Post Pancreatitis Diabetes Mellitus

His FBS is 110,180,250, but his PPBS after dinner is 404 and his RBS at 6pm evening was 357mg/dl and he still compalints of decreased consistency of stools 3 to 4 times a day. My concerns are - 1) Is it advisable to add humaninsulin 30/70 in morning and basal insulin at night? or How to titrate basal insulin? Or switch him back to premix insulin twice daily as before? He is not willing for basal bolus regimen, as it will increase cost and number of injections too. 2) Should I change him from rifaximin to pancreatic enzymes tablets? 3) How about using pioglitazone and metformin combination in this case instead of Glimipiride+Metformin? 4) Can the stool problem may be caused by 2gm of metformin too? But he has been taking metformin for a long while, and has been having stool issues recently only. Seek your valuable opinion on this case Chief Complaints A 45 year old male patient presented to the OPD with complaints of generalized weakness, paresthesia foot soles at bedtime and decreased consistency of stools with 3 to 4 times in a day History He is a known case of T2DM on premix insulin 30/70 taking it irregularly He is chronic alcoholic and has been admitted for pancreatitis few months back after which he was discharged om huminsulin mixtard 30/70 He still takes alcohol on/off but has decreased significantly He is a sales person by profession and has erratic parttern of meals and have been skipping meals in the past too. He has not been taking his insulin regularly and admits 2 to 3 episodes of hypoglycemia in the past too. Vitals His RBS was 357mg/dl. Rest WNL Physical Examination His weight is 53 kgs Management Seeing his job,episodes of hypoglycemia and everything, I had advised him glargine 10 units S/C at bedtime along with Glimipiride 1mg+ Metformin 1000mg twice daily along with rifaximin 550mg TDS, PPI, Pregabalin 75mg HS.

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Start with pre mixed insuline 20 in morning 15 in evening. After 1 week,7 points suger check is recommended. According to result of 7 point suger check,we will adjust insuline and will decide whether to go for Regular and NPH.... Start him on pancreatic enzyme replacement. No need of rifixamine Do not use metformin, if there is issue of insuline resistance, use pioglitazone at low doses. 7mg. Bd

It seems like a case of PEI (Pancreatic Exocrine Insufficiency) from the presentation. You need to go for FE1 (Faecal Elastase 1) estimation and the patient about the consistency of his stool by showing Bristol Stool Chart (if it is type 5 or more then likely to favour PEI). @Sepuri Krishna Mohan Sir, @Shivraj Agarwal Sir please suggest!

1-I would suggest - switch him.back to pre- mix insulin as before - considering cost factor and no significant advantage 2..Rifaximin or pancreatic enzymes , it will hardly make a difference- because his increased frequency of stools is due to 2 gm metformin 3.Instead of Pioglitazone + metformin combination- I would prefer tab VOLGA - R twice a day - it contains repaglinide 0.5 mg + voglibose 0.3 mg - an AJANTA pharma product .This is ideally suited for this patient because his PPBG is 404 after dinner and RBS is 357 at 6.P.M .although his FBS is 110 Both repaglinide and voglibose are very effectively in lowering PPBS without significantly affecting FBS 4.His long term dosage of metformin 2 gm is responsible for his diarrhea. As suggested VOLGA- R - does not contain metformin at all and so no need to give Rifaximin THANKS

Sir, can we go for premix insulin in morning and basal insulin glargine at bedtime?
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