptoms.
[17-06-2025 15:37] PPM 2: Also she had a good mixed meal lunch before the glucon d
[17-06-2025 16:26] PPM 1: Yes it's what is really intriguing if the hypothesis were proven true as to why does the adrenergic activity of muscle tremors persists long after the hypoglycemia is compensated
[17-06-2025 17:41] PPM 2: Let me review some literature and get back on this sir.
[17-06-2025 18:40] PPM 1: @Meta AI @~Dr.Abdulsalam any literature on hypoglycemia hyperawareness manifesting as neuroglycopenic hypoglycemia tremors particularly with respect to the dys-correlation in onset and recovery from tremors visa vi blood sugar values as elucidated in the conversations below:
[16/06, 21:35]cm: Why glucon d after lunch?
[17/06, 05:40] Patient DM1 MP Advocate 2: Sir ,because the patient was having a problem of shivering
[17/06, 07:12 cm: At 1:30 PM immediately after lunch?
Patient couldn't check the glucose during shivering as she was in office?
[17/06, 07:13]cm: After how much time of taking the glucon d tablet did the shivering stop?
[17/06, 08:02] Patient DM1 MP Advocate 2: Half an hour later
[17/06, 08:04] Patient DM1 MP Advocate 2: Sir, I had checked my sugar and had lunch but shivering was not getting better, so I took Glucon-D tablet
[17/06, 08:12]cm: So when did the shivering start exactly?
[17/06, 09:20] Patient DM1 MP Advocate 2: 1:20 pm
[17/06, 12:14] Metacognitist Mover and Shaker1: A pattern of autonomic dysregulation is emerging and possibly not linked to Hypoglycemia.
[17/06, 14:38]cm: But she did feel better after glucon d
[17/06, 14:39]cm: It may have been 60 at 1:20 PM and it increased to 102 at 1:30PM along with the catecholamine induced shivering as well as glucose liberation
[17/06, 14:41] Metacognitist Mover and Shaker1: Placebo?
Autonomic symptoms like shivering are very commonly due to Hypos but Whipples triad does not apply when she does not have a hypo?
[17/06, 14:41] Metacognitist Mover and Shaker1: Which means this is autonomic dysfunction from something else?
[17/06, 14:43]cm: She didn't check in time to detect the hypo
[17/06, 15:36] Metacognitist Mover and Shaker1: Understandable but this is a hypothesis as well. If this continues, she will perhaps need a CGM to correlate with symptoms.
[17/06, 15:37] Metacognitist Mover and Shaker1: Also she had a good mixed meal lunch before the glucon d
[17/06, 16:26]cm: Yes it's what is really intriguing if the hypothesis were proven true as to why does the adrenergic activity of muscle tremors persists long after the hypoglycemia is compensated
[17/06, 17:41] Metacognitist Mover and Shaker1: Let me review some literature and get back on this sir.
[17-06-2025 18:41] Meta AI: The discussion revolves around a patient with diabetes experiencing shivering and tremors, potentially related to hypoglycemia, but with a complex pattern of autonomic dysregulation. Key points include:
1. Shivering started at 1:20 PM, with glucose possibly being 60 mg/dL, and improved after Glucon-D tablet consumption.
2. Glucose levels increased to 102 mg/dL after lunch, but tremors persisted.
Possible explanations:
1. Autonomic dysfunction: Shivering and tremors might not be directly linked to hypoglycemia.
2. Delayed response: Adrenergic activity persists after hypoglycemia is corrected.
3. Placebo effect: Glucon-D might have had a psychological impact.
To better understand, a Continuous Glucose Monitoring (CGM) system could help correlate symptoms with glucose levels. Relevant literature might explore:
1. Hypoglycemia-associated autonomic failure (HAAF)
2. Adrenergic symptoms in diabetes
3. Glucose variability and autonomic dysfunction
Would you like me to search for specific studies or papers on this topic?
[17-06-2025 18:41] PPM 1: @Meta AI please do
[17-06-2025 18:41] Meta AI: The patient's symptoms suggest a complex interplay between hypoglycemia and autonomic dysregulation. Let's dive into the possible explanations:
- Autonomic Dysfunction: Shivering and tremors might not be directly linked to hypoglycemia, but rather a manifestation of autonomic nervous system dysfunction, which is common in diabetes.
- Delayed Response: Adrenergic activity can persist after hypoglycemia is corrected, leading to prolonged symptoms.
- Placebo Effect: Glucon-D might have had a psychological impact, contributing to symptom improvement.
To better understand the relationship between glucose levels and symptoms, a Continuous Glucose Monitoring (CGM) system could provide valuable insights.
Relevant studies on this topic explore:
- Hypoglycemia-Associated Autonomic Failure (HAAF): A condition where recurrent hypoglycemia leads to impaired counterregulatory responses and hypoglycemia unawareness.
- Adrenergic Symptoms in Diabetes: Research on the role of adrenergic activity in diabetes, including its impact on symptoms like tremors and shivering.
- Glucose Variability and Autonomic Dysfunction: Studies on how glucose fluctuations affect autonomic nervous system function.
Some key findings include¹ ²:
- HAAF is a vicious cycle of recurrent hypoglycemia, caused by impaired glucagon and epinephrine responses.
- Antecedent hypoglycemia can shift glycemic thresholds for sympathoadrenal activation to lower plasma glucose concentrations.
- Reduced sympathoadrenal responses play a key role in the pathogenesis of HAAF.
Would you like more information on these topics or specific studies?
[17-06-2025 18:41] Meta AI: https://diabetesjournals.org/diabetes/article/54/12/3592/14019/Mechanisms-of-Hypoglycemia-Associated-Autonomic
[17-06-2025 20:42] PA: 6:30 am drink 1/2 cup black tea without sugar and 1 roti
8:40 am drink 1/2 glass coconut water
9:20 am before breakfast sugar 190, 0.25 mg Glimepiride Tablet, 1 Omeprazole tablet, 2 roti with bottle gourd fry
11:20 am after breakfast sugar 124
11:40 am drink 1 glass coconut water and Musk Melon
1:30 pm before lunch sugar 154
Salad,3 roti with bottle gourd fry
3:30 pm after lunch sugar 160
3;35 pm eat salad
6 pm eat some roasted makhana and dry fruits
[17-06-2025 20:49] PPM 1: 👍
[17-06-2025 21:43] PA: 8:45 am eat Mixture
9:45 pm before dinner sugar 169, 0.25 mg Glimepiride Tablet, 1 Omeprazole tablet, Rice with Tuar dal
1 Metformin Tablet
[17-06-2025 23:37] PPM 5: Here's a comprehensive *literature synthesis* exploring the phenomenon of *neuroglycopenic hypoglycemia presenting with tremors in the context of hypoglycemia unawareness, particularly focusing on the **dys-correlation between symptom onset and glucose readings* — as illustrated in your WhatsApp discussion:
---
## 🧠 *Overview of Key Insights*
Recent literature reveals that the onset and resolution of hypoglycemia symptoms—especially autonomic ones like *tremors and shivering—can often **lag behind or precede actual blood glucose changes, especially in patients with **hypoglycemia unawareness* or *autonomic dysfunction. The disconnect between **perceived symptoms* and *measured glycemic values* may stem from:
* *Altered thresholds for counterregulatory response*
* *Impaired sympathetic nervous activity*
* *Delayed cerebral glucose normalization* after plasma glucose recovery
* *Persistent adrenergic effects* despite glycemic normalization (e.g., catecholamine clearance lag)
---
## 📚 *Key Literature on Hypoglycemia Symptom-Glycemia Mismatch*
1. *Nwokolo, M. (2020).*
Brain responses in T1DM with impaired hypoglycemia awareness
📖 King’s College London Thesis.
➤ [Link to full thesis (PDF)](https://kclpure.kcl.ac.uk/portal/files/156366778/2020_Nwokolo_Munachiso_0201831_ethesis.pdf)
Explores how patients with impaired awareness exhibit *altered CNS and autonomic responses, potentially leading to **discrepant symptom timing* relative to blood glucose values.
2. *Walkinshaw, E. (2018).*
Relationship between IAH and autonomic neuropathy in T1DM
📖 University of Leeds Thesis.
➤ [PDF](https://etheses.whiterose.ac.uk/id/eprint/22423/1/Walkinshaw%20Thesis%20260718.pdf)
Demonstrates how *loss of sympathetic warning signals (e.g., tremors)* occurs in T1DM with autonomic neuropathy, often *uncoupling symptoms from actual hypoglycemia*.
3. *Schultes, B., et al. (2024).*
Hypoglycemia unawareness – Pathophysiology and clinical implications.
📖 Biomedicines, 12(2), 391.
➤ [PDF](https://www.mdpi.com/2227-9059/12/2/391/pdf)
Describes how *altered glucose sensing and counterregulatory responses* lead to *post-hypoglycemic adrenergic symptom persistence*, such as tremors.
4. *Frier, B. M. (2009).*
Hypoglycemia. In Diabetes and the Brain.
➤ [Springer Chapter](https://link.springer.com/chapter/10.1007/978-1-60327-850-8_6)
A foundational reference showing that *tremors can precede or outlast glucose dips, reflecting **autonomic dysfunction* rather than accurate glucose levels.
5. *Geddes, J. (2011).*
Hypoglycemia in adults with and without IAH
📖 University of Edinburgh Thesis.
➤ [PDF](https://era.ed.ac.uk/bitstream/handle/1842/5584/Geddes2011.pdf)
Notes *delayed recovery of cognitive and autonomic function* following hypoglycemia, explaining mismatched symptom resolution.
6. *Awoniyi, O., et al. (2013).*
Hypoglycemia in Type 1 Diabetes.
📖 Current Diabetes Reports, 13, 713–720.
➤ [Springer Link](https://link.springer.com/article/10.1007/s11892-013-0411-y)
Discusses *mismatch between caloric supply and insulin effect, and how it can lead to **false or prolonged symptoms* unrelated to glucose readings.
7. *Giannakopoulos, A., et al. (2022).*
Hypoglycemia-associated autonomic failure (HAAF)
📖 Clinical Diabetes, 40(2), 250–258.
➤ [PDF](https://diabetesjournals.org/clinical/article-pdf/40/2/250/704736/diaclincd210100.pdf)
Distinguishes HAAF from unawareness, suggesting that *symptoms like tremors may persist even after glycemia normalizes*.
8. *Verhulst, C.E.M. et al. (2022).*
Glycaemic thresholds and symptom responses in T1DM.
📖 Diabetologia.
➤ [PDF](https://link.springer.com/content/pdf/10.1007/s00125-022-05749-8.pdf)
Systematic review showing *individualized thresholds* for symptom onset and glucose recovery, *amplifying symptom-glycemia mismatch*.
9. *Fritsche, A. et al. (2001).*
Avoidance of hypoglycemia restores awareness via β-adrenergic pathways.
📖 Annals of Internal Medicine, 134(9).
➤ [Link](https://www.acpjournals.org/doi/abs/10.7326/0003-4819-134-9_part_1-200105010-00009)
Shows how restoring β-adrenergic sensitivity improves symptom-glycemia correlation.
10. *Mcaulay, V., et al. (2006).*
Effects of acute hypoglycemia on cognition and motivation in T1DM.
📖 Journal of Clinical Psychopharmacology.
➤ [PDF](https://www.academia.edu/download/118766418/01.jcp.0000203202.41947.6d20241009-1-wnhk38.pdf)
Demonstrates that *cognitive and autonomic recovery lags plasma glucose restoration*, validating anecdotal observations like the one discussed.
---
## 🔍 Clinical Interpretation from the Literature
The following conclusions support the clinical phenomena seen in your WhatsApp discussion:
* ✅ *Tremors and shivering* may be part of *delayed adrenergic fallout* after glycemia is normalized—especially in IAH (Impaired Awareness of Hypoglycemia).
* ✅ In patients with *autonomic dysfunction or blunted β-adrenergic response, **subjective symptoms may not match real-time glucose values*.
* ✅ Use of *Glucon-D* post-meal improving symptoms might be *coincidental* or due to *perceived reassurance, rather than a true glycemic correction—possibly a **placebo or threshold-related response*.
* ✅ Suggestion for *CGM correlation* is evidence-backed—continuous monitoring could delineate whether symptoms correlate with blood glucose troughs or are due to unrelated autonomic activity.
---## 📌 Recommendation
For patients like the one described:
* Deploy *CGM with event markers* for symptoms like tremors/shivering.
* Consider *autonomic function testing* if symptoms are frequent and unrelated to glucose.
* Investigate *HAAF* and IAH with counterregulatory hormone profiling if needed.
---
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[18-06-2025 00:13] PPM 2: In the present study, the 5 h OGTT was performed in subjects without diabetes with medically unexplained symptoms. Among them, 92% had hypoglycemia below 70 mg/dL (3.9 mmol/L) 4–5 h after glucose loading, and their symptoms worsened during that time period. This finding suggested that the complaints included many symptoms associated with hypoglycemia. Additionally, the analysis based on the pattern of insulin secretion revealed that autonomic symptoms persisted even after glucose loading in the early insulin secretion group, indicating that the symptoms may be related not only to hypoglycemia but also to the timing and amount of insulin secretion. Therefore, monitoring blood glucose and insulin fluctuations in patients with medically unexplained symptoms could be useful.
[18-06-2025 00:13] PPM 2: https://ww.nature.com/articles/s41598-025-91544-5w
[18-06-2025 00:15] PPM 2: Meanwhile, since the relationship between blood glucose and symptoms is unclear, some studies have examined the diagnostic utility of the 5 h OGTT11,12,13,14. Charles et al. reported that 23%–25% of those who underwent the 5 h OGTT developed hypoglycemia during the test, with or without hypoglycemic symptoms. Furthermore, 78% of those who did not experience hypoglycemia experienced hypoglycemia-like symptoms13. Thus, they concluded that hypoglycemia was not related to symptoms but to other factors. Our study results showed a similar frequency of post-load hypoglycemia and occurrence of symptoms consistent with hypoglycemia. However, hypoglycemia alone could not explain all symptoms associated with blood glucose fluctuations. Therefore, other factors involved in blood glucose regulation, such as insulin, may be influential.
[18-06-2025 00:16] PPM 2: The analysis of insulin secretion patterns revealed that the early secretion group had higher insulin secretion and maximal insulin levels than the other groups, and no improvement in fasting autonomic symptoms was observed with glucose intake. It is possible that higher insulin levels lowered blood glucose levels and sustained autonomic symptoms; however, in this study, blood glucose levels during that period were within the normal range. Therefore, it is possible that the sympathomimetic effects of insulin itself sustained autonomic symptoms. Hyperinsulinemia increases heart rate and venous blood noradrenaline concentrations and is associated with increased vasoconstrictive nerve activity in the skeletal muscle, keeping sympathetic nerves above baseline23, although the underlying mechanism is unclear, and further research is needed.
[18-06-2025 00:18] PPM 2: There appears to be a consistent pattern of Glucon-D tablet intake after lunch. I'm even more convinced this is not a true hypo and likey giving a placebo effect
[18-06-2025 00:19] PPM 2: Was there objective evidence for shivering or was it perceived so by the patient?
[18-06-2025 07:52] PPM 1: Perceived
[18-06-2025 07:52]PPM 1: I guess she mentioned glucon d intake after lunch for the first time this week?
[18-06-2025 07:57] PPM 1: Very useful inputs @PPM5 @PPM2 and these bring about a lot of insights in this domain of "hypoglycemia unawareness vs hyperawareness" that we first reported around this patient here 👇
And the other patient here 👇
@CR we may need to open a new thesis ProJR on hypoglycemia
[18-06-2025 11:49] PPM 2: 1(Fasting sugar 188)
[18-06-2025 11:50] PPM 2: 2 (Fasting sugar 161)
[18-06-2025 11:50] PPM 2: Looks like previously too there was glucose intake eve after lunch. Chocolate etc.
[18-06-2025 13:18] PPM 1: Thanks for bringing this to my notice. Had missed it earlier
[18-06-2025 13:19] PPM 1: 👆This is where I too noticed (Fasting sugar 161)
[18-06-2025 19:37] PA: Today's Fasting sugar 148
9:20 am before breakfast sugar 1520.25 mg Glimepiride Tablet 1 Omeprazole tablet
2 roti with sponge gourd fry
11:20 am after breakfast sugar 198
11:40 am eat apple and drink 1 glass coconut water
1:30 pm before lunch sugar 136 Salad, 2 roti with sponge gourd fry
3:30 pm after lunch sugar 132
4:10 pm eat salad
6:30 pm eat some roasted makhana and dry fruits
[18-06-2025 22:12] PA: 7:50 pm eat long sew
10 pm before dinner sugar 1550.25 mg Glimepiride Tablet 1 Omeprazole tablet Rice with sponge gourd fry and brinjal curry 1 Metformin Tablet.
[18-06-2025 23:45] PA: After dinner sugar 204
[19-06-2025 13:46] PPM 1: 👍
[19-06-2025 20:17] PA: 6 am fasting sugar 135
9:25 am before breakfast sugar 141, 0.25 mg Glimepiride Tablet, 1 Omeprazole tablet
2 roti with soya chunks fry
11:25 am after breakfast sugar 184
11:45 am papaya and drink 1 glass coconut water
1:30 pm before lunch sugar 124
Salad, 2 roti with soya chunks fry
3:30 pm after lunch sugar 183
4:20 pm eat salad
6:45 pm eat some roasted makhana and dry fruits
7:50 pm eat 1 kachori
[19-06-2025 21:46] PA: 9:45 pm before dinner sugar 153
0.25 mg Glimepiride Tablet, 1 Omeprazole tablet, Rice with soya chunks curry and yellow lentil
1 Metformin Tablet
[19-06-2025 22:11] PPM 1: 👍
[19-06-2025 22:13] PPM 2: Looks like her autonomic symptoms are getting triggered when the sugars are close to 100
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