Diabetes/Weight loss/24years Male

Another interesting case of Young Onset Diabetes Complaints of only and only weight loss Male patient aged 24 years who visited an EMO at Distt Hospital for RBS 420mg/DL. He was prescribed Jardiance (Empagliflozin) in morning with two glass of water as per prescription. He even has history of taking Metformin and Glimipiride combination, but probably irregularly. Upon reporting to my OPD, his RBS is 318mg/dl I have started him on gliclazide and Metformin combination in BD along with Pioglitazone 15mg OD. Asked him to follow up after 2 days on 15/03/2020 with FBS, PPBS and before dinner sugar levels, HBA1c, KFT, Lipid Profile. Kindly suggest what could have been done best for this patient in terms of treatment?

Dear Dr Ajeet Singh, Wonderful case Scenario. This could be a case of 1) T2DM with Family history of T2DM. 2) T1DM. It probably doesn't fit into 1) T2DM in the young because per se T2DM in the young usually appears before the age of 18 years and most often patients are overweight or Obese. It's most unlikely that they present with Weight loss. They do respond to simple Metformin most often in my clinical practice. They usually present with signs of IR, Insulin Resistance like Acanthosis Nigricans. 2) LADA is most unlikely as LADA is defined as Diabetes looks like T2DM, responds to OHA in the initial stages but slowly doesn't respond to OHAs, requires and responds to Insulin only in the later course of disease process. Most often we are mistaken for T2DM in the initial period. GAD 65 Antibodies would clinch the Diagnosis of LADA. Coming to the case Scenario, 24 yr old adult with blood sugar of 420 mg/do should be screened for either presence or absence of Urinary and Blood Ketones. Without ordering for Ketones, I don't think it's rational to prescribe Empagliflozin Tablet. H/O irregular medication, Glimepiride plus Metformin. The best thing you could have done to this patient would be 1) Order for Urinary and Blood Ketones. C Peptide Serum Insulin 2) Even in the absence or presence of KB, you should have put him on either Rapid Acting Insulins in case of DKA OR Biphasic Premixed Insulins in case of Non DKA. Best would be Basal Bolus Insulin Regimen until the blood sugar levels become normal. Next thing is to wait for the results and go accordingly. For discussion sake, Empagliflozin has no role in this 24 yr old Male as SGLT2 Inhibitors are indicated in Patients suffering from T2DM with either Established ASCVD OR At high risk of developing ASCVD. Take home message. Initiate Insulin Therapy in abnormal Hyperglycemia associated with Weight loss at any given age. Once you make a Clinical/Provisional Diagnosis F/B Final Diagnosis based on the relevant investigations treat the patient accordingly. Thanks again dear Ajeet Singh and Sandip. Any questions, queries are most welcome. Regards and thanks, Dr Sepuri Krishna Mohan. Sorry for my delayed response because I was busy in my OPD.
Thank you doctor

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Young diabetics should be screened for LADA, T1DM, DKA before considering for any OADs rampantly. When the BSL is high, one should not be tried with OADs as it mostly causes glucotoxicity & early pancreatic beta cells fatigue. Here ideally insulin should have been started & later on achieving HbA1c 7% OADs can be tried. This would have been the most ideal approach to such a young diabetic. @Sepuri Krishna Mohan Sir, @Dr. Dineshchandra Sharma Sir can suggest better than me, I hope.
Thanks for replying sir@Sandip Debashis Mishra . I wanted to tag you as well.

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Weight loss 1 tsf of ashwagandha churn with milk daily for 3 months, chandra prabha vati 2 bd ...... Daily 2 cups of milk , milk products like curd, butter should be taken more , ground nuts soaked in water over night , groundnut oil for cooking , all types of dry fruits should b taken daily, seasonal fruits sply banana may be more useful........ Avoid stress and anxiety with meditation ....keep mentally calm n happy ........ Regular exercise that tones up muscles should be done ...
Firstly check C peptide / insulin levell Then according HBA1c and FBS PP medicine are taken .....intially only metformin 500 mg Sr or 1000 mg Sr BD and diet controle. Then observe in one month ....and after 3 month HBa1c again .if not controle sugar level then glimipride added , I am 24 yr age , I am diabetic since 1.5 yr. And maintain sugar level .
Looking like a case of Type1 DM . LADA is second DD. Check for ketone bodies . Look for GAD65, ICA, IAA, IA-2A antibodies and C peptide. Weight loss indicates decreased insulin secretion, pancreatic bankruptcy. Ideal treatment is insulin only.
Looks juvenile DM Start insulline Rest is ok treatment Once HBA1C brought down then you put him on oral medication Modify life style Check insulline levels Prevent DKA
He may be a case of juvenile diabetes Insulin may be required
It might seem surprising that someone so young could develop type 2 diabetes, but the disease is on the rise among the under-30 set. In fact, 5.7 percent of all new cases of diabetes occur in people between 18 and 29, the U.S. Centers for Disease Control and Prevention estimate. Not neccessary that he,being a young must have Juvenile diabetes. Elevated RBS was probably due to inagiquate or abcence of appropriate treatment. You are right with letest supporative investigations. But initially he is advised to be on Insuline rather than oral antidiabetic druv in view of probablity of hepeto toxicity.
In my opinion please start Basal Insulin before dinner 12 unit and Tab Glimy M2 one before BREAKFAST for 3 days again major Blood SUGAR and if SUGAR raised then increase the dose 2 unit for next 3 days this should continue till Blood SUGAR comes normal then finally adjust the dose
Young pt with diabetes may be type 1 or 2 or 1.5 mean LADA or MODY ...or pancreatic diabetes management is different for each so before management proper diagnosis is required Send c peptide and anti gad antibodies Usg pancreas Start insulin sc injection
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