RARE CAUSE OF ELEVATED FASTING BLOOD SUGAR!!

Dr. Michael Somogyi speculated that hypoglycemia during the late evening induced by insulin could cause a corrective hormone response that produces hyperglycemia in the early morning. This phenomenon was
named as Somogyi phenomenon. Patients with somoygi phenomenon have a higher fasting blood sugar levels. It is a common mistake that the patient increases night dose insulin to control the fasting values but
still lands up with higher fasting values!
The causes of Somogyi phenomenon include

• Excess or ill-timed insulin
• Missed meals or snacks
• Inadvertent insulin administration.

Somogyi phenomenon is probably rare. It occurs in diabetes mellitus type 1 and is less common in diabetes mellitus type 2. If the cause is found out early and treated the prognosis for Somogyi phenomenon is
excellent, and there is no evidence of long-term sequelae.

WHY THIS HAPPENS??

The ability to suppress insulin release is an important physiologic response that people with type 1 Diabetes cannot carry out. Defense against hypoglycemia involves production of glucose from non-carbohydrate sources (gluconeogenesis and glycogenolysis) This mechanism is dependent on an intact glucose sensor system in the CNS, pancreas, and afferent nerves.

HORMONES WHICH HELP INCLUDE:

• The first to act and the most important hormone is Glucagon. Glucagon acts on the liver to stimulate glycogenolysis and gluconeogenesis
• Epinephrine increases the delivery of substrates from the periphery, decreases insulin release, stimulates glucagon release, inhibits glucose utilization by several tissues, and stimulates a warning system with sweating, anxiety, and tachycardia.
• Cortisol may aid in prolonged and severe cases of Somogyi phenomenon by blocking glucose use and stimulating hepatic glucose output
• Growth hormones are similar to those of cortisol

INVESTIGATIONS

Laboratory studies for identifying Somogyi phenomenon include fasting blood glucose, nocturnal blood glucose, HbA1c, and frequent glucose sampling. The fasting blood glucose level is expected to be inappropriately elevated due to hormonally induced rebound. A glucose reading in the middle of the night will disclose hypoglycemia as a result of insulin therapy. This will establish the diagnosis. Obtaining an HbA1C level may be helpful if it is within the reference range or low despite an elevated fasting glucose level. It supports the concept of a rebound fasting hyperglycemia in the face of normal glucose control. An elevated HbA1C does not rule out Somogyi phenomenon.

Frequent glucose monitoring may be necessary to confirm the diagnosis and look for other periods of hypoglycemia that may lead to rebound hyperglycemia. Frequent hypoglycemia is responsible for hypoglycemic unawareness, which may cause the typical symptoms of hypoglycemia to be missed.

Treatment & Management
Somogyi phenomenon should be suspected in patients presenting with atypical hyperglycemia in the early morning that resists treatment with increased insulin doses.

If nocturnal blood sugar is confirmatory or if suspicion is high, reduce evening or bedtime insulin. Clinical signs, including weight gain, normal daytime blood sugar levels, and relatively low HbA1c,
suggest over treatment.

We insist every patient to go for SMBG (self monitoring of blood glucose) and 7 point blood sugar charting. This will help identify somogyi phenomenon early and manage it efficiently. Controlling of fasting blood sugar is essential as there is evidence linking increased fasting blood sugar levels to microvascular complications.

PNEUMOCOCCAL VACCINE AND DIABETES

India is the world leader in diabetes. People with diabetes are more prone infections. Pneumococcal infections are a common cause of morbidity and mortality, and people with diabetes are more prone to develop pneumococcal infections. With the availability of the pneumococcal vaccine, most international organizations now recommend that people with diabetes should be vaccinated against pneumococcal disease.  The two major types of diabetes are type-1 (insulin-dependent) diabetes mellitus, which is due to destruction of insulin producing cells in the pancreatic islets, and type-2 (noninsulin-dependent) diabetes mellitus, which is characterized by insulin resistance, often associated with other features such as obesity, hypertension, dyslipidemia, and accelerated arteriosclerosis.

Patients with diabetes have higher risk for bacterial and viral infections. The most common infections are preventable bacterial infections of the skin, the urinary tract, and the respiratory tract. Apart from the morbidity associated with the long term complications of Diabetes infections with influenza and pneumococcus contribute to the overall morbidity and mortality in diabetes patients.

Diabetes mellitus has been identified as an independent risk factor for developing respiratory tract infections. Streptococcus pneumoniae remains the major cause of pneumonia in spite of widespread vaccination. Apart from pneumonia and its complications, viz., empyema and lung abscess, the pneumococcus also causes other clinical syndromes such as sinusitis, otitis media, tracheobronchitis, bacteremia, meningitis and peritonitis, some of which have high case fatality rates. Diabetes is a well-known risk factor for pneumococcal infection.

Diabetic patients have a normal response to pneumococcal vaccination, and vaccination is a cost-effective preventive strategy. Immunization with Pneumococcal Polysaccharide Vaccine (PPV, which includes 23 purified capsular polysaccharide antigens representing 85-90% of the serotypes of S. pneumoniae) in diabetic patients significantly reduces morbidity and mortality related to pneumococcal disease.  The 23 valent PPV (PPV23) can be given as a subcutaneous or intramuscular injection (preferably in the deltoid muscle or lateral mid thigh).  The antibody response after a single dose of PPV begins 7-10 days after vaccination

During influenza outbreaks, pneumococcal vaccines may be useful in preventing secondary pneumococcal infections. CDC's Advisory Committee on Immunization Practices (ACIP) recommends a single dose of PPSV23 for all people 65 years and older and for persons 2-64 years of age with certain high-risk conditions. The vaccine is generally safe, but mild local side effects may be seen. Injection site reactions consisting of pain, soreness, erythema, warmth, local indurations occur. Fever is the most common side effect.

Indian Recommendations

The Geriatric Society of India recommends the use of PPV for

persons aged 50 years and above and

Persons aged 2 years or above with certain underlying medical conditions such as diabetes.

Revaccination

A one-time revaccination is recommended by the ADA and ACIP for individuals >64 years of age, previously immunized when they were <65 years of age, if the vaccine was administered >5 years ago.

Should All Diabetic Patients Receive Pneumococcal Vaccination?

Diabetes is in itself a risk factor for invasive pneumococcal infection. In addition, there exist a substantial number of diabetic patients who have other co-morbidities like renal complications, coronary artery disease, COPD, chronic liver disease, malignancies, etc. For this subset of diabetic patients, pneumococcal vaccination should be recommended on priority by virtue of being at more risk than those with diabetes alone. The final decision lies with the treating physician as invasive pneumococcal infection is not so common in India.

OBSTRUCTIVE SLEEP APNOEA

Obstructive sleep apnea (OSA) or obstructive sleep apnea syndrome is the most common type of sleep disorder caused by obstruction of the upper airway. It is characterized by repetitive pauses in breathing during sleep, despite the effort to breathe, and is usually associated with a reduction in blood oxygen saturation. These pauses in breathing, called "apneas" typically last 20 to 40 seconds.
SIGNS & SYMPTOMS

• Unexplained daytime sleepiness
• Restless sleep
• Loud snoring (with periods of silence followed by gasps). 
• Morning headaches
• Insomnia
• Trouble concentrating
• Mood changes such as irritability, anxiety and depression
• Forgetfulness
• Increased heart rate and/or blood pressure
• Decreased sex drive
• Unexplained weight gain
• Increased urination and/or nocturia
• Frequent heartburn or gastroesophageal reflux disease
• Heavy night sweats.

WHY THIS HAPPENS?
                             The normal sleep/wake cycle in adults is divided into REM (rapid eye movement) sleep, non-REM (NREM) sleep, and consciousness. NREM sleep is further divided into Stages 1, 2 and 3 NREM sleep. The deepest stage (stage 3 of NREM) is required for the physically restorative effects of sleep. NREM stage 2 and REM, which combined are 70% of an average person's total sleep time, are more associated with mental recovery and maintenance. During REM sleep in particular, muscle tone of the throat and neck, as well as the vast majority of all skeletal muscles, is almost completely attenuated, allowing the tongue and soft palate/oropharynx to relax, and in the case of sleep apnea, to impede the flow of air to a degree ranging from light snoring to complete collapse. In the cases where airflow is reduced to a degree where blood oxygen levels fall, or the physical exertion to breathe is too great, neurological mechanisms trigger a sudden interruption of sleep. These arousals rarely result in complete awakening, but can have a significant negative effect on the restorative quality of sleep. In significant cases of OSA, one consequence is sleep deprivation due to the repetitive disruption and recovery of sleep activity.

TREATMENT MODALITIES

• avoiding alcohol
• Avoiding medications that relax the central nervous system (for example, sedatives and muscle relaxants),
• losing weight
• quitting smoking.
• Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep.
• continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open.
• There are also surgical procedures intended to remove and tighten tissue and widen the airway, but none has been reproducibly successful.

DRUG ABUSE!

                 Cannabis is commonly used to prepare Bhang, Hasish, Hash, Marijuana, Charas & Ganja. All these names are familiar to most of us. No No! I don’t mean we use it, but somewhere or the other we would have definitely heard about it. Cannabis grows like any other plant in most parts of the world. The key ingredient is THC – TetraHydroCannabino. This results in relaxed state of mind, lowering of worry, hunger and finally the person falls asleep. Cannabis can be smoked or consumed. The effects of THC last for 2-3hours when smoked, and for 24hours when ingested. The stems of Cannabis (Hemp) are used to prepare ropes.

Cannabis has been tried as medicine also. It is said to activate receptors in body, control vomiting, affect appetite, control cancer symptoms. Cannabis has also been tried in treating pain, anxiety and muscle spasticity.

Flowers, Buds, Leaves, Dried plant material, Resins, Powder and Oil are used.

 Known to India for more than 5000 years.  This wonderful plant has been mentioned in our ancient literature for its magical properties. Vedas refer to cannabis as one of the five sacred plants. It has been referred as a source of joy giver, happiness and liberator. In old times cannabis was used to relieve people from fear. Mythology says that once Lord Shiva was wandering in fields after a family tiff, he got tired and slept off near some leaves. On getting up he had those leaves and felt rejunuvated. After this incident it seems Lord Shiva made cannabis his favourite food.

                In the middle ages soldiers drank Bhang prepared from cannabis before going for battle. Bhang is prepared by mixing Nuts, Spices, Sugar, and Cannabis and is boiled in milk or yogurt. This preparation can also be rolled and eaten as small balls. Other preparations are ganja and charas. Cannabis is used in several parts of the country for religious purposes.

 IT IS LESS HARMFUL THAN ALCOHOL.

SCENARIO OF DRUG USAGE IN DIABETES

                The bad effect of these drugs is well known and has been publicised in the media very well. So I am not gonna go into details of drug abuse in general population but restrict myself to specific effects of these drugs in Diabetes.

Illicit drug use is extremely common amongst young people including many with type 1 or type 2 Diabetes. Cocaine, heroin and ecstasy appear to most severely affect glycemic control and the number of emergency hospital admissions and long-term complications. In addition, clinic attendance is much worse in illicit drug users. Some studies suggest that the onset of diabetes may be hastened by regular use but further research is needed. Questioning patients with diabetes regarding illicit drug use and adopting a non-judgemental approach would seem to be appropriate.

               

GENERAL EFFECTS –

Smokers have 3 times more risk of developing Diabetes compared to general population

Drug addicts develop diabetes earlier compared to general population

Risk of developing diabetes is more when drug abuse is combined with alcohol abuse (>15 alcohol beverages per week)

Risk is more when bad habits are combined with Obesity and family history of Diabetes

Drug abusers have poor glycemic control, tend to ignore their treatment regimens, have erratic lifestyle and do not attend reviews regularly. Final effect is they have high HbA1c.

SPECIFIC EFFECTS –

COCAINE – Acts as CNS stimulant. It also acts on adrenal medulla to release hormones which in abnormal amounts can lead to disastrous effects. These hormones increase blood glucose levels by altering carbohydrate metabolism, they inhibit insulin secretion.  Final effect – increased glucose production and decreased glucose clearance.

HEROIN – acts on opoid receptors in the body. Heroin stimulates both insulin & glucagon. There is defective pancreatic beta cell response to glucose stimulation.

ECSTASY – used most commonly as recreation drug. Diabetics using this drug are at risk of developing ketoacidosis and hyponatremia.

OTHER DRUGS – there have been some reports of associated serious hypoglycaemia.

CONCLUSION

                The data regarding drug abuse in India is minimal. I have not come across any statistics which deals with drug abuse in diabetics in India. But that doesn’t mean no diabetic in India is addicted to drugs. We do not bother to go into relevant details and ask leading questions regarding drug abuse. Reason may be due to social stigma or maybe fear of losing the patient. Well in this article I have put in some facts of drugs and also their effects in diabetes. I hope there will be population based studies to give attention to this problem in the future.

THANKS INDIBLOGGER!

Hi all

I was debating in my mind for the past few days if this post is necessary . Finally i decided!! It is my duty to convey my thanks to the website and people behind it. This website has given my blog some meaning.

                I completed my UG in 2005 and joined a tertiary care centre in the department of General Surgery. I had an opportunity to treat various kinds of Diabetic wounds. This continued for nearly 3 years. In this period i was able to understand the basic problem responsible for the wounds- its none other than the patient himself! With life long medication, meaningless restrictions, lack of understanding of the disease and lack of proper counselling all contribute to Diabetic wounds and also other complications of Diabetes. What little can i do to stop it? Only option that came to my mind was that i need to specialize in Diabetes treatment so that i can do something more on the preventive aspects.

                I was lucky enough to get placement in one of chennai’s best diabetology hospitals.  While working in this esteemed institution i completed my Post Graduation in Diabetes. Now i had the knowledge & experience to treat Diabetes but i wanted to cover a much larger segment of the society. How do i do it?

Run camps?

Conduct CME?

Mail everybody?

Keep talking to patient and his family?

These are good but not practically effective so i wanted to harness the power of internet. Wanted more people to listen and read about diabetes, have better understanding... result of this small desire – www.riyazsheena.blogspot.com i started posting like crazy. Few people visited my site.. only Few people!! Hey that was not the idea... this number of people i could have covered in my clinic... why waste time on internet....slowly my frequency of posts dropped.... this lead to lesser number of people peeping into my blog.. page clicks dropped to single digits!!

Nobody is interested in Diabetes!

Nobody knows my blog!

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At this point of time when i was nearly about to stop posting in my blog my dear friend Dr.Roshan Radhakrishnan who is a avid blogger himself introduced me to www.indiblogger.in from the time i entered this wonderful website everything was easy

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