Category: General

Glucose monitoring is required to maintain the fine balance between high and low blood sugars. Regular glucose monitoring can help identify low sugars (hypoglycemia) and high sugars. Glucose monitoring is advised before the meal (pre-meal) to decide on the dose of correction insulin to be given. The blood sugar is checked on waking up to decide on the doses of long acting insulin and make sure that there are no low sugars. Blood sugars are checked 2 hours after the meal (post meal) to understand how high the sugars go after a meal. This can help adjust the insulin dose to a meal.

It is not just the HbA1c and the self-monitored blood sugars that are important. It is also important to know how the blood sugars behave throughout the day. This can be done with a Continuous Glucose Monitoring System (CGMS). We usually use a Medtronic Enlite Sensor or an Abbott Freestyle Libre Flash monitoring system. CGMS has helped doctors and patients understand the details of daily blood glucose fluctuations. This helps them make better decisions for patients.

Type 1 children and adults can get their sugars better controlled by using multiple insulin doses or insulin pumps. In this process of achieving good blood sugars there is a risk of low blood sugars. Over time, it has become clear that we need to maintain good blood sugar control even in children with type 1 diabetes to prevent diabetes complications. The targets for blood sugars is as follows:

• Fasting plasma glucose level of 70 – 130 mg/dl on waking
• a plasma glucose level of 70-130  mg/dl before meals at other times of the day
• a plasma glucose level of 90–160  mg/dl after meals

And children and young adults (less than 18 years) are encouraged to maintain their HbA1c less than 7.5 %. These targets are lesser than the previously recommended targets for children with diabetes.

Type 1 diabetes is a lifelong problem for both patients and their care givers. It involves daily monitoring of sugars, minding the diet, adjusting the life-style to prevent low sugars, 4 or more shots of insulin daily and watching out for hypoglycemia. No wonder that the risk of psychological problems are higher in subjects with type 1 diabetes. It is important that patients and families develop effective coping strategies to overcome difficulties. 15-25% of adolescents with type 1 diabetes experience depression which is much higher than the general population.

“Diabetes distress “includes negative feelings that are directly related to diabetes. For example, feeling extreme frustration with blood sugars, feeling bogged down by all the daily management tasks, or feeling isolated in the diabetes experience. Prolonged diabetes distress can lead to ‘diabetes burnout,’ a term used to encompass the feeling of being unable to cope with diabetes. It is important that patients and families discuss this with the doctor and health care team. Hiding these symptoms can be detrimental for diabetes care and eventually lead to complications.

Type 1 diabetes involves autoimmune destruction of the pancreatic beta cells. This basically means that the cells that produce insulin in the pancreas (Beta cells) are destroyed by cells called lymphocytes in the blood. These lymphocytes are involved in the normal defense mechanisms of the body against the bacteria and virus. However in some genetically prone individuals, these cells attack the beta cells of pancreas.

In a new mode of experimental therapy, regulatory T cells (Tregs) from patients with type 1 diabetes were isolated and used to “re-educate “the immune system of the patient. This would help dampen the unregulated immune response against the beta cells at the same time making sure that the body is fit to take care of infections (normal immune response). The science on understanding the disease is progressing at rapid speed. And it is good news.

Growth hormone is produced by the pituitary. The maximum secretion of growth hormone occurs during the growth stages after which the rate of production reduces in adults. GH acts on the liver where it produces IGF-1 (Insulin like Growth Factors) which mediates some of the actions of GH. By 30’s the production of GH reduces significantly. This is a physiological phenomenon. Other than aiding growth, GH is involved in protein, fat and carbohydrate metabolism. Adults undergoing surgery or radiation in the region of pituitary may develop deficiency of pituitary hormones including growth hormone. These patients can use GH to prevent the adverse consequences of GH deficiency.

However, GH is one of the most misused drugs for body building. GH helps amino acid uptake into muscle and protein synthesis in muscle. It further helps to burn fat and helps repair injured tissues. But GH use in adults may be associated with high blood pressure, headaches, joint pain, carpal tunnel syndrome, elevated blood sugars and water retention. There are no long term studies on GH use in healthy adults.

All medicines have indications where it can be legally used. GH is approved only for use in children with growth disorders and in adults with GH deficiency. GH is banned in performance sports and detection of GH or its markers form an important component in doping tests. It is not OK to use GH hormone for body building.

Most of us would know at least one person with thyroid disease. Yes, it is official: thyroid is one of the most common diseases in the community. It has been intriguing why the number of cases getting diagnosed with one or the other form of thyroid disease is increasing. Various factors may be contributing to this:

: more awareness of the disease and hence more testing

: easy availability and faster turnover of thyroid function tests

: more cases of medicine induced thyroid disease

: iodization has increased the number of mild autoimmune thyroid diseases in the community at the cost of reducing severe thyroid disease

: more imaging ( ultrasound, CT, MRI , PET scans) of the neck has led to more nodules being diagnosed

: increase in thyroid cancer related to various factors including earlier detection of small thyroid cancers

: certain chemicals known as “ endocrine disruptors” which include Bisphenol A, PCB, phalates, perchlorates etc. may be causing more thyroid related problems.

I commonly come across patients presenting to me with blood sugars which are quite high (FBS > 200 mg/dl). Talking to them, I realize that they were detected to have mild to moderate elevation in blood sugars (130-140 mg/dl), which they tried managing with diet and exercise and then gave it up. It later was ignored and now they turned up with weight loss, frequent urination and tiredness.

We have to think of this condition as beyond the routine diabetes that we come across. This is a subject with significant deficiency of insulin with derangement of fat and protein metabolism in addition to carbohydrate metabolism. The beta cells of the pancreas which secrete insulin are suppressed due to high sugars (it is called glucotoxicity).
The best solution for this problem is insulin. Insulin can correct the insulin deficiency and relieve the glucotoxicity. This helps the insulin producing beta cells to get active and produce insulin. In the due course of time, insulin can be stopped and the subject can start using oral anti diabetic drugs. Studies have shown that when insulin is started at diagnosis, subjects tend to have better function of the beta cells 1 year later.

Glucometers are wonderful instruments that have revolutionized the way that we manage diabetes. These instruments continue to become smaller in size and incorporate various features in them, like the ability to sort out fasting and postprandial values, communicating with other devices (like pumps) and reporting in standardized formats. However, patients and healthcare providers continue to doubt the accuracy of these meters. Some patients even reject them outright!

It is important to understand that glucometers use fingerstick capillary blood to estimate sugars. This is different from the laboratory where the blood is collected from a vein. However, the machine is internally tuned to reflect venous plasma sugars. In fasting state when the blood sugars are recently constant, the values of sugars of samples simultaneously collected from the vein and fingerstick should give nearly similar values. But after a meal, sugars may change rapidly and finger stick values may differ physiologically from the venous sugars. Further, a certain degree of inaccuracy is expected in biological samples estimated by different methods. This is true for comparisons between different glucometers and between lab and glucometer values.

The ISO standards recommend that 95 % of values with a glucometer should be within 20% of glucose values above 75 mg/dl (which means that if the real value of plasma sugars is 100mg/dl, glucometer should show values between 80 mg/dl and 120mg/dl) and 15 mg of glucose values below 75 mg/dl ( which means if the real value of plasma sugar is 60 mg/dl, then the meter should show 45 mg/dl and 75 mg/dl). Diabetes organizations have called for more accurate instruments. Consumers using these machines should understand this approved standard.

There are other factors that can lead to inaccuracies with glucometers which we will discuss in the following article.

Type 2 diabetes is a progressive disease. As the years progress, more patients require different medicines and finally, injectable medicines. Some common medicines used in diabetes are further associated with weight gain and hypoglycemia. Diabetes therapies are evolving. Once a week therapies like Dulaglutide (marketed as Trulicity) have made it more convenient for patients.

Medicines in a class called “GLP-1receptor agonists “are associated with weight loss and no hypoglycemia, despite being very effective agents. We have been using medicines like Liraglutide (Victoza) for many years. The convenience has been enhanced by the Trulicity by making it a weekly therapy. The starting dose is 0.75 mg which can be increased to 1.5 mg/day. They have the capacity to reduce fasting blood sugars by 20-30 mg/dl and postprandial sugars by 40-50 mg/dl. HbA1c also came down by more than 1%. Unlike patients on insulin who gain weight, patients on Trulicity lose about 2-3 kg of weight. These drugs do not cause hypoglycemia (low sugars), however, some patients on Trulicity may experience some nausea and on rare occasions, vomiting. Most side effects disappear with continued use of these drugs. A new drug in this class called Lixisenatide (Lyxumia) is soon to hit the market.

Our diabetologists and endocrinologists are experienced in the use of GLP-1 receptor agonists including Victoza and Trulicity.

It is not unusual to be on long-term steroid therapy. Long term steroids may be used for lung diseases, rheumatological conditions, skin diseases or as a part of cancer treatment viagra 100mg prix. Although most patients detest the use of “steroids”, they are very valuable drugs. Taking steroids under supervision is safe and very effective. However, care should be taken in starting, continuing and stopping steroids.

Before starting steroids, the physician should be convinced that it is absolutely essential and the diagnosis should be confirmed. The patient should not have any infections or medical conditions that may get worsened with steroids. Sometimes there may be a medical condition which can predictably worsen with steroids. In this scenario, all care should be taken to anticipate and make necessary changes.

While on steroids, the patient should be monitored for possible adverse effects of steroids. Preventive therapy should be done to reduce the risk of weight gain, worsening diabetes, hypertension and osteoporosis. Steroids should be tapered and stopped as soon as the medical needs are met.

Once a decision is made to discontinue steroids, it should be done at a planned pace and the patient should be advised to anticipate and prevent an adrenal crisis (something like a withdrawal syndrome). Your endocrinologist is the best healthcare provider to help you deal with long-term steroid therapy.