There are diabetic visiting clinic who is in a constant trouble because of ongoing uncontrolled diabetes and frequent never ending visits to a physician.Today’s story revolves around Mr X who visited last month. A top class executive in a firm. Patient presented with a lot of anxiety, lack of concentration, he could barely sit and the attention span was very pathetic. He could barely concentrate, very negative in attitude and to every suggestion used to give a counterpoint. In total he was one of the difficult ones we get in practice. The records were scrutinized, revealed that he is on 86 units of injection insulin and oral tablets and also on medicine for hypertension.The dose of medicines was on a rising trend. He had gained weight in last 6-8 months of eight to ten kilograms. On examination was very irritable and could barely concentrate. On repeated questioning revealed a loss of memory. He said whenever he used to visit his doctor with high blood sugars his dose of medicines used to be increased. His struggle became a painful exercise where after each visit the sugars were high and his dose of insulin kept on increasing. He had similar values of blood sugar when he was on 20 units insulin , now dose has increased and the sugar values are the same.
Am I getting a poor quality medicines? This is what we think as a layman.
Why the medicines are increasing?
Why i am not relieved ?
What is the cause of weight gain?
This is a common phenomena where the episodes of low sugar begets high sugars.
What is this paradox?
Something mystical, conjuring. Somogyi in 1960 explained this phenomena of Somogyi’s effect.whenever we have low sugars below the physiological limit over body’s defense starts acting. Your defense wants to keep you alive, so it leads to lowering of our insulin levels and increases hormones like glucagon, cortisol, catecholamines. The insulin is suppressed and the stress hormones goes up.So our own system keeps us alive by increasing the blood sugar levels.this is what is happening in our case , there is an episode of low sugars and the defence is increasing sugars and the doctor is less aware of the concept and he further steps up the insulin dose .So the vicious circle is being created where hypoglycaemia is bringing hyperglycemia and the circle is complete.Though the sugars are high it is actually the episodes of hypos which has led to anxiety, irritable behaviour . poor concentration and weight loss.The weight is increasing because of high doses of insulin. Blood pressure is rising because of recurrent hypos and the over dose of insulin. The situation is tricky we are treating the patient and the drug is causing hypoglycaemia .
What we did?
The doses of insulin were reduced to half and patient was adviced to come after a week. After a week patient was more attentive, less irritable, could listen to instructions patiently and was cracking jokes. We had reduced the medicines to our surprise sugars were better controlled .What led to better control? In this case the patient was receiving more insulin then required which actually was causing hypos and when the patient recorded the sugars after few minutes of hypos it came high because of our body’s defence .So hypoglycaemia begets hyperglycemia. What should be done ? This a team work between your doctor and you .Steps to have better sugar control are-
Control over diet
Be cautious for symptoms of hypos.
Support your doctor with information of hypos
Do not press for faster control of sugars
Doctors should have concern for hypos.
Proper selection of a doctor , preferably an Endocrinologist and a patient approach towards sugar control is the key to avoid the constant trauma faced by Mr X because of overuse of insulin and recurrent hypos.