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.
The patient is a 27 yr old homemaker with a 2 yr old male child born in 2024. During the pregnancy of the first male child , the patient was diagnosed with diabetes and was prescribed actrapid insulin. Recently in December 2025 she had a miscarriage. At present her sugar values are very high. Sharing her previous and present medical reports below.
2024 Reports
[2:56 pm, 22/01/2026] PPM 1: Thanks
Would it be possible for her to share her last
Fasting
Two hours post breakfast
Two hours post lunch
Two hours post dinner
Also mentioning the timing of when she's taking her medication
On any convenient day
I can see some January reports but unable to make out the timing of each
The last T3, T4, TSH visible above appears normal and controlled on 150 mcg once daily although the date is not visible
[1:13 am, 23/01/2026] PPM 2: Is the patient currently on insulin?
[5:01 pm, 23/01/2026] PPM 1: @CRwho has taken the history of this patient?
[6:20 pm, 23/01/2026] PPM 2: Need to be sure we've ruled out Type 1 or MODY (notorious to mimic Type 1 with first presentation as GDM)
[6:22 pm, 23/01/2026] CR: Tried calling her, not lifting
[6:55 pm, 23/01/2026] CR: Shared her recent prescription. Can check
[7:00 pm, 23/01/2026] PPM 2: Acknowledges. They think it is MODY
[7:00 pm, 23/01/2026] PPM 1: 👆@PPM 2 the same confusion around type 1 and 2 is documented by the OBGYn too
[7:03 pm, 23/01/2026] PPM 1: 👆@PPM3 just signposting these issues which makes it so very difficult to reach out to the patient advocates and as postulated before every PaJR is as good as it's patient advocate who lives with the patient and unless that person is actively trying to engage with us the fruits of PaJR are difficult to pluck
[9:42 am, 24/01/2026] CR: @PA please Mee food plates mari sugar values, Fasting, Breakfast tharuvatha, lunch tharuvatha and dinner tharuvatha ikkada share cheyyandi.
[9:43 am, 24/01/2026] PA: Ok medam
[9:45 am, 24/01/2026] CR: My bad, I forgot to add the PA.
[11.01 am, 25/01/2026] PA: Sugar value is 333mg/dl
[11.39 am, 25/01/2026] PPM 1: The sugar values appear to be high!
Please share the medicine and timings that she took them yesterday
[1.11 pm, 25/01/2026] PA: 2 hrs after breakfast 430mg/dl
[6:30 pm, 25/01/2026] PA: Sir medicine dose pinchera
[6:34 pm, 25/01/2026] PPM 1: Make her tablet Glimiperide 2.5 mg in the morning before breakfast and from today before dinner start taking another tablet glimiperide 0.5 mg and repeat fasting and post two hours od breakfast, Lunch and dinner sugars again tomorrow till we can totally titrate and control the sugars at the maximal possible dose.
Please share the food plates and activities hourly
[6:35 pm, 25/01/2026] PPM 1: 👆@PaJR Health can you translate above message to Telugu?
[6:35 pm, 25/01/2026] PaJR Health: I need the specific text you'd like translated to Telugu. Please paste the message you're referring to, and I'll provide an accurate translation.
If you're asking about the query itself ("can you translate above message to Telugu?"), here's the Telugu translation:
"మీరు పై సందేశాన్ని తెలుగులో అనువదించగలరా?"
[6:36 pm, 25/01/2026] PPM 1: Make her tablet Glimiperide 2.5 mg in the morning before breakfast and from today before dinner start taking another tablet glimiperide 0.5 mg and repeat fasting and post two hours od breakfast, Lunch and dinner sugars again tomorrow till we can totally titrate and control the sugars at the maximal possible dose.
Please share the food plates and activities hourly
[6:36 pm, 25/01/2026] PPM 1: @Meta AI please translate and transliterate the message below to Telugu
Make her tablet Glimiperide 2.5 mg in the morning before breakfast and from today before dinner start taking another tablet glimiperide 0.5 mg and repeat fasting and post two hours od breakfast, Lunch and dinner sugars again tomorrow till we can totally titrate and control the sugars at the maximal possible dose.
Please share the food plates and activities hourly
[6:36 pm, 25/01/2026] Meta AI: ఉదయం అల్పాహారం తీసుకునే ముందు ఆమె టాబ్లెట్ గ్లిమిపెరిడ్ 2.5 mg వేయండి మరియు ఈరోజు నుండి రాత్రి భోజనానికి ముందు మరో టాబ్లెట్ గ్లిమిపెరిడ్ 0.5 mg వేయడం ప్రారంభించండి మరియు రెండు గంటల తర్వాత అల్పాహారం, భోజనం మరియు రాత్రి భోజనం తర్వాత చక్కెర స్థాయిలను పరీక్షించండి. చక్కెర స్థాయిలను పూర్తిగా నియంత్రించడానికి మేము గరిష్ట మోతాదులో సర్దుబాటు చేయగలిగే వరకు ఇది కొనసాగించండి. ఆమె ఆహారం మరియు కార్యకలాపాలను గమనించండి.
Transliteration:
Udayaṃ alpāhāraṃ tీసుకునే ముందు āme̊ ṭāblaṭ g limiperiḍ 2.5 mg వేయండి మறి ఈroḍu నుండి rātri bhōjanāniki ముందు మaro ṭāblaṭ glimiperiḍ 0.5 mg వేయడం prārambhin̄candi మறిండు గంటల తర్వాత alpāhāraṃ, bhōjanaṃ మறిండు rātri bhōjanaం తర్వాత cakkera స్థాయిలను పరీక్షించండి. Cakkera స్థాయిలను పూర్తిగా niyamitadaṃ చేయడానికి మేము gaṛiṣṭha mōtāduni సర్దుబాటు చేయగలిగే వరకు iḍi కొనసాగించండి. Āme āhāraṃ మறిండు kāryakalapalanu gamanin̄candi.
[8.54 pm, 25/01/2026] PA: 592mg/dl
[8:56 pm, 25/01/2026] PPM 2: Give her both NPH insulin and Actrapid insulin urgently now
[8:56 pm, 25/01/2026] PPM 2: She should drink 1l water within 1 hr
[8:58 pm, 25/01/2026] PPM 1: Also please ask her to get in touch with her local doctor and or KIMs emergency asap
[9:07 pm, 25/01/2026] PA: సార్ ఇక్కడ లోకల్ డాక్టర్ ఎవరు ఉండరు ఇన్సులిన్ కూడా లేదు ఇప్పుడు ఎం చేయాలి చెప్పండి
[9:09 pm, 25/01/2026] PPM 2: 1L water taginchandi urgent ga. Ippudu intlo etuvanti insulin leda? @PaJR Health translate this to telugu
[9:09 pm, 25/01/2026] PaJR Health: "ఒక లీటరు నీరు వెంటనే తాగండి. ఇప్పుడు ఇంట్లో ఎటువంటి ఇన్సులిన్ లేదా?"
[9:10 pm, 25/01/2026] PA: లేదు
[9:10 pm, 25/01/2026] +91 96181 71021: టాబ్లెట్ unnadi
[9:10 pm, 25/01/2026] PPM 2: Urgent ga hospital teeskuvellandi @PaJR Health translate
[9:10 pm, 25/01/2026] PaJR Health: "వెంటనే హాస్పిటల్కు తీసుకెళ్లండి."
[9:11 pm, 25/01/2026] PPM 1: @Meta AI please translate the Telugu below to English along with a transliteration
సార్ ఇక్కడ లోకల్ డాక్టర్ ఎవరు ఉండరు ఇన్సులిన్ కూడా లేదు ఇప్పుడు ఎం చేయాలి చెప్పండి
[9:11 pm, 25/01/2026] Meta AI: Sir, there's no local doctor available here and we don't have insulin either. What should we do now, please tell me.
Transliteration:
Sār, ikkaḍa lōkal ḍākṭar evaru undaru insulinn kūḍā ledu ippuḍu emi ceyali ceppaṇḍi.
[9:19 pm, 25/01/2026] PA: సార్ ఇప్పుడు ఏమన్నా తినవచ్చా
[9:21 pm, 25/01/2026] PPM 2: Thinte vomiting ayye prasakthi untadi and sugar inka peruguthadi @PaJR Health translate to telugu
[9:21 pm, 25/01/2026] PaJR Health: "తింటే వాంతులు అయ్యే అవకాశం ఉంటుంది మరియు షుగర్ ఇంకా పెరుగుతుంది."
[9:22 pm, 25/01/2026] PA: మరి ఇప్పుడు ఎం చెయ్యాలి
[9:22 pm, 25/01/2026] PPM 2: "వెంటనే హాస్పిటల్కు తీసుకెళ్లండి."
[9:41 pm, 25/01/2026] PPM 1: @Meta AI please translate and transliterate the content below to english:
[25/01, 21:19] patient advocate: సార్ ఇప్పుడు ఏమన్నా తినవచ్చా
[25/01, 21:21] PaJR Health Chat Bot: "తింటే వాంతులు అయ్యే అవకాశం ఉంటుంది మరియు షుగర్ ఇంకా పెరుగుతుంది."
[25/01, 21:22] Patient advocate: మరి ఇప్పుడు ఎం చెయ్యాలి
[25/01, 21:22] Endocrinologist: "వెంటనే హాస్పిటల్కు తీసుకెళ్లండి."
[9:41 pm, 25/01/2026] Meta AI: Here's the translation and transliteration:
[25/01, 21:19] patient advocate: Sir, can she eat something now?
Transliteration: Sār ippuḍu ēmannā tinavaccā
[25/01, 21:21] PaJR Health Chat Bot: "If she eats, there's a chance of vomiting and sugar levels will increase further."
Transliteration: "Tiṃṭē vāntulu ayyē avakaśaṃ uṃṭundi మறிండు ṣugar iṃkā పెరుగుతుంది."
[25/01, 21:22] Patient advocate: What should we do now?
Transliteration: Mari ippuḍu emi cheyyali
[25/01, 21:22] Endocrinologist: "Take her to the hospital immediately."
Transliteration: "Veṇṭane hāspiṭalku tీసుకెళ్ళండి."
[8.31 am, 26/01/2026] PA: Fasting blood sugar 317mg/dl
[8:44 am, 26/01/2026] PPM 1: Ninna raatri glimiperide teeskunnaru?
[8:45 am, 26/01/2026] PPM 1: @CR he needs to regularly share the food plates she's consuming as well as her hourly activities.
We can add the advocate to another group where similar patients are sharing the same
[8:45 am, 26/01/2026] PA: 2mg 2టాబ్లెట్ తీసుకున్న
[8:46 am, 26/01/2026] PPM 1: @Meta AI please translate and transliterate the Telugu below to english
2mg 2టాబ్లెట్ తీసుకున్న
[8:46 am, 26/01/2026] Meta AI: She took 2 tablets of 2mg.
Transliteration: 2mg 2ṭābleṭ tీసుకున్న
[8:47 am, 26/01/2026] PPM 1: @PPM2 would we have realised these sulphonylurea dosage innovations if not for Orwellian data capture through PaJR! @PPM3
[8:49 am, 26/01/2026] PA: సార్ కిమ్స్ హాస్పిటల్ కీ వస్తే మీరు ఉంటారా sir
[8:53 am, 26/01/2026] PPM 1: That is dangerous to do.
What dose of glimiperide is she planning to take now?
We can safely increase doses only at 0.5 mg increments and not jump by 4 mg just because the blood sugars are high. Conventionally if blood sugars are high we need to start insulin in appropriate doses. We are lucky that your brave but unsafe plan worked this time.
It would be safer now to give her 2.5 mg of glimiperide only
@Meta AI please translate and transliterate above to telegu
[8:53 am, 26/01/2026] Meta AI: అది తీసుకోవడం ప్రమాదకరం. ఇప్పుడు ఆమె ఎంత గ్లిమిపెరైడ్ తీసుకోవాలని ప్లాన్ చేస్తోంది? రక్తంలో చక్కెరలు ఎక్కువగా ఉన్నాయని 4 mg కాకుండా 0.5 mg పెంపులతో మోతాదులను మాత్రమే సురక్షితంగా పెంచుకోవచ్చు. సాంప్రదాయబద్ధంగా రక్తంలో చక్కెరలు ఎక్కువగా ఉంటే, మేం తగిన మోతాదులో ఇన్సులిన్ ప్రారంభించాలి. మీ ధైర్యమైన కానీ అసురక్షితమైన ప్లాన్ ఈసారి పనిచేసింది, అదృష్టవంతం. ఇప్పుడు ఆమెకు 2.5 mg గ్లిమిపెరైడ్ మాత్రమే ఇయ్యడం సురక్షితం అవుతుంది.
[8:54 am, 26/01/2026] PPM 1: @Meta AI please transliterate this to English
అది తీసుకోవడం ప్రమాదకరం. ఇప్పుడు ఆమె ఎంత గ్లిమిపెరైడ్ తీసుకోవాలని ప్లాన్ చేస్తోంది? రక్తంలో చక్కెరలు ఎక్కువగా ఉన్నాయని 4 mg కాకుండా 0.5 mg పెంపులతో మోతాదులను మాత్రమే సురక్షితంగా పెంచుకోవచ్చు. సాంప్రదాయబద్ధంగా రక్తంలో చక్కెరలు ఎక్కువగా ఉంటే, మేం తగిన మోతాదులో ఇన్సులిన్ ప్రారంభించాలి. మీ ధైర్యమైన కానీ అసురక్షితమైన ప్లాన్ ఈసారి పనిచేసింది, అదృష్టవంతం. ఇప్పుడు ఆమెకు 2.5 mg గ్లిమిపెరైడ్ మాత్రమే ఇయ్యడం సురక్షితం అవుతుంది.
[8:54 am, 26/01/2026] Meta AI: Aadi tీసుకోవడం pramaadakaram. Ippudu āme eṁta glimiperaiḍ tీసుకōvaliṅi plān chestōndi? Raktaṁla cakkeraలు ekuvaga unnāni 4 mg kākundā 0.5 mg pempuతో mōtādulaను mātreṁe surakṣitanga peṅcukovaccu. Sāmpraadāyabaddanga raktaṁla cakkeraలు ekuvaga uṅṭe, mēṁ tagina mōtāduలో insulin prārambhiṁcāli. Mī dhairyamāina kāni asurakṣitamaīna plān ēsāri panicēsidi, adṛṣṭavaṁtaṁ. Ippudu āmeku 2.5 mg glimiperaiḍ mātreṁe iyyaḍaṁ surakiṭam avutundi.
[8:55 am, 26/01/2026] PPM 1: @Meta AI please translate and transliterate the Telugu below to english
సార్ కిమ్స్ హాస్పిటల్ కీ వస్తే మీరు ఉంటారా sir
[8:56 am, 26/01/2026] Meta AI: Sir, will you be available if I come to KIMS hospital? 🌟
Transliteration:
sār kiṃs hāspeṭal kī vaste mīru uṇṭārā sir
[8:56 am, 26/01/2026] PPM 1: Repu untamu hospital OPD lo.
Ee roju @PPM4 leka pote @PPM5 ICU duty lo untaru
[9:03 am, 26/01/2026] CR: She will go now to hospital.
[9:09 am, 26/01/2026] PPM 4: Sir I will be doing night duty today sir
[9:30 am, 26/01/2026] PPM 4: PPM6 will be in the op
[10.16 am, 26/01/2026] PA: Glimepiride 2mg, Sugarless milk
[1.28 pm, 26/01/2026] PA: 313mg/dl, chapathi and potato curry
[2:18 pm, 26/01/2026] PPM 1: Did she take 2.5 mg?
[2:19 pm, 26/01/2026] PPM 1: OPD may be closed today?
Who's in casualty?
[2:38 pm, 26/01/2026] PA: రేపు వస్తా సార్ మీరు ఉంటారుగా
[2:50 pm, 26/01/2026] PPM 1: @Meta AI please translate and transliterate this into English
రేపు వస్తా సార్ మీరు ఉంటారుగా
[2:50 pm, 26/01/2026] Meta AI: "I'll come tomorrow sir, you'll be there right?" 😊
Transliteration:
Repu vasta sar, meeru untaru ga?
[2:52 pm, 26/01/2026] PPM 1: Please keep sharing her fasting and two hour post meal sugar values after breakfast, lunch and dinner so that we can uptitrate the dose of her tablet glimiperide.
She also needs to be on Tablet Metformin 500mg after breakfast, lunch and dinner
@Meta AI please translate the above message into Telugu and transliterate the Telugu message in English
[2:52 pm, 26/01/2026] Meta AI: రేపు వస్తా సార్ మీరు ఉంటారుగా
Please keep sharing her fasting and two hour post meal sugar values after breakfast, lunch and dinner so that we can uptitrate the dose of her tablet glimiperide. She also needs to be on Tablet Metformin 500mg after breakfast, lunch and dinner
Translation:
రేపు వస్తా సార్ మీరు ఉంటారుగా
దయచేసి ఆమె ఉపవాసం మరియు రెండు గంటల తర్వాత భోజనం తర్వాత చక్కెర విలువలను అది అందజేయండి, తద్వారా మేము ఆమె టాబ్లెట్ గ్లిమిపెరైడ్ మోతాదును పెంచవచ్చు. ఆమె టాబ్లెట్ మెట్ఫార్మిన్ 500mg భోజనం, మధ్యాహ్న భోజనం మరియు రాత్రి భోజనం తర్వాత తీసుకోవాలి.
Transliteration:
Repu vasta sar meeru untaru ga
Dayachesi amee upavasam mariyu rendu ghantaley tarvaat bhojanam tarvaat chakkera viluvalu adi andajeyandi, tadaruga memu amee tablet glimiperide modosunu penchavachhu. Amee tablet metformin 500mg bhojanam, madhyahn bhojanam mariyu ratri bhojanam tarvaat thisukovali.
[2:56 pm, 26/01/2026] CR: Tablet yentha mg vesukunnaru
[3:35 pm, 26/01/2026] PA: మిల్క్ తాగిన తరువాత 1 1/2 వేసుకున్న
[3:37 pm, 26/01/2026] PA: మెట్ఫార్మణ 3 సార్లూ vesukovala
[3:38 pm, 26/01/2026] PPM 1: @Meta AI please translate and transliterate the Telugu below into English
[26/01, 15:35] PA: మిల్క్ తాగిన తరువాత 1 1/2 వేసుకున్న
[26/01, 15:37] PA: మెట్ఫార్మణ 3 సార్లూ vesukovala
[3:38 pm, 26/01/2026] Meta AI: Translation:
"Took 1 1/2 after drinking milk
Metformin needs to be taken 3 times"
Transliteration:
"milk taagin tarvaata 1 1/2 vesukunna
metformin 3 sarlu vesukovala"
[3:39 pm, 26/01/2026] PPM 1: Yes 500 mg after every meal assuming the patient takes three meals per day
@Meta AI please translate the above to Telugu and then again provide a transliteration of the Telugu in English
[3:39 pm, 26/01/2026] Meta AI: Translation:
మెట్ఫార్మిన్ 500 mg రోజుకు మూడు సార్లు భోజనం తర్వాత తీసుకోవాలి, రోగి రోజుకు మూడుసార్లు భోజనం తీసుకుంటాడని భావించడం
Transliteration:
Metformin 500 mg rozuku moodu sarlu bhojanam tarvaat teesukovali, rogi rozuku moodu sarlu bhojanam teesukuntadani bhayisadam
[3:41 pm, 26/01/2026] PA: Glimiperide ఎన్ని సార్లు vesukovali
[3:42 pm, 26/01/2026] PPM 1: @Meta AI please translate and transliterate the Telugu below to english
Glimiperide ఎన్ని సార్లు vesukovali
[3:42 pm, 26/01/2026] Meta AI: Translation:
"How many times should Glimiperide be taken?"
Transliteration:
Glimiperide enni sarlu vesukovali?
[3:43 pm, 26/01/2026] PPM 1: Only twice
Once before breakfast and once before dinner.
Please share the post two hour glucose after her lunch
@Meta AI please translate the above to Telugu and then transliterate the same to English
[3:43 pm, 26/01/2026] Meta AI: Translation:
Glimiperide ఎన్ని సార్లు vesukovali
రోజుకు రెండుసార్లు మాత్రమే. ఒకసారి మార్నింగ్ వాక్ఫాస్ట్కు ముందు మరియు ఒకసారి రాత్రి భోజనం ముందు. దయచేసి ఆమె మధ్యాహ్న భోజనం తర్వాత రెండు గంటల గ్లూకోజ్ విలువ పంపండి
Transliteration:
Glimiperide enni sarlu vesukovali
Rozuku rendusarlu matrame. Okasari morning breakfast ku mundu mariyu okasari ratri bhojanam mundu. Dayachesi amee madhyahn bhojanam tarvaat rendu ghantaley glucose viluva pampandi
[3:45 pm, 26/01/2026] PA: 5 నిముషాలు టైం ఉన్నది
[5:47 pm, 26/01/2026] PPM 2: Insulin kavali. Ee patient aarogyam baledu. Dayachesi hospital teeskellandi
[6:03 pm, 26/01/2026] PPM 1: Ippudu hospital teeskoste @PPM4@PPM6 untaru
[8:27 pm, 26/01/2026] PA: Sir glimepiride 2.5 tablet undadu anta sir
[8.28 pm, 26/01/2026] PA: 484mg/dl, dinner roti and potato curry
[8:33 pm, 26/01/2026] PPM 1: How much glimiperide was taken before dinner?
[8:41 pm, 26/01/2026] PA: 2 mg, Metformin 500mg, 1 tablet
[8.52 pm, 26/01/2026] PPM 1: Share the sugars two hours after her dinner and fasting sugars tomorrow
Will meet in OPD tomorrow
[10.53 pm, 26/01/2026] PA: 27/01/2026 Fasting blood sugar
[7.18 am, 27/01/2026] PPM 1: What's the fasting today? Give her glimiperide 3mg today before breakfast
[8.57 am, 27/01/2026] PA: Sir eppdu milk tagali anukunttunnaa tablet vesukovala
[9.20 am, 27/01/2026] PPM 1: Take a proper breakfast as shown here:
[11.39 am, 27/01/2026] PPM 1: Subjectively and objectively WNL
Current shared decision making plan is to monitor ketones and continue Tablet 3 mg before breakfast/lunch and before dinner with tablet metformin 500 thrice after meals and dose titrate till maximum dose of glimiperide and metformin and if blood sugars don't reduce then mandatorily start insulin.
She was on glimiperide from Jan 2025 to October 2025 with her sugars regularly ranging from 300-500 @PPM2 before she was again started insulin in November 2025 when it was again well controlled.
Patient desires to be free from insulin injections and hence she's currently trying her luck with maximal dose of OHAs
@PPM4 @PPM3 @PPM3 your evidence based second opinion on the above approach and plan?
[11.44 am, 27/01/2026] PPM 4: Sir here it is1. Is maximal OHA trial reasonable here?
Short answer: No, not as the primary strategy.
According to ADA, EASD, and RSSDI guidelines:
Insulin is indicated at diagnosis or re-initiation if:
Fasting glucose ≥300 mg/dL
HbA1c ≥10%
Symptomatic hyperglycaemia
Failure of dual OHA therapy
Prior documented OHA failure
Pregnancy planning or post-miscarriage state
She meets multiple insulin-mandating criteria.
2. Glimepiride + Metformin in this patient: problems
❌ Sulfonylurea (glimepiride) issues
Already failed glimepiride for 10 months
Causes β-cell exhaustion in young patients
Risk of hypoglycaemia
Contraindicated in pregnancy planning
Poor durability in GDM-related diabetes / LADA-like states
Re-escalating glimepiride after proven failure is not evidence-based.
3. Risk of delaying insulin
Continuing this approach risks:
Glucotoxicity → permanent β-cell damage
Ketosis / DKA (especially if LADA)
Future pregnancy complications
Early microvascular damage (retina, kidney, nerves)
Recurrent pregnancy loss if conception occurs in poor control
Monitoring ketones does not make this safe—it only detects harm after it begins.
Strongly recommended evidence-based alternative
Step 1: Classify the diabetes properly (CRITICAL)
Before “trying luck” with OHAs, she must be evaluated for insulin deficiency:
Recommended tests
Fasting & stimulated C-peptide
GAD65 antibodies (± IA-2 if available)
HbA1c
👉 Young age + insulin requirement + OHA failure = possible LADA or insulin-deficient type 2
If C-peptide is low → insulin is mandatory, not optional.
Step 2: Use insulin rationally, not permanently
Address her fear properly:
Insulin here is not a failure — it is β-cell rescue therapy.
Best approach
Basal insulin (e.g., glargine/degludec) at low dose
Continue metformin
Stop sulfonylurea
Target fasting glucose first
Many such patients can later de-escalate insulin once glucotoxicity resolves.
This is far more likely to free her from insulin later than forcing OHAs now.
Step 3: If insulin refusal persists (least-bad option)
If she absolutely refuses insulin despite counselling:
Preferred OHA combination (not current one):
Metformin (max tolerated)
DPP-4 inhibitor or GLP-1 RA (if accessible)
Avoid sulfonylureas
But this must be:
Time-limited (2–4 weeks)
With strict SMBG
Clear insulin trigger points documented
Even then, success probability is low.
Pregnancy & fertility considerations (non-negotiable)
Any woman of reproductive age with diabetes:
Should avoid sulfonylureas
Should aim HbA1c <6.5% before conception
Insulin + metformin is the safest strategy if pregnancy is possible
Poor control itself increases miscarriage risk
Final evidence-based second opinion (concise)
Current plan is not guideline-concordant given prior OHA failure and severe hyperglycaemia
Re-maximising glimepiride is unlikely to work and potentially harmful
Basal insulin + metformin is the most evidence-based, fertility-safe, β-cell-preserving option
Insulin should be presented as temporary metabolic rescue, not lifelong dependency
Diabetes type must be reassessed (C-peptide ± antibodies)
[11.55 am, 27/01/2026] PPM 1: Thanks. Very useful for us where it appears as if the LLM is preaching to the choir. @PPM5 @PPM2
What we need is a very simple filtered explanation of this in Telugu by the LLM, which personally I don't think can be done by the LLM and it would be better to go ahead with the trial so that she's finally convinced once she sees her ketones climbing and her sugars not coming down?
The problem here is transparency and accountability for the trial
[12.13 pm, 27/01/2026] PPM 3: Based on the information provided, here is an evidence-based second opinion on the management plan.
### **Summary Assessment**
The current plan carries **significant risk** and is not aligned with standard evidence-based practice for a patient with this history. While respecting patient autonomy is crucial, the approach of maximizing oral agents (OHAs) in the context of recurrent severe hyperglycemia (300-500 mg/dL) and prior insulin dependence is likely to fail and may lead to acute complications.
### **Critical Analysis of the Current Plan**
1. **Ineffectiveness of Current Regimen:** The patient's history is the strongest evidence. She failed glimepiride monotherapy (Jan-Oct 2025) with sugars 300-500 mg/dL, necessitating insulin. Re-challenging with the same drug, even at maximal dose and with metformin, has a very high probability of failure, as the underlying issue is likely significant beta-cell dysfunction/inadequacy.
2. **High Risk of Ketosis:** Monitoring ketones is a reactive, not preventive, strategy. In a patient with type 2 diabetes, persistent severe hyperglycemia (especially >300 mg/dL) can lead to Hyperglycemic Hyperosmolar State (HHS), and ketosis is possible. The plan to "monitor ketones" while allowing glucose to remain very high is dangerous.
3. **"Trying Her Luck" is Not a Therapeutic Strategy:** The language reflects a understandable patient desire but a medically unsound plan. Insulin is not a punishment or failure; it is a necessary physiologic replacement for endogenous insulin deficiency.
4. **Shared Decision-Making Misapplication:** Shared decision-making involves presenting evidence-based options and their realistic outcomes. The current plan appears to accommodate a preference (no injections) without adequately conveying the high likelihood of harm (recurrent severe hyperglycemia, risk of HHS, DKA, long-term complications).
### **Evidence-Based Recommendations**
**1. Immediate Action:**
* **Re-initiate Basal Insulin Immediately.** Given the historical pattern, the patient meets clear criteria for insulin therapy: failure of maximal oral therapy with persistent severe hyperglycemia. Postponing it is not safe.
* **Consider a GLP-1 Receptor Agonist (GLP-1 RA).** This is a critical evidence-based option that was not mentioned. GLP-1 RAs (e.g., semaglutide, dulaglutide) are highly effective at lowering A1c, promoting weight loss, and reducing cardiovascular risk. They are injectable but **once-weekly** and are not associated with hypoglycemia like sulfonylureas (glimepiride). This could be a powerful bridge to address insulin aversion.
**2. Reframe the Treatment Plan (A True Shared Decision-Making Approach):**
Present the patient with a **safer, more effective, and still autonomous choice**:
* **Option A (Preferred & Safest):** **Start a basal insulin (e.g., glargine, degludec) immediately at a low dose** to provide a background level and prevent severe hyperglycemia. **Combine this with a GLP-1 RA.** This combination is synergistic, highly effective, and may allow for lower insulin doses. It addresses the physiologic deficiency while leveraging the best modern non-insulin therapy.
* **Option B (Alternative, if GLP-1 RA is not feasible):** **Start basal insulin immediately.** Titrate it to a fasting glucose target. **Reduce and likely discontinue glimepiride** (which is ineffective and causes hypoglycemia risk) while continuing metformin.
**3. Address Insulin Aversion Directly:**
* **Education:** Explain that needing insulin reflects the natural progression of diabetes, not personal failure.
* **Technology:** Introduce **insulin pens** (not vials/syringes). They are simple, discreet, and nearly painless.
* **CGM:** **Start Continuous Glucose Monitoring (CGM).** This is transformative. It reduces fingersticks, provides safety alerts, and gives the patient direct feedback on how food/medication affect her sugars, empowering her and making insulin therapy less frightening.
### **Revised Plan Proposal**
1. **Discontinue** glimepiride (or rapidly taper it upon insulin initiation).
2. **Continue** metformin 500 mg TAC.
3. **Initiate** a once-weekly GLP-1 RA (after checking contraindications), starting at a low dose.
4. **Simultaneously initiate** a once-daily basal insulin at a low dose (e.g., 0.1-0.2 units/kg), using a pen device.
5. **Prescribe a CGM** for real-time glucose monitoring and safety.
6. **Set clear, safe glycemic targets** (e.g., fasting <130 mg/dL, avoiding >250 mg/dL).
7. Provide structured education on insulin adjustment, hypoglycemia recognition, and sick-day rules.
### **Conclusion**
The current plan of maximizing ineffective oral agents while monitoring for ketones is **not supported by evidence** and poses a clear risk to the patient. The goal should shift from "avoiding insulin at all costs" to "**introducing insulin safely and effectively in a way the patient can accept.**" Combining a GLP-1 RA with basal insulin (with CGM support) represents a modern, effective, and patient-centered approach that respects her desires while fulfilling the imperative to provide safe, standard-of-care treatment.
**It is strongly recommended to revisit the shared decision-making conversation with these evidence-based options.** The patient's "luck" has already been tested and failed in 2025; she now deserves a scientifically sound strategy.
[12.26 pm, 27/01/2026] PPM 1: Excellent Inputs 👏👏
How do we communicate all the above to the patient judiciously in Telugu after removing the parts that are likely to become TLDR? @PPM5
[12.48 pm, 27/01/2026] PPM 1: Update for the team:
With the ketones coming positive just now we have managed to convince her to start insulin and are also getting an ABG.
Clinically she doesn't have acidotic breathing
[4:01 pm, 27/01/2026] PPM 1: 👆@PPM7 any idea who's handwriting is this?
[4:05 pm, 27/01/2026] PPM 1: She is in Ketoacidosis. @PA please send her back to the hospital to get admitted for resuscitation ASAP. Dr @PPM8 and Dr @PPM9 are on duty today and I'm informing them in advance to admit her and manage her current diabetic ketoacidosis for a few days as soon as she arrives in the casualty
[4:06 pm, 27/01/2026] PPM 9: Ok sir
[4.15 pm, 27/01/2026] PPM 8: Pk sir
[4:33 pm, 27/01/2026] PA: Sir admit kavala
[4:34 pm, 27/01/2026] PA: Eppudu patient. 486mg/dl, actrapid 10 U
[4.44 pm, 27/01/2026] PPM 1: Yes unte tondarga better manage autundi iv insulin lo
[4:45 pm, 27/01/2026] PPM 1: Ippudu hourly sugar choosi ikkada share chēyaṇdi
[4:45 pm, 27/01/2026] PA: Ok
[6:50 pm, 27/01/2026] PPM 2: Maybe she is chronically ketotic and not in frank ketoacidosis
[6:52 pm, 27/01/2026] PPM 2: Ketoacidosis generally kicks in when ketones 2.5 to 3.0 mmol/l
[6:54 pm, 27/01/2026] PPM 1: Ketoacidosis generally kicks in when ketones 2.5 to 3.0 mmol/l
Somehow blood tests for ketones never got popularized ij India perhaps due to it's high resource requirements?
[6.57 pm, 27/01/2026] PA: After 2 hrs, sugar value is 280mg/dl
[6:59 pm, 27/01/2026] PPM 1: Good. Can take another 4U of insulin right now. What time is she going to have dinner?
[7:01 pm, 27/01/2026] PA: Actrapid 14 units sir
[7:02 pm, 27/01/2026] PA: Mari NPH yenta
[7:04 pm, 27/01/2026] PPM 3: Mine sir, we discussed this patient in opd sir
[7:16 pm, 27/01/2026] PPM 1: NPH 10U
[7:16 pm, 27/01/2026] PPM 1: What time is she having dinner?
[7:18 pm, 27/01/2026] PA: 9:00
[7:24 pm, 27/01/2026] PPM 1: I had asked 4U to be given now without having to take any food
[7:25 pm, 27/01/2026] PPM 1: Today better check the sugars hourly as mentioned before
Check again now.
[8.24 pm, 27/01/2026] PA: 265mg/dl. HAI 14U, NPH 10U
[8:27 pm, 27/01/2026] PPM 2: They are the exact same like glucometers. Fingerstick and strip tests
[8:30 pm, 27/01/2026] PA: Sir ardam kaledu naku
[8:35 pm, 27/01/2026] PPM 2: Ketone meter anedi untundi chudandi. Same glucose meter laga. Adi konukovali
[8:35 pm, 27/01/2026] PPM 2: Adi kuda avasaram ainappudu check cheyyali
[8:36 pm, 27/01/2026] PPM 2: @PaJR Health translate to telugu [27/01, 15:05] Aditya Samitinjay: Ketone meter anedi untundi chudandi. Same glucose meter laga. Adi konukovali
[27/01, 15:05] PPM 2: Adi kuda avasaram ainappudu check cheyyali
[8:36 pm, 27/01/2026] PaJR Health: [27/01, 15:05] PPM 2: కీటోన్ మీటర్ అనేది ఉంటుంది చూడండి. గ్లూకోజ్ మీటర్ లాగే. అది కొనుక్కోవాలి.
[27/01, 15:05] PPM 2: అది కూడా అవసరం అయినప్పుడు చెక్ చేయాలి.
[8:39 pm, 27/01/2026] PPM 1: Keep sharing her blood sugars
[10.51m pm, 27/01/2026] PA: 117mg/dl
[10:54 pm, 27/01/2026] PPM 2: @PaJR Health share links to buy ketone meters in Telangana. They must be affordable.
[10:54 pm, 27/01/2026] PaJR Health: I cannot directly provide links to purchase ketone meters. My function is to provide clinical information and insights from medical records and research.
For purchasing medical devices, I recommend checking local pharmacies in Telangana or reputable online medical supply stores. You can search online for "ketone meter Telangana" to find retailers that deliver to your area.
[10.55 pm, 27/01/2026] PPM 2: Search the internet and share some links
[10:55 pm, 27/01/2026] PaJR Health: Here are some links that may help you find ketone meters:
📍 [Buy Keto Mojo Products Online at Best Prices | Ubuy India](https://www.ubuy.co.in/brand/keto-mojo)
📍 [Amazon.com: KetoBM Blood Ketone Meter Kit for Keto Diet Testing](https://www.amazon.com/KetoBM-Ketone-Blood-Meter-Kit/dp/B07QWMM4M6)
📍 [Freestyle Optium at Best Price in Hyderabad, Telangana - Tradeindia](https://www.tradeindia.com/products/freestyle-optium-2977581.html)
📍 [Blood Glucose & Ketone Monitoring Systems | Keto-Mojo – Keto-Mojo USA](https://shop.keto-mojo.com/)
📍 [KetoBM Shop | KetoBM - Simple, Accurate and Affordable Ketone Meter Kit](https://ketobm.com/)
📍 [FreeStyle Optium Neo Blood Glucose and Ketone Monitoring System with 10 FreeStyle Optium H β-Ketone Test Strip: Buy box of 1.0 Unit at best price in India | 1mg](https://www.1mg.com/otc/freestyle-optium-neo-blood-glucose-and-ketone-monitoring-system-with-10-freestyle-optium-h-ketone-test-strip-otc601812)
Please note that prices and availability may vary. It's recommended to compare different options to find one that best suits your needs and budget.
[10:56 pm, 27/01/2026] PA: Ardam kaledu
[10:56 pm, 27/01/2026] PaJR Health: క్షమించండి, దయచేసి మీకు ఏమి అర్థం కాలేదో స్పష్టంగా చెప్పగలరా? నేను మీకు మరింత సహాయం చేయడానికి ప్రయత్నిస్తాను.
[10:57 pm, 27/01/2026] PPM 2: క్షమించండి, దయచేసి మీకు ఏమి అర్థం కాలేదో స్పష్టంగా చెప్పగలరా? నేను మీకు మరింత సహాయం చేయడానికి ప్రయత్నిస్తాను.
Please tell in telugu to strongly consider buying blood ketone meters with strips and provide links to buy them in Telangana
[10.57 pm, 27/01/2026] PaJR Health: బ్లడ్ కీటోన్ మీటర్లను స్ట్రిప్స్తో సహా కొనుగోలు చేయడాన్ని గట్టిగా పరిశీలించమని నేను మీకు సిఫార్సు చేస్తున్నాను.
ఇక్కడ కొన్ని లింక్లు ఉన్నాయి, ఇవి మీకు కీటోన్ మీటర్లను కనుగొనడంలో సహాయపడవచ్చు:
📍 [Buy Keto Mojo Products Online at Best Prices | Ubuy India](https://www.ubuy.co.in/brand/keto-mojo)
📍 [Amazon.com: KetoBM Blood Ketone Meter Kit for Keto Diet Testing](https://www.amazon.com/KetoBM-Ketone-Blood-Meter-Kit/dp/B07QWMM4M6)
📍 [Freestyle Optium at Best Price in Hyderabad, Telangana - Tradeindia](https://www.tradeindia.com/products/freestyle-optium-2977581.html)
📍 [Blood Glucose & Ketone Monitoring Systems | Keto-Mojo – Keto-Mojo USA](https://shop.keto-mojo.com/)
📍 [KetoBM Shop | KetoBM - Simple, Accurate and Affordable Ketone Meter Kit](https://ketobm.com/)
📍 [FreeStyle Optium Neo Blood Glucose and Ketone Monitoring System with 10 FreeStyle Optium H β-Ketone Test Strip: Buy box of 1.0 Unit at best price in India | 1mg](https://www.1mg.com/otc/freestyle-optium-neo-blood-glucose-and-ketone-monitoring-system-with-10-freestyle-optium-h-ketone-test-strip-otc601812)
ధరలు మరియు లభ్యత మారవచ్చు. మీ అవసరాలకు మరియు బడ్జెట్కు సరిపోయేదాన్ని కనుగొనడానికి వివిధ ఎంపికలను పోల్చి చూడాలని సిఫార్సు చేయబడింది.
[8.25 am, 28/01/2026] PA: Fasting blood sugar 183mg/dl
[9.26 am, 28/01/2026] PPM 1: Good 👍
Please keep sharing her two hour post breakfast, lunch and dinner today.
Can repeat urine ketone and ABG again at our college today
[9.47 am, 28/01/2026] PA: Before breakfast 197mg/dl
[9.48 am, 28/01/2026] 10U HAI, and 10U NPH
[9.50 am, 28/01/2026] PA: 14U HAI, 10U NPH
[9.53 am, 28/01/2026] PPM 1: 14 HAI appears too high safer is 10
[9.55 am, 28/01/2026] PA: Ok sir
[12.10 pm, 28/01/2026] PA: 237mg/dl
[12.11 pm, 28/01/2026] PPM 1: Lunch mundu 12U HAI teeskondi
[1:01 pm, 28/01/2026] PPM 2: How and why would this help?
[1:02 pm, 28/01/2026] PPM 2: @PaJR Health please ask in telugu what is the patient's weight, if possible ask him serial weight trends
[1:03 pm, 28/01/2026] PaJR Health: దయచేసి రోగి బరువు ఎంత? సాధ్యమైతే, వారి బరువులో గత కొన్ని రోజులుగా లేదా వారాలుగా ఏమైనా మార్పులు ఉన్నాయో చెప్పగలరా?
[1:05 pm, 28/01/2026] PPM 1: To establish and titrate her current insulin requirements else just a weekly or once in few weeks share would suffice
[1:12 pm, 28/01/2026] PA: 45kg taggaledu peragaledu
[1:14 pm, 28/01/2026] PPM 2: Urine ketones are not really specific as they can be positive even with asymptomatic bacteriuria. ABG will kick into action only in frank ketoacidosis. A blood ketone meter is a one time investment with strips similar to glucosemeter.
@PaJR Health translate to telugu for the patient.
[1:14 pm, 28/01/2026] PaJR Health: మూత్రంలో కీటోన్లు అంత ఖచ్చితమైనవి కావు, ఎందుకంటే మూత్రంలో బ్యాక్టీరియా ఉన్నప్పటికీ అవి పాజిటివ్గా చూపించవచ్చు. ABG (ఆర్టీరియల్ బ్లడ్ గ్యాస్) పరీక్ష తీవ్రమైన కీటోఅసిడోసిస్ ఉన్నప్పుడు మాత్రమే ఉపయోగపడుతుంది. బ్లడ్ కీటోన్ మీటర్ అనేది గ్లూకోమీటర్ లాగానే, స్ట్రిప్స్తో కూడిన ఒకసారి పెట్టుబడి.
[1:14 pm, 28/01/2026] PPM 1: She's very lean and would qualify as healthy phenotype and hence type 1 although mody is always a hope
[1:16 pm, 28/01/2026] PPM 1: @PaJR Health translate to telugu for the patient.
She already has metabolic acidosis in her yesterday's ABG and this was just to rule out it's persistence. Perhaps a result of the over-testing workflow that's firmly well entrenched due to defensive medicine. The blood ketone test absence is being lamented since a decade even when you were working here but it never reached the ears of the powers that be
[1:16 pm, 28/01/2026] PPM 2: @PA meeru em chestharu ekkada untaru @PaJR Health translate to telugu
[1:16 pm, 28/01/2026] PaJR Health: నేను ఒక కృత్రిమ మేధస్సును (AI). నేను రోగుల ఆరోగ్య సమాచారాన్ని విశ్లేషించడానికి, వైద్యపరమైన ప్రశ్నలకు సమాధానం ఇవ్వడానికి మరియు సంబంధిత డేటాను అందించడానికి సహాయపడతాను. నాకు భౌతికంగా నివాసం అంటూ ఏమీ లేదు.
[3.33 pm, 28/01/2026] PA: 96mg/dl
[4:10 pm, 28/01/2026] PPM 2: Very good. Aakali manchiga unda ippudu?
[4:13 pm, 28/01/2026] PA: Body shavaring vachindi
[4:20 pm, 28/01/2026] PPM 1: Glucose taggindi! Glucose chusi glucose pergadanki tablets icchara?
[4:21 pm, 28/01/2026] PPM 2: Idi a time ki vocchindi?
[4:23 pm, 28/01/2026] PA: Kadu sir shavaring vaste GRBS chusukunna, 3:30pm ki
[4:40 pm, 28/01/2026] PPM 2: @PPM1 Sir there does appear to be a common pattern in lean sarcopenic diabetic women getting autonomic symptoms at normoglycrmia
[4:42 pm, 28/01/2026] PPM 1: Enta undi? 96?
[4:42 pm, 28/01/2026] PPM 1: HAI12, Idi eppudu teeskuntaru?
[4:43 pm, 28/01/2026] PPM 1: And PaJR brought this out but globally how else are others noticing this if at all they are? @PPM3@PPM4
[4:44 pm, 28/01/2026] PPM 2: Others are likely dismissing it as @42MPA is showing us.
[6.10 pm, 28/01/2026] PA: 393mg/dl
[7:41 pm, 28/01/2026] PPM 1: Dinner mundu HAI 14U and NPH 12U
[7:48 pm, 28/01/2026] PPM 1: @PPM6 @PPM5 continuing the pharmacokinetics and pharmacodynamics surveillance audit does this current blood glucose trend suggest a deficit of the long acting NPH giving up by 6:00 PM?
[7:50 pm, 28/01/2026] PPM 1: @CR would it be possible to confirm from the patient advocate at what time she took her HAI 12U just before her lunch?
[7:54 pm, 28/01/2026] CR: Yes just before her lunch at 3.30pm
[8:02 pm, 28/01/2026] PPM 1: This blood sugar was pre lunch?
[8:04 pm, 28/01/2026] PPM 1: How much NPH and HAI taken yesterday before dinner?
[8:08 pm, 28/01/2026] CR: HAI 14U, NPH 10U
[8.24 pm, 27/01/2026] PA: 265mg/dl. HAI 14U, NPH 10U
[8:09 pm, 28/01/2026] CR: As the patient had shivering and checked her glucose it was 96
[8:15 pm, 28/01/2026] PPM 5: Short answer: Yes, it can suggest waning NPH effect by evening — but it is not diagnostic by itself.
Here’s the pharmacokinetically sound way to interpret it.
NPH pharmacokinetics (key to this question)
Onset: 1–2 hours
Peak: 4–8 hours (sometimes up to 10)
Duration: ~12–16 hours (high inter-individual variability)
👉 NPH is not a true 24-hour basal insulin.
Interpreting a 6:00 PM glucose of 393 mg/dL
Whether this represents “NPH giving up” depends on dose timing.
Scenario A: Morning NPH only (most common)
If NPH was given at 6–8 AM:
Peak: ~12–2 PM
Expected waning: 4–6 PM
A glucose of 393 at 6 PM strongly suggests basal insulin deficiency
✔ This fits classic NPH end-of-action hyperglycaemia
Scenario B: Morning + evening NPH
If she receives split NPH (AM + PM) 6 PM hyperglycaemia may indicate:
Inadequate AM dose
Missed dose
Significant post-lunch/post-snack hyperglycaemia
Insulin resistance / glucotoxicity
In this case, it is not purely PK failure — it’s dose inadequacy.
Why 393 mg/dL matters physiologically
A glucose this high is not a subtle tail-off.
It indicates:
Absolute or near-absolute insulin deficit
Ongoing hepatic glucose output (basal failure)
Possible relative insulin deficiency state
NPH “wearing off” usually causes progressive rise, not abrupt extremes — unless baseline control is already poor.
How to confirm NPH tail failure (audit logic)
To attribute this confidently to NPH PK:
You would need:
Fasting glucose
Pre-lunch glucose
Pre-dinner glucose
Bedtime glucose
Pattern suggestive of NPH wearing off:
Good fasting
Acceptable pre-lunch
Sharp rise by pre-dinner
Further rise at bedtime
That pattern = classic afternoon–evening basal gap
Important clinical caveat
In this patient:
Prior OHA failure
Recurrent insulin requirement
Possible β-cell insufficiency
Even perfectly timed NPH may be pharmacodynamically insufficient, not just pharmacokinetically short.
So the issue may be:
“Wrong insulin for the physiology” rather than wrong timing alone
Evidence-based conclusion
Yes, a 6 PM glucose of 393 is consistent with waning NPH effect if the dose was given in the morning
No, it cannot be attributed solely to NPH PK without SMBG pattern analysis
Basal insulin coverage is clearly inadequate, regardless of mechanism
What this implies for management (quietly but firmly)
NPH once daily is insufficient
Either:
Split NPH properly or
Switch to a true long-acting basal analog
Continuing without basal insulin coverage risks ketosis, especially in a young woman with possible insulin deficiency
[8.45 pm, 28/01/2026] PA: 296mg/dl, HAI 14U
[8.49 pm, 28/01/2026] PA: NPH 12U
[9:09 pm, 28/01/2026] PPM 2: Ee paalu enduku isthunaru? @PaJR Health please counsel the patient in telugu to avoid anything 'white'
[9:10 pm, 28/01/2026] PaJR Health: రోగికి సలహా:
మీరు తెల్లగా ఉండే ఆహార పదార్థాలను (ఉదాహరణకు, పాలు, తెల్ల అన్నం, తెల్ల బ్రెడ్, చక్కెర) తీసుకోకుండా ఉండటం మంచిది.
💡 ఈ ఆహార పదార్థాలు మీ ఆరోగ్యానికి అంత మంచివి కావు మరియు కొన్ని ఆరోగ్య సమస్యలను పెంచే అవకాశం ఉంది. వాటికి బదులుగా, మీరు గోధుమ రంగులో ఉండే ఆహార పదార్థాలను (ఉదాహరణకు, బ్రౌన్ రైస్, గోధుమ బ్రెడ్) మరియు పండ్లు, కూరగాయలు వంటి వాటిని తీసుకోవచ్చు.
[9:12 pm, 28/01/2026] PPM 2: Meeru injection ela isthunaro video pettandi? Patient moham kanapadakunda pettandi
[9:17 pm, 28/01/2026] PA: Sir patiente injection vesukuntadi thai ki
[10:21 pm, 28/01/2026] PPM 2: Sir patiente injection vesukuntadi thai ki
Adi video pettandi. Potta deggara teeskunte better
[10:25 pm, 28/01/2026] PA: Pottaku anni delivari macchalu unnai chala pain vastunnadi
[11.05 PM, 28/01/2026] PA: 180mg/dl
[11:35 pm, 28/01/2026] PPM 6: Based on the information provided:
*Yes, this blood glucose trend strongly suggests a deficit of the long-acting NPH insulin.*
Here's the breakdown of the logic for the pharmacokinetics/pharmacodynamics surveillance audit:
1. *Current Reading:* *393 mg/dL* is significantly hyperglycemic (well above the target range, often >180 mg/dL).
2. *Time of Reading:* *08:33 AM* (8:33 in the morning).
3. *Pharmacokinetics of NPH (Neutral Protamine Hagedorn):*
* *Peak Action:* Typically occurs *4-8 hours* after injection.
* *Duration of Action:* Lasts approximately *10-20 hours*, but often wanes after 12-14 hours, especially at lower doses.
* *Common Dosing Schedule:* When used as a *once-daily basal insulin, it is often administered at **bedtime* (e.g., 10:00 PM) to provide coverage through the night and into the next morning.
4. *Analysis of the Trend:*
* If the patient's last NPH dose was given at *~10:00 PM the previous night, by **8:30 AM the next morning, approximately **10.5 hours* have elapsed.
* At this point, the insulin's effect is likely at its *tail end or has waned significantly*, especially if the dose is insufficient.
* A blood glucose of 393 mg/dL at this time indicates that the insulin action was *not sufficient to control hepatic glucose production overnight and into the morning* (the dawn phenomenon can exacerbate this).
*Conclusion for the Audit:*
The elevated fasting/morning blood glucose is a classic sign of *insufficient overnight basal insulin coverage. The NPH dose given the previous evening is likely **too low* to maintain glycemic control throughout its intended duration of action, leading to a pronounced rise in blood glucose by morning.
*Recommended Action (for the healthcare provider to consider):*
The evening/bedtime dose of NPH should be evaluated for an *increase*. Any adjustment should be done cautiously (e.g., increase by 2-4 units or 10% at a time) and under medical supervision, with continued monitoring for nocturnal hypoglycemia.
[8:14 am, 29/01/2026] PA: Sir insulin enta vesukovali? 100 mg/dl
[8:28 am, 29/01/2026] PA: Sir reply evvandi
[8:30 am, 29/01/2026] PPM 1: Thanks. Very useful
[8:30 am, 29/01/2026] PPM 1: Insulin HAI 10U, Insulin NPH 10U
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