Case Studies

Presenting Complaints

• Headache, tiredness towards the evening – since last 2 years.
• Abdominal pain and bloating, acid eructation’s – last 1 year
• Numbness and tingling of lower extremities – last 1 year
• Past history – not significant
• Family history of diabetes – present in father who died at the age of 62 of myocardial infarction about 20 years ago

Mr. Sudesh Kumar was apparently asymptomatic about 2 years ago when he noticed that he used to get a headache almost every evening, and used to feel tired and was unable to concentrate on his work. He had visited his family doctor who had prescribed analgesic (paracetamol), anxiolytic (alprazolam) and multivitamin, multimineral combination. Significant relief was obtained, but it lasted only for about two months followed by a recurrence of symptoms. Sudesh Kumar neglected to visit his doctor again.

About a year ago he noticed an uncomfortable sense of fullness after meals and a burning sensation in the chest on lying down. This progressed to persistence of the feeling on waking up and after even small meals. When the symptoms became intolerable he visited his family doctor again and was prescribed cisapride and ranitidine. He complained of numbness and tingling sensation in his feet, and was prescribed multivitamin tablets. Again there was relief lasting for a few days followed by a recurrence of symptoms which gradually grew in intensity, necessitating consultation with a physician.

Type 2 diabetes is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin or a defect in its action. It is generally believed to occur as a result of an environmental-genetic interaction wherein the effect of a challenging environment upon a genetic predisposition results in the gradual development of the frank diabetic state. This stage progresses from impaired glucose tolerance i.e. the inability to dispose of a glucose load within 2 hours (postprandial hyperglycemia) to fasting hyperglycemia which further aggravates the postprandial defect and rapidly precipitates further worsening of glycemia.

The Type 2 diabetic state is often not diagnosed, or neglected or inadequately treated. Continuous exposure of tissues to high blood glucose concentrations increases non-enzymatic glycosylation (glycation) of proteins resulting in the development of abnormalities in the functions of several of these proteins e.g. growth factors, coagulation factors, enzymes, channel proteins, vascular endothelium; and contributes to the development of the chronic complications of diabetes.

The aim of treating Type 2 diabetes is to normalize plasma glucose concentration as soon as possible without producing an unacceptable risk of hypoglycemia. Quick return to near normoglycemic levels helps cut down tissue exposure time to hyperglycemia to a minimum. This is especially useful when the level of hyperglycemia is in the upper zone i.e. > 270mg/dl (15mmol/L); a concentration known to be rapidly harmful to tissues.

Insulin produces a predictable decrease in plasma glucose concentrations, especially in the presence of hyperglycemia which is known to interfere with the absorption of sulphonylureas.

The occurrence of acid eructations in the presence of an 'essentially normal' barium swallow and follow through examination indicates that the cause of the symptoms is likely to be a developing diabetic autonomic neuropathy. This is reversible during the early stages hence the need for a reliable and effective medication for controlling hyperglycemia in type 2 diabetes.

Therapy

As Sudesh Kumar’s blood glucose values were very high i.e. fasting 336 mg/dl and 2 hr. post prandial 422 mg/dl, he was prescribed Human Mixtard® 15 I.U., divided 2/3rd in the morning before breakfast and 1/3rd in the evening before dinner