A male patient aged 63 years known case of T2DM with HTN with polyneuropathy has been under treatment from another GP reported to me for check up. He has been taking - TAB GLUCONORM G3 twice daily Tab Ajaduo 25 OD Tab. Telma 40mg OD His sugars are very much controlled. First visit on 23/05/2020 Complaints - paresthesia foot soles especially while sleeping and pain calf muscles,increased frequency of urine esp. at night and Vitals and RBS are normal too. I asked him to take same medicines gluconorm g3 and ajaduo as written above. I added tab Pregabid NT at bedtime + Tab Rejunex OD once daily + Vit D3 60K weekly + Tab Ultracet SOS and Tab Telma H OD. Ordered a panel of investigations and USG KUB. Second visit on 26/05/2020 His paresthesia on foot soles has been resolved almost 80%, but still has pain in calf muscles. Results of the panel investigations and USG KUB are - TFT -Normal Uric Acid - 8.5 HbA1C - 6.9 % VIt D3 - WNL VIT B12 - MARKEDLY ELEVATED (Also gives history of 12 injections of Vit B12 given I/M in the past) Lipid Profile is deranged as attached. GRADE 1 Prostatomegaly on USG KUB. My concerns are - 1) Paresthesia - We have to give pregabalin and Nortriptyline along with methylcobalamin 1500mcg once daily. Can I give pregabid NT and Rejunex OD at bedtime? 2) Uric Acid - As it is asymptomatic, and he has been taking empagliflozin for a long time, which actually aid in uric acid removal thru urine, but his uric acid levels are elevated instead. Is it necessary to burden this patient with a dose of furic 40 daily? 3)Regarding lipid profile, can I prescribe him cap maxepa OD afternoon along with a dose of Rosuvas F 15 mins before dinner. 4) Regarding prostatomegaly, Urimax D at bedtime? 5) As his Vit D3 are WNL, monthly once Vit D3 60k supplementation. 5) What to do regarding his elevated Vit B12 levels???



Dear Dr Ajeet Singh, Very happy and healthy good morning first. Thanks again for tagging me to answer your question. Coming to the case Scenario, 1) Your line of treatment is absolutely correct. But with hold Methyl Cobalamine for few months as you mentioned that the B12 are high. Nothing to worry about Hypervitaminosis B12 as it's a water Soluble Vitamin and needs no further treatment except not loading the patient with B12. 2) As long as the patient is asymptomatic ie no complaints regarding Gouty Arthritis, the patient doesn't require either Allopurinol OR Febuxostat. You better label it as Hyperuricemia. Advice the patient regarding Diet which reduces the Serum Uric Acid levels like No Red meat No poultry No Pork. No fish especially Sardine type of fish, Turtle Fish, No Cauliflower, No green Peas, No Beens, No Mashrooms. No Alcohol especially Beer. Advice the patient to lose weight. R/O certain diseases associated with Hyperuricemia like Hypothyroidism Psoriasis DKD Any way the patient has T2DM obviously. 3) Your line of treating Dyslipidemia is perfect. 4) As long as the patient has no symptoms don't put the patient on Alpha Blockers, as it's Grade 1. Treatment depends on PVR, Post Void Residue. Cross Consultation of Urologist if possible or else you only can manage Prostatomegaly. 5) Absolutely correct treatment 6) By mistake you had put 5 twice, it's 6 about B12. Nothing to worry about Hypervitaminosis B12. Due course it gets eliminated from urine. Don't overload the patients with B12 or Methylcobalamine. No specific treatment is available for Hypervitaminosis B12. Just stay calm. Don't change the treatment for Diabetes. Combination of Empagliflozin and Linagliptin is the best out of all. Counsel the patient regarding Genito Urinary Hygiene Adequate Hydration. Thanks again for giving me the opportunity to answer your question. Regards and thanks, Dr Sepuri Krishna Mohan.

Thank you doctor

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Dear dr Ajeet Singh My advice would be 1 either continue pregaba Nt or shift on gabapentin 300mg+tab nortryptiline 10mg 1od Avoid vitb12 formulations as pt is in hypervitaminosis which will get settled normal level in due course of time as such there is no chelating agent for the same. 2 definitely he need febuxoate 40 or 80 mg since SGLT 2i are known to eliminate uric acid but they are not uricosuric 3 anti lipids are need of mx 4yes BEP do make nocturnal urination hence he need either urimax D or silodosyn +Dutasteride 8mg 1od 5 vit d3 may be kept for maintenance monthly or 3monthly

Thanx dr Ramesh Kumar Singh

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You can continue with Methylcobalamin, Pregabalin & Nortryptiline As there is prostatomegaly, SGLT2i should be withdrawn & Tamsulosin+Dutasteride to be started. Febuxostat 40mg to be given for hyperuricemia. Gluconorm G3 to be modified to Gluconorm G4 Forte VitD3 monthly once & Rosuvastatin + Fenofibrate to be continued

Thank you doctor

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Since patient has nocturnal frequency of urine, suggesting prostatism, with Ultrsound evidence of BPH , it is better to avoid Nortryptalin, which has cholinergic properties. Frequency can be observed, uroflometry can be done, and urimax can be started if there is evidence of obstruction. Pregabalin alone can be continued. Since B12 is in excess, oral B12 can be reduced to twice weekly. Since Vit B12 is water soluble, restriction of intake alone is sufficient to bring it to normal levels. Since Vit D3 is normal, it is enough to give maintenance daily dose like gemcal or shellcal. No need for VITD3 60 K Rosuvas alone is enough for dyslipidemia. Duolexetine is alternative drug for nocturnal calf pain. Raised uric acid has to be treated with diet and drugs effectively, since this is a risk factor for heart and kidney .

Your discussion is absolutely right

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Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Adv Diabetic diet Tab Galvus Met 50/500 twice daily before breakfast and dinner Tab Pregalin M SR 150mg after dinner Cap Urimax D daily at bedtime Tab Trental 400mg bd Tab Tropan 5mg bd Tab Febuxor 40mg daily before dinner Tab Risuvas F daily before dinner Tab Telma 40mg daily morning Tab Vitamin D3 60k once in month

For parasthesia: pregabalin For URIC acid: diet. Plus febugout 40 od For lipid : rosuvas 10 od at night For HTN and DM continue same medication as it’s in control zone Continue treatment for BPH

Kindly advise the patient to perform renal function test creatinine ,urine albumin and aslo a fundoscopy considering he has already developed neuropathy , Also glimiperide 6 mg is a higher dose , more prone for hypoglycemia Considering empagliflozin with BPH as more chances of UTI

1- Stop Vit B12 medication.. 2- Add Rosuvas F , febutaz 40 3- Continue Preagabalin NT 4- he is having grade 1 prpstatomegaly as he is symptomatic u can add tab urimax 0.4 mg hs. 5- Give Vit D supplements for 8 weeks 6- Add tab Evion LC once daily x 10 days

@Sepuri Krishna Mohan @Dr. Sandip Debashis Mishra Please give your valuable opinion for this case

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