Uncontrolled T2DM with Hypothyroidism(Anti TPO+ve)

A 35 year old female housewife by profession and diabetic for last 12 years Chief Complaints Known case of T2DM and hypothyroidism (112 mcg Levothyroxine) for last several years presented to OPD with uncontrolled sugars and problem of paraesthesia foot History Before visting me she was already on voglinorm GM 2 forte in the morning and Empagliflozin/Linagliptin 25/5 once daily Vitals BS was 280 mg/dl RBS was to the tune of 300 and 350 mg/dl Investigations Anti TPO >1300 C - Peptide Stimulated/Post Prandial - 3.9 HBA1C - 8.2 As sugars were not getting controlled, I asked her for a C- peptide, but its coming normal too Management I initially started her on - FIRST VISIT Gliclazide 60 mg XR + metformin 500 mg BD dapagliflozin 10 mg OD Follow up visit - SECOND VISIT (Similar sugars again 300+) Gliclazide 60 mg XR + metformin 500 mg 2tabs morning and 1 tab evening Dapagliflozin 10mg Follow up visit - THIRD VISIT( Similar sugars again 300+) When she visited me yesterday with report of anti-tpo and c-peptide still her sugar uncontrolled to the tune of fasting and random similarly around 350 I have changed the medicines to gluconorm G 4 forte twice daily and Pioz 15mg once-daily and Voglibose 0.3 thrice daily for a week. Counseling for insulins was done right from the first visit My concern is which insulin to start her on, Ryzodeg or Lantus/Degludec?

2 Likes

LikeAnswersShare

She has beta cell apoptosis bcz of sulfonilureas So better shift on insulin I will prefer basal bolus insulin with monitoring and titration of units Orally i will prefer to continue dapagliflozin+metformin 10+1000 mg +vildagliptin 50mg Anti TPO are raised suggestive of thyroditis hence treat it To bring the hba1c in control keep regular monitoring and followup But diet control Weight and obesity management

Valuable opinion
0

View 1 other reply

A case of hashimoto's thyroiditis with uncontrolled DM and sulfonyl urea failure Patient needs,to be shifted to insulin - better will be time tested Huminsulin 30 :70 . Insulin can be supplemented with Pioglitazone 15 mg B.D and dapagliflozin 10 mg O.D. Treatment of thyroid disease is equally important to control DM .In addition to L-,Thyroxine supplements - Iron and calcium supplements are also required

Rather than changing OADs & increasing their dose, we should think it as a case of SUF (secondary SU failure) and think of starting insulin. Ryzodeg 20iu BID & Remozen-V BID + Metformin 500mg BID SMBG advice to be given to home monitor the BSLs.

Valuable opinion
0

hypothyroidism 1) hypothyroisism or hyperthyroidism is an endocrine disorder 2) in this situation HTN DIABETIC complications are known. there is hypertension commonly found wth endocrine disorders 3) diabetis is itself is endocrine disoder. so once patient is having deformity in one system then associated complications are known . it is nighter because of shigru nor due to kanchnar guggul if so then everybody who eats shevaga sheng in diet will suffer from HTN contineu with confidence with same line of treatment and add chandraprabhavati 2-0-2 to regulate hormonal system.

My suggestions are as follows 1. She definitely has evidence of secondary OHA failure so there is no point in keeping her on any sulphonureas  2. Put her on twice daily metformin/ Dpp4 combination therapy  3. Start her on Rhyzodeg twice daily maybe 20-0-20 units to begin with  4 She needs good life style Managment with a proper dietary advice including excercise 5 . If insulin / Dpp4/metformin still doesn’t control after good insulin titrations then add SGLT2 inhibitors . 6. She has autoimmune thyroiditis and treat appropriately with Thyroxine to keep Tsh between 1-2 IU Levels

Valuable opinion
0

Add lantus 10 units and daily increase by 5 units till FBS 110 and ppbs 140 mg. Add sglt2 like remoglif 100 mg bd.pio can be stopped

Valuable opinion
0

As per her age she is more likely to be in the category of LADA kindly go for anti GAD65 antibodies and shift her completely on bolus basal insulin regimen and stop dapa as to prevent DKA in this high blood glucose settings

Cases that would interest you