I have a 45 yrs old patient who is a known T2 diabetic of 3 yrs duration. He is a marketing manager, who has a erratic eating pattern and a hectic roaming field work He is very content with my treatment because just last month,he has achieved good glycemic control with a HbA1c of 6.52 % , FBS 96 mg/dl , PPBS 128 mg/dl. He has no other comorbid conditions or any complications. He is neither a hypertensive nor hypothyroid. His Medication includes DAONIL 5mg 1 tablet Before breakfast, VOGLIBOSE .3 mg 1 tablet three times before meals . Today at around 230 PM, He called me very agitated on my mobile to say that he has not been feeling well since 2 hrs. He was complaining that he has been feeling weak, giddy, heart beating faster and some trembling of hands. He doubted this situation to be an episode of hypoglycaemia and confirmed with his glucometer reading at 62 mg/dl. He took his lunch one hour early comprising 2 rotis and potato curry but still has been having the same troublesome symptoms. What do you think I should have suggested him on the phone to relieve him of his hypoglycaemia immediately as he cannot come to your clinic at that moment ?



This is an irrational treatment first of all. No T2DM patient aged around 45 yrs, has an erratic eating habit, a hectic roaming field work, can be put on SU like Glibenclamide to start with and Voglibose TID. This is not called treatment at all because there is no Metformin in the prescription. As per the Recommendations of ADA/EASD consensus for the treatment of T2DM, any patient suffering from T2DM should be put on Metformin as first line of choice unless otherwise contraindicated. The next drug can be anything like SU like Glimepiride OR Gliclazide in Indian Scenario. OR AGI like Voglibose in Indian Scenario. OR DPP4 Inhibitors OR Basal Insulin OR TZD like Pioglitazone in Indian Scenario. OR SGLT2 Inhibitors OR GLP1 Analogues. In the given case scenario the poor patient went in to Hypoglycemia. Still he is in Stage 1 only. What's important now is 1) Correction of Hypoglycemia as ADA has warned very strictly against the hazardous effects of even single episode of Hypoglycemia could lead to CAD CVA Dysarthria Aphasia Seizures Coma Death if not treated properly. So this gentleman should take care of Hypoglycemia first by taking 20 g of Glucose dissolved in Water and repeat if necessary. As a protocol, any hypoglycemia caused by SU especially Glibenclamide should be hospitalized and kept under observation for at least 72 hours because out of all Hypoglycemia episodes the most dangerous and serious is that's caused by Glibenclamide. Now a days no one is using Glibenclamide except in the Government Hospital set up. This molecule must be discouraged to the possible extent. Not only Hypoglycemia, but interfering with Ischemic preconditioning of the heart is one of the major disadvantages. In many International conferences I have witnessed speakers saying SU Vanished. In a country like India though we can not avoid SU, we still have better molecules like Glimepiride or Gliclazide. 2) The prescription should be changed with immediate effect like ask him over phone, after stabilisation of Hypoglycemia to report before the treating Physician immediately. Take off all. Start Metformin 500 mg SR. Up titrate to maximum dose of 1,000 mg BD. Next best add on would be DPP4 Inhibitors like Linaglipin 5 mg. In case not to the target slowly introduce AGI Voglibose. So in the given case both are important Correction of Hypoglycemia immediately Change the molecules with immediate effect. Thanks for presenting a good case and regards.

yes Dr. SU induced hypoglycemia is extremely relevant in ds case...

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This post of mine is going to create a record of some sort, the longest ever written ! Today , I am going to be the first to use the Disagree button ! This post is dedicated to Our esteemed Influencer Dr Krishna Mohan. ! What is an irrational treatment ? Where is it written that a T2DM patient aged 45 yrs , who has an erratic eating pattern and hectic working style cannot be put on SU drug like Glibenclamide ( quote: DrKM ). It seems our respected doctor is not aware of lives of our majority Indian patients. All need a cost effective approach. Most of them don't have the luxury of tiffin breaks and lunch intervals. Most have an erratic eating disorder and a busy day all the time, for instance, auto drivers, lorry drivers, maintenance workers etc.. Even doctors have an erratic eating pattern ! I have number of incidents to quote if you wish, where in they themselves had to take Treatment for Hypoglycaemia. Did I say that Glibenclamide was the drug, I started with, in this patient ? Did you read the clinical history properly ? But Dr KM is bit too keen to prove me wrong. I don't know the reason ! DrKM means to say that whoever has been prescribing Glibenclamide in the past and who continue to do so are not in line! DrKM wants to play the role of a teacher, Nothing wrong with that, But there is a way to contradict ! DrKM says " This is not called Treatment " . What does he mean by that ? Is it death sentence ? DrKM talks about Recommendations, as if he was on the panel of ADA/EASD. Let me remind DrKM that the recommendations are meant to be mere Guidelines to consider for treatment. The recommendations are never meant to be the Law ! This has been written over and over again at the outset of the chapter, that finally physician's clinical judgement is more important, Next important is the patient's preferences which has a very vital role to play in devising the management regimen . ADA/EASD have never attempted to impose their views on doctors worldwide. Why I chose Glibenclamide for my patient ? I do know that Metformin Is the first drug to be considered in the pharmacotherapy of a T2Diabetic. Unfortunately my patient has shown repeated episodes of UGI upset , with as little as 500mg. So I decided to take him off the drug ! DrKM asks us to choose only SU of his liking, Glimepiride and Gliclazide in Indian patients. I ask Do we the clinical research data to consolidate your point. Sadly He cannot find it. ! He feels that there is no role of Glibenclamide and Glipizide ( even though he didn't mention it ), Meglitinides ( Repaglinide and Nateglinide ) in T2DM. We already know that Glibenclamide is the most potent of all SUs and most economical too. DrKM seems very empathetic when he comments " this poor patient went into hypoglycaemia " ! What does he mean by that ? Poor socio-economic status. ? or because you pity him that he is my patient ? DrKM further rambles, " he is in Stage 1 " . This is indeed hilarious ! I am yet to come across Stages of hypoglycaemia in Stages except for Mild, Moderate and Severe. I wonder what is Stage 1 ? More is coming ! He comments" ADA has warned very strictly against the hazardous effects of even one single episode of hypoglycaemia could lead to CAD , CVA, dysarthria, aphasia, seizures, coma and death. " . I challenge him on this forum to bring out any passage/ excerpt/recommendations issued by ADA that proclaims this above said subject applicable for Hypoglycaemia for all ages ! And then let me ask everyone, how many of us has seen a patient with hypoglycaemia landing in CVA and ACS. ? DrKM further advises " as a protocol,a hypoglycaemia caused by a SU especially Glibenclamide should be hospitalized and kept for at least 72 hrs " This is a misinterpretation ! This patient has been taking Glibenclamide 5 mg daily for the last 6 months with uneventful period.. How can this drug at this modest dosage cause prolonged hypoglycaemia ? Neither this drug was taken in higher doses ( more than 20 mg /day ) , nor did he take inadvertently nor is it a suicidal attempt ( first dose effect ) DrKM seems to bent upon one leg when he says that Glibenclamide is no longer prescribed by private practice doctors and only used in government hospital setups. This means to say that government of India and government medical officers are ignorant to be still using this molecule ! I am yet to hear from any endocrinologist that Glibenclamide is bad and must be discouraged at all levels. And I am also yet to come across any government directive that Glibenclamide is being considered to be banned or to be issued with a black box warning ( as for Pioglitazone ). He views that Glibenclamide interfere with ischemic preconditioning of heart . This is yet again misunderstood. Why would any body keep Glibenclamide in a diabetic with ACS or Heart failure ? I like to remind you that even ADA/EASD have no plans to ban Glibenclamide. They infact use it by the name of Glyburide on par with Glimepiride usage ! Let me tell DrKM , this interesting news that Glibenclamide has been used and is still being used in clinical trials in South Africa in women with GDM and Progestational Diabetes. The results available are favourable and match with that of Insulin therapy. Glibenclamide has the added benefit that it doesn't cross the placenta, where as other SUs do. ! What does DrKM mean when he says" SU vanished."? SUs have the best A1c reducing potential, next to Insulin In cases where Glimepiride and Gliclazide have failed, ther Glibenclamide has proved effective. DrKM seems very interested to change the treatment for this patient who had only one single episode of hypoglycaemia without investigating the cause of hypoglycaemia. I wonder at DrKMs audacity to suggest costlier molecules like linagliptin ! Before commenting , DrKM should have read the clinical history once more. This patient had a near perfect A1c and Glucose levels under target goals but our learned DrKM is very eager to suggest treatment changes as an easy option,instead of identifying the cause of hypoglycaemia. We, at Curofy should be learning and respecting each other, not try to intimidate, just because there is a scoring system and you are way up the ladder ! This sounds like a feudal system. It is time to modify the system. Back to the case, We always attempt to control the blood sugars effectively as nearer to the target goals, this may tilt the patient towards hypoglycaemic zones at times.Let us not forget that when you are performing Gymnastics, you are bound to get hurt, in the same way ,in the persuit of tight glycemic control, hypoglycaemia is bound to come up. I spoke to my patient at length in my clinic and I enquired into his affairs. He admitted that he has taken DAONIL 5mg as usual before breakfast but had taken little than usual breakfast and in addition he also missed his 11 AM snack . THAT explained why he had the hypoglycaemia. ! So I took this excellent opportunity in educating him about the importance of regular intake of meals both in right quantity and quality, and also the importance of small snacks at 11 AM and 4 - 5 PM, thereby avoiding the risk of even Subclinical hypoglycaemia . I am highly disappointed that our esteemed Influencer DrKM could not come up with the rationale of treating of this patient's hypoglycaemia. Let me explain : Glibenclamide acts by stimulating Insulin secretion. Voglibose acts by slowing the intestinal CHO digestion / absorption , by inhibiting the intestinal Alpha glucosidase. By inhibiting this enzyme, CHO in the form of polysaccharide / starch breakdown is slowed down and the absorption of CHO in glucose form is delayed. so if we ask him to take regular food which is a mixture of CHO, proteins and fats, heis not going to improve immediately because Voglibose is acting against the CHO breakdown, proteins donot breakdown so early and easily and also stimulate Insulin secretion to a little extent. Fats impair the CHO absorption. Hence The availability of glucose to the body is almost too little at that moment. Therefore we should ask the patient to take plain Glucose 15 - 20 gms in powder or in liquid form immediately, This will resolve his hypoglycaemia because Voglibose won't interfere with glucose absorption but may do with table sugar. Even chocolates don't do any good because they are composed mainly of proteins, fat and little glucose in sugar form. Thanks for patient Reading . Now I think I am in the record books as the longest post ever. !

I totally disagree with you. when you are a clinical diabetologist why you have mentioned yourself in undergraduate category. If you disagree with answer it is ok as there are differences of opinions but why are you criticizing Dr. Krishna Mohan Sir? he has not criticized you anywhere but encouraged you telling that you have posted very good case. secondly whatever you have mentioned in your answer you have not mentioned it in your question totally. you have partly mentioned in question. secondly whatever answers are given by doctors you try to respect them. if you don't like to follow don't follow them and try your best to treat as you are the best judge of your patient as you have practically seen and examined him. try to accept differences of opinions but don't humiliate anyone.Mohan Sir is very very senior and I feel if you respect others in return you will be respected by others.t ake as much as you can and forget where you don't agree. so it is my request to you please don't humiliate anyone from now.

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Dear Dr Lele, let me clarify your doubts, one by one 1.No matter how many times I correct or edit myself in my profile settings, it still showing that I am undergraduate, Then How can I derive any mileage by calling myself an undergraduate, instead of senior doctor with 30 yrs of experience. 2. Why do you say it is criticism, I was stating facts, of what he wrote, .I hold difference of opinion and I contradicted quoting him . There should be nothing wrong with that.. His very post started with unnecessary criticism ( pl read his post again,and he didn't even bother to address or even acknowledge me by my name ) 3.whatever clarifications,one needs from the question , He or she should ask from me, instead of jumping to conclusions and showing that I was incompetent. And I posted my explanation and DrKM was miles away from question . I asked in the post what is remedy for his hypoglycaemia in that clinical setting, but instead he went loggerheads in lambasting my treatment that it is irrational and which is why that " poor " patient landed in hypoglycaemia. There should be a minimum courtesy. ! 4. I always respect my seniors and juniors And I expect the same etiquette from them. DrKM never showed that in the post except for adding that it was a good case after attempting to dissect me ! 5. you are Right when you say that I am best judge to Treat my patient, but. a senior member like DrKM should Remember this . Finally What do I gain from humiliating anybody, Everybody gets what do deserve. " The boomerang effect ". I was talking about subject and contradicting him .where he went wrong. That seems to be a problem when people have a dogmatic approach. We should evolve , correct ourselves and move forward.

hypoglycaemia is more dangerous than hyperglycemia. so immediate attention n treatment required if BSL of 62 mg is confirmed, then ask him to consume 15 gm glucose in 100 ml water or 100 ml concentrated fruit juice repeat BSL after 10 min. relax if normal. else repeat the above step of 15 gm glucose in 100 ml water or a concentrated fruit juice. repeat BSL. relax if normal. if still low, ask the patient to consume the next/ subsequent major meal. it may b noted that I mentioned glucose n not sucrose, coz voglibose will not allow the sucrose to b immediately broken down n hence will not increase BSL immediately, as is reqd in ds case. continuous SMBG is to b reinforced, as to find out which other times is he going into hypoglycemia. re enforcement of regularity in timings, quantity n quality of meals, along with a disciplined exercise lifestyle cannot b over ruled. voglibose can b withheld for some time. may or may not b introduced, depending on the SMBG reading

Good Analysis

Please read the clinical history, particularly the medication part. The last passage should be read again to grasp my Question Hint : I am not just asking a remedy for his hypoglycaemic condition but also the rationale of such approach ! Remember , this is his first Hyperglycemic episode. Keep guessing and Please do write. I will post my answer tomorrow !

This is hyperglycemic. or HYPOGLYCEMIC EPISODE??

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Such pts can always keep candy or chocolate in there pockets ,as many times if noone in the home pt finds difficult to make a drink with trembling hands & giddiness So can consume a candy with immediate effect. His glycemic control is fantastic Dr u can reduce the dose of Voglibose to .2 mg ,before food. Many pts get diarrhoea due to voglibose thus reducing sugar

you are partly correct, do read my blog

Ask him to take a glass of sweetened sugar or glucose drink or chocolate or sweets, whatever is handy. Also advise bread or chapatis. Check blood sugar after an hour and then monitor for 24 hours as daonil has a long half life. Such patients should be managed by metformin only. Avoid sulphoureas.

You are partly correct. no rationale explained


You are Right but read my blog

Your patient's BL sugar is well controlled.now on hypoglycemic. he should take chocolates,candies,biscuits.keep these with him..acc to me he can be put on Metformin only.He will have better control.Moreover we should avoid advise in phone.

also try n avoid a fat based sweet for treating hypoglycemia. fat does not allow the BSL to b raised quickly / in other words, fat blunts the hyperglycemic response of sugars. so for treatment of hypoglycemia, only pure sugars to b given

Absorption is delayed with fat.

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