DIABETES

Case Studies
 • History: A 55 year old lady, presents with
excessive thirst since 4 days. She has bilateral
knee pain. She has no other symptoms.
• Examination: Height is 156 cm and the weight is
80 kg. Examination indicates a blood pressure of
120/80 mmHg. Heart rate is 80 /min. There are
Case-1 no other significant findings.
• Tests: Fasting Plasma Glucose (FBG) - 142
mg/dl, Post-prandial plasma glucose (PPPG) –
258 mg/dl, HbA1c - 8.1 %
 Diagnosis: Type 2 Diabetes with Obesity (BMI:
32.87)
Management
• Diabetes awareness
• Diet control- reduce refined carbohydrate
Diagnosis & intake, reduce oil intake, consume at least two
Management servings of vegetables per day
• Physical Activity
• Walking 30 minutes per day for 5 days or
equivalent
• Yoga / resistance exercises 2 days/ week
• Tab Metformin 500mg twice daily
• Screening for diabetes related complications
 • Recently diagnosed diabetes and obesity
• Diet and exercise to reduce weight would be
the first step.
• Metformin therapy is indicated to control blood
Explanation glucose level
• As diabetes is often diagnosed after a delay,
routine screening for both microvascular
complications and cardiovascular complications
should be started at the time of diagnosis itself.
 • History: A 45 year old gentleman comes for
diabetes management. He is hypertensive and
on ramipril 5 mg once a day, and is taking
atorvastatin 10 mg at bedtime. He is taking
Metformin 500 mg in the evenings and
glimepiride 1 mg in the morning. He smokes a
packet of cigarettes a day.
• Examination: The height is 156 cm and the
Case-2
weight is 79 kg. Examination indicated a blood
pressure of 130/90 mm Hg. Heart rate is 70
/min. There were no other significant findings.
• Tests:FPG – 180 mg/dl & PPPG- 340 mg/dl
 Diagnosis: Type 2 Diabetes with Obesity (BMI-32.46)
Management
• Stop Smoking
• Counselling, information about hypoglycaemia
• Diet control- reduce refined carbohydrate intake,
Diagnosis & reduce oil intake, consume at least two servings of
vegetables per day
Management • Physical Activity- Walking 30 minutes per day for 5
days or equivalent
• Yoga / resistance exercises 2 days/ week
• Tablet Metformin 500 mg twice a day
• Tab Glimepiride 2 mg/day
• Screening for diabetes related complications
• Specialist Referral
 • This gentleman already has diabetes
• On glimepiride and metformin. As the dose of
Explanation glimepiride 1 mg is not able to control his blood
glucose levels, the dose has been increased to 2
mg
 • History: A 59 year old male clerk comes for
diabetes assessment. He walks 30 minutes
per day and consumes a health vegetarian
diet. He does not smoke or take alcohol. He is
taking metformin 1000 mg twice a day.
• Examination: The height is 166 cm and the
weight is 84 kg (BMI: 30.48). Examination
Case-3 indicates a blood pressure of 130/90 mm Hg.
Heart rate is 79 /min. There are no other
significant findings.
• Tests: FPG -145 mg/dl & PPPG- 271 mg/dl
 Diagnosis: Uncontrolled Type 2 Diabetes
Management
• Counselling, information about hypoglycaemia
• Diet control- reduce refined carbohydrate intake,
reduce oil intake, consume at least two servings of
vegetables per day
Diagnosis & • Physical Activity- Walking 30 minutes per day for 5
Management days or equivalent
• Yoga / resistance exercises 2 days/ week
• Tablet Metformin 500 mg twice a day
• Tab Gliclazide MR 30 mg/day
• Screening for diabetes related complications
• Specialist Referral
 • This person has uncontrolled type 2 diabetes.
• Metformin is not optimally controlling the blood
Explanation glucose levels. Hence, a sulfonylurea has been
started.
 • History: A 19 year old man comes with fever and a
reddish discoloration of the right foot since 15 days. He
is taking pre-mixed insulin twice a day, since diabetes
was diagnosed 10 years ago. He has been feeling
breathless since past 2 days.
• Examination: The weight is 69 kg. Examination indicates
a blood pressure of 120/70 mm Hg. Heart rate is 70
Case-4 /min. There are no other significant findings. Lower
limb pulses are well felt. His ankle jerks are sluggish.
There is reddishness over the dorsum of the foot with
also a small ulcerated area. Redness appears till the
ankle.
• Tests: FPG 299 mg/dl & PPPG 344 mg/dl
 Diagnosis
• Type 1 diabetes
• Complicated diabetic foot infection
Diagnosis & Management
Management • Urgent referral to specialist centre. Consider
giving first dose of intravenous antibiotic prior to
referral.
 • This is a patient with a complicated, life threatening
diabetic foot ulcer with breathlessness due to
probably acute respiratory distress syndrome
• The patient requires admission at a higher centre,
intravenous antibiotics
• All type 1 diabetes subjects need to be referred to
higher centre
Explanation • This particular patient with type 1 diabetes was
taking pre-mix insulin prior to presentation. Premix
insulin is, in general, not suitable for type 1
diabetes- who need to be managed with basal (long
acting insulin) and bolus injections (3-4 meal time
short acting insulin) for proper control
 • History: A 60 year old lady presents with diabetes of
5 years duration. She is on gliclazide modified release
(MR) 60 mg once a day. She is also on metformin
1000 mg twice a day. She has lost two kg in the last 2
months. She also has severe polyuria, and polydipsia.
• Examination: The height is 150 cm and the weight is
60 kg. Examination indicates a blood pressure of
Case-5 130/90 mm hg. Heart rate is 89 /min. There are no
other significant findings.
• Tests: FBG – 201 mg/dl & PPBG- 263 mg/dl,
HbA1c -9.2%
 Diagnosis- Type 2 diabetes (uncontrolled)
Management
• Diabetes awareness, information about
hypoglycaemia, diet control- reduce refined
carbohydrate intake, reduce oil intake, consume at
least two servings of vegetables per day
Diagnosis & • Physical Activity-Walking 30 minutes per day for 5
days or equivalent, Yoga / resistance exercises 2
Management days/ week
• Tablet Metformin 1000 mg twice a day
• Tab Gliclazide MR 60 mg/day
• Inj. Glargine or NPH insulin 10units at bedtime
• Screening for diabetes related complications
• Specialist Referral
 This lady with diabetes, uncontrolled blood glucose levels
and osmotic symptoms requires insulin. Basal insulin or
premix (30/70) insulin may be used. Basal insulin is an ideal
option, and the starting dose is 10 units of glargine or NPH
insulin at bedtime. If premix insulin is used, gliclazide may
be stopped and metformin continued, and dose of premix
insulin could be 0.5 units/kg/day. In this lady of 60 kg, the
starting dose of premix insulin would be 60 x 0.5 = 30 units
Explanation per day (20 units before breakfast and 20 units before
dinner). If basal or premix insulin or other complicated
regimens are considered, then the patient is best referred
to another centre. Newer drugs called gliptins and other
medicines that bring down glucose by increasing urinary
excretion are available, but they are expensive, and need
to be prescribed at a specialist level currently.
 • History: A 75 year old gentleman, presents with
recurrent episodes of giddiness since 2 days. He
has diabetes being treated with tablet
glibenclamide 2.5 mg once a day for diabetes,
diagnosed ten days ago. At that time, the fasting
blood glucose was 148 mg/dl and the post
breakfast value was 202 mg/dl.
• Examination: indicates a blood pressure of
Case-6 130/80 mmHg. Heart rate is 102 /min. There are
no other significant findings.
• Tests: Random Plasma Glucose (FBG) - 59 mg/dl
 Diagnosis: Type 2 Diabetes with drug induced
hypoglycaemia
Management
He was given 4 teaspoons of glucose dissolved in
water. After fifteen minutes the blood glucose was
still 58 mg/dl. He was given intravenous 50%
dextrose (50 ml) and then placed on a 5% dextrose
Diagnosis & drip for the next 24 hours. He was asked to stop
Management glibenclamide and come for follow up every day.
When his fasting blood glucose rose to 130 mg/dl,
he was prescribed diet control and physical activity.
After one month, his blood glucose levels were well
controlled on this, with fasting blood glucose of 102
mg/dl and a post-meal value of 167 mg/dl.
 • Episode of hypoglycaemia
• Glibenclamide is particularly liable to cause
hypoglycaemia in the elderly
• Hypoglycaemia can last for 72 hours or more, so
careful follow up is important
• Prompt referral to specialist is advisable unless in mild
cases (like the example above)
Explanation • Specific preventive advice is important: (a) do not skip
meals and take tablets even during illness (b) Always
take 15-40g carbohydrate if the patient develops
hypoglycemic symptoms (c) eat regular meals (d)
during severe illness, monitor blood glucose
constantly (e) consult the doctor if there is vomiting or
reduced intake for any reason for more than 12 hours,
or if hypoglycemic symptoms do not disappear with
oral glucose.
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