Case Study About Osteomyelitis

A 26 year old woman has suffered from Type 1 DM since the age of five years. Her insulin regimen includes pre-prandial administration of insulin lispro and once a day administration of insulin glargine. Lately, her glucose control has deteriorated significantly and there is great variability in her measurements. She is affected by the occurrence of 'unpredictable' hypoglycaemias, for example, one hour after a meal. When asked by her physician, she reports that her stomach feels full even many hours after a meal. She also reports retching and heartburns. What is the diagnosis and treatment? Most likely, this patient with long-standing DM, is suffering from gastro-paresis. The significant delay of gastric motility leads to the delayed transfer of food to the intestine and consequently delayed absorption of carbohydrates in the blood. This explains the post-prandial hypoglycaemia, at the time when insulin lispro exerts its peak activity, whereas there is no respective absorption of glucose from the food.

Delayed and unpredictable propulsion of food in the intestine renders the synchronization of injected insulin with food absorption difficult. A gastric prokinetic agent, like metoclopramide (at a dose of 10 mg before meals), could help with food propulsion. At the same time, changing the type of insulin from a rapid analogue to regular insulin can be effective in ameliorating the problem (regular insulin acts a bit later than the insulin analogue). Another alternative could be the administration of the insulin analogue after the meal or even fragmentation of its dose, with administration of a few units in small intervals after the meal, and monitoring of blood glucose levels.

Administration of insulin via a continuous insulin pump is also indicated in people with this problem.

Note: Hypoglycaemia can occur in non-diabetics when there is hypersecretion of insulin from tumours, such as insulinomas, some sarcomas, etc. These cases are rare and will not be further analysed in this book.

Also, in non-diabetics, one can frequently find low blood sugar levels 35 hours after a meal rich in carbohydrates. This hypoglycaemia is due to hypersecretion of insulin and possibly denotes these people are potential diabetics (decreased initial first phase of insulin secretion, together with delayed hypersecretion at a second phase, comprise a premature detectable abnormality of carbohydrate metabolism in these people).

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