SEPTEMBER 2024 - 3 Years Old child, Type1 Diabetes, Insulin Hypoglycemia, Intermittent, Bloating 1 Month
PATIENT DATA LOG OF SEPTEMBER - 2024
01/09/24
Patient Advocate: 1.09.24
7.30am blood suger 80
7.30am nuts and dates
7.45am milk and puffed
02/09/24
Patient Advocate: 9.45am 2u lispro insulin
9.55am rice with papaya, chayote, green banana, long beans, Spiny guard, pumpkin, egg and salad
12.00noon mosambi, apple
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
4.00pm blood sugar 228
5.30pm sour curd
7.00pm oats
9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 4u lantus insulin
PaJR PHR Moderator: (Gotokal er fasting dekhe uporer montobbo korechilam.
Aajker fasting ta jaante parle bhalo hoto) 👆
03/09/24
Patient Advocate: 2.09.24
7.30am nuts and dates
7.45am milk and puffed rice
9.45am 2u lispro insulin
9.55am rice with papaya, chayote, sponge gourd, long beans, green banana, soyabean and salad
12.00noon blood suger 267
12.00noon mosambi
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish
5.30pm sour curd
7.00pm banana
9.45pm blood sugar 107
9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 4u lantus insulin
04/09/24
Patient Advocate: 03.09.24
7.30am nuts and dates
7.45am milk
9.45am 2u lispro insulin
9.55am rice with pointed gourd, tometo, papaya, long beans, bitter gourd, spiny gourd, egg and salad
12.00noon mosambi
1.45pm blood sugar 257
1.45pm 3u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
4.00pm blood sugar 140
5.30pm sour curd
7.00pm oats
9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 4u lantus insulin
12.00night blood sugar 179
04/09/24
7.30am blood sugar 174
7.30am nuts and dates
7.45am milk
05/09/24
Patient Advocate: 9.45am 2u lispro insulin
9.55am rice with pointed gourd, ribbed gourd, long beans, bitter gourd, spiny gourd, tomato, egg and salad
12.00noon mosambi
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
4.00pm blood sugar 211
5.30pm sour curd
7.00pm little bit of dosa and banana
9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pn 4u lantus insulin
06/09/24
Patient Advocate: 5.09.24
7.30am nuts and dates
7.45am milk
9.45am 2u lispro insulin
9.55am rice with pointed gourd, chayote, green banana, papaya, long beans, bitter gourd, egg and salad
12.00noon blood sugar 249
12.00noon mosambi
1.45pm 3u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
4.00pm blood sugar 71
5.30pm sour curd
7.00pm banana
9.30pm pizza
9.45pm 2u lispro insulin
9.55pm rice with as same as lunch dish
10.40pm 4u lantus insulin
PaJR PHR Moderator: 2 unit of lispro appears less and 3 units appears dangerously close to hypoglycemia!
If only we could procure 2.5
Check fasting sugars to decide the suitability of the current lantus dose
Patient Advocate: Ok Sir
6.09.24
7.30am blood sugar 135
7.30am milk and puffed rice
07/09/24
Patient Advocate: 9.45am 2u lispro insulin
9.55am rice with chayote, green banana, papaya, long beans, pointed gourd, tomato, bitter gourd,spiny gourd and salad
12.00noon mosambi
1.45pm blood sugar 174
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish include fish
5.30pm sour curd
7.00pm banana
9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 4u lantus insulin
08/09/24
Patient Advocate: 7/09/24
7.45am milk and puffed rice
9.45am 2u lispro insulin
9.55am rice with pointed gourd chayote brinjal tomato fish and salad
12.00noon mosambi
1.45pm blood sugar 148
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish
5.38pm sour curd
7.00pm banana
9.45pm 2u lispro insulin
9.55pm khichdi
10.40pm 4u lantus insulin
12.00noon blood sugar 45
PaJR PHR Moderator: 12:00 AM hypoglycemia!? Any symptoms?
Patient Advocate: No Sir
1 teaspoon sugar was given
PaJR PHR Moderator: No symptoms?
She needs CGM to prevent such episodes
Patient Advocate: 8.09.24
7.30am blood sugar 101
7.30am nuts and dates
7.45am milk and puffed
09/09/24
Patient Advocate: 9.45am 2u lispro insulin
9.55am rice with pointed gourd, chayote, green banana, papaya, long beans, egg and salad
12.00noon mosambi
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
4.00pm blood sugar 129
5.30pm sour curd
7.00pm oats
9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 3u lantus insulin
10/09/24
Patient Advocate: 9.09/24
7.30am nuts and dates
7.45am milk and puffed rice
9.45am 2u lispro insulin
9.55am rice with chayote, green banana, papaya, long beans, pointed gourd, egg and salad
12.00noon mosambi
1.45pm blood sugar 280
1.45pm 3u lispro insulin
1.55pm lunch with same previous dish except egg
4.00pm blood sugar 285
5.30pm sour curd
7.00pm banana
9.45pm blood sugar 297
9.45 3u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 4u lantus insulin
PaJR PHR Moderator: Slightly high today due to x factors!
Patient Advocate: 10/09/24
7.30am nuts and dates
7.45am milk with palm (tal)
9.45am 2u lispro insulin
9.55am rice with papaya, chayote, bitter gourd, long beans, green banana, and salad
12.00noon blood sugar 218
12.00noon mosambi
1.45pm 3u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
5.30pm sour curd
7.00pm milk with palm and banana
9.45pm blood sugar 208
9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
11/09/24
Patient Advocate: 10.40pm 4u lantus insulin
11/09/24
7.30am fasting blood suger 72
7.30am nuts and dates
7.45am milk with puffed rice
PaJR PHR Moderator: Low fasting reflects the need for optimizing dose of lantus
Higher post meal sugars means the lispro needs to be optimised but again due to x factors as well as known factors such as diet and exercise, this is difficult as the sugar levels keep varying till we able to monitor it more meticulously
12/09/24
Patient Advocate: 9.45am 2u lispro insulin
9.55am rice with papaya, chayote, bitter gourd, spiny gourd, ribbed gourd, tomato, egg and salad
12.00noon mosambi
1.45pm blood sugar 89
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
5.30pm sour curd
7.00pm banana
9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 4u lantus insulin
12.00night blood suger 93
PaJR PHR Moderator: The lispro should have been 1 unit yesterday at least starting from before lunch and dinner
The lantus needs to be reduced to 3
Patient Advocate: Ok Sir
Sir ekhane ekta jinish lakshya kara jachhe lantus ta use korte korte kichhu din por por pen er madhya haoa(air) dhuke jachche sei samay lantus ja deoa hoy puro ta dhoke na takhon sugar level bere jai।
Abar air ta barkore diye tarpor push korle takhon sugar level thik thak ashe।
Kintu air ta jadi alpo thake tahole bar korte asubidha hay
PaJR PHR Moderator: @Meta AI please translate this for our other group members
Meta AI: I'd be happy to help! Please share the text you'd like me to translate, and let me know which language you'd like it to be translated into.
PaJR PHR Moderator: @Meta AI Sir ekhane ekta jinish lakshya kara jachhe lantus ta use korte korte kichhu din por por pen er madhya haoa(air) dhuke jachche sei samay lantus ja deoa hoy puro ta dhoke na takhon sugar level bere jai।
Abar air ta barkore diye tarpor push korle takhon sugar level thik thak ashe।
Kintu air ta jadi alpo thake tahole bar korte asubidha hay
Meta AI: I can translate that for you. Here's the translation:
"When using Lantus, after a few days, air enters the pen, and if the full dose is not administered at that time, the sugar level rises. If air is removed by tapping and then injecting, the sugar level remains under control. However, if there is less air, it is difficult to administer the dose."
Please note that this text appears to be discussing the use of an insulin pen, specifically Lantus, and the importance of removing air from the pen to ensure accurate dosing and blood sugar control. If you have any further questions or need additional assistance, feel free to ask!
PaJR PHR Moderator: 👆@Participant 19 @Participant 20 @Participant 21 would you like to comment on this?
Sir ekhane ekta jinish lakshya kara jachhe lantus ta use korte korte kichhu din por por pen er madhya haoa(air) dhuke jachche sei samay lantus ja deoa hoy puro ta dhoke na takhon sugar level bere jai।
Abar air ta barkore diye tarpor push korle takhon sugar level thik thak ashe।
Kintu air ta jadi alpo thake tahole bar korte asubidha hay
@Meta AI please translate this for our other group members
I can translate that for you. Here's the translation:
"When using Lantus, after a few days, air enters the pen, and if the full dose is not administered at that time, the sugar level rises. If air is removed by tapping and then injecting, the sugar level remains under control. However, if there is less air, it is difficult to administer the dose."
Please note that this text appears to be discussing the use of an insulin pen, specifically Lantus, and the importance of removing air from the pen to ensure accurate dosing and blood sugar control. If you have any further questions or need additional assistance, feel free to ask!
Participant 20: Will need a trend to make any reasonable conclusion.
Please also consider Thyroid and Adrenal insufficiency as he could be at high risk for Autoimmune polyglandular syndromes.
Patient Advocate: Same problem was seen first time also in lispro pen
PaJR PHR Moderator: Here's the trend since last 6 months 👇
https://narmeenshah.blogspot.com/2024/07/3-year-old-child-type1-diabetes-insulin.html?m=1
@Narmeen Shah @Participant 22 can you put it in an LLM and see if you can share it graphically since last one month and separately for last one week?
Narmeen Shah: Ok sir
PaJR PHR Moderator: Inputs from our pediatric endocrinologist in NJ:
I’m not sure I understand the question correctly: air bubbles have to be removed from pens at first use, and from syringes at every use. Typically, if the technique is correct, then after the first expulsion of air from a cartridge, there should be no way for air to enter the cartridge. Now, they will have to waste some insulin at the start to get rid of air… sometimes they have to do it a few times, because some cartridges can have more air.
Has someone watched the technique of injection?
My mother has been using Basalog Pens for at least 10 years now. And she had this issue initially, until we made her watch some instructional videos. She was loath to waste even small amounts of insulin initially, because of the cost, so she was skipping the step of removing air bubbles!
Here’s one, but if you have something in a local language, it’ll be better.
https://youtu.be/ZcfKG0Mp3kI?si=cW7ggTLgBJxlytmq
PaJR PHR Moderator: Please share a video of how you use the pen today keeping the patient deidentified
I think he may have shared a similar video earlier. Is it in her case report link?
Patient Advocate: এই কলমটির বর্তমান অবস্থা পর্যন্ত দুবার বাতাস( air) বার করা হয়ে গেছে, আর সেটা শুরু তে নয় দুবারই ব্যবহারের মাঝখানে l
12/09/24
7.30am blood sugar 53
7.30am nuts, chocolate
and dates
7.45am milk and puffed rice
9.45am 2u lispro insulin
9.55am rice with papaya, chayote, bitter gourd, spiny gourd, tomato, pumpkin, egg and salad
12.00noon mosambi
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
4.00pm blood suger 128
5.30pm sour curd
7.00pm banana
9.45pm 2u lispro insulin
9.55pm dinner with as same as previous dish
10.40pm 3u lantus insulin
13/09/24
PaJR PHR Moderator: The hypoglycemia is the effect of 4U of lantus on 11/9/2024!
Did she have any symptoms of hypoglycemia?
Patient Advocate: No Sir
13.09.24
7.30am nuts and dates
7.45am milk and puffed rice
9.45am 2u lispro insulin
9.55am rice with pointed gourd, chayote, papaya, green banana, long beans, ribbed gourd, bitter gourd, pumpkin egg and salad
12.00noon blood sugar 282
12.00noon apple
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
5.30pm sour curd
7.00pm banana
9.45pm blood suger 57
9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 3u lantus insulin
14/09/24
PaJR PHR Moderator: Let's start with the trends of fluctuations for this week.
Also @Patient Advocate can you share an image of the paper based charts that you keep for this and last month?
The case report contains some paper based charts from few months back I guess
Because we don't have CGM here we are unable to keep track of the number of asymptomatic hypoglycemia events this patient is having @Participant 20
@Participant 23 had promised to find out some monitoring equipment developed by his IIT colleagues but I guess that didn't materialize?
We also looked for CGM monitors suitable for 3 years old children and found some but perhaps we gave up earlier due to logistics.
Any idea what they may use for monitoring for 3 years old diabetics in UK and US?
Narmeen Shah: Greetings sir 🙏
Sir I tried my best for two days to plot the data into graph using llm, python coding and spss software as well as manually but wasn't able to get the desired output and unable to merge both the graphs with respect to time. Beyond my expertise. 🙏
Below are the visualizations for what I was able to do so far.
(For the whole month of August 2024)
PaJR PHR Moderator: Well done 👏
The fluctuations are standing out
Was her lantus ever increased to 5?
Would be nice to see what has been brewing in September till now
Do update her case report with the above images that you generated
Narmeen Shah: Yes sir. Here's the data I extracted.
https://docs.google.com/spreadsheets/d/18DeTEzBh_cm27WhVqF3dLloLw6JnEBGNl5Uj1gPv4wY/edit?usp=sharing
Here's the input & output.
https://colab.research.google.com/drive/1rh2STRsbpcS4Cxihgnf0mGf75Cu7MiwT?usp=sharing
PaJR PHR Moderator: Let's archive all the above into her case report
Narmeen Shah: Ok sir
Participant 20: I'm aware that Abbott Freestyle Libre has been discussed. What's the progress on that front?
PaJR PHR Moderator: Can you share if it can be ordered on Amazon for a three year old child?
Patient Adavocate: 14/09/24
7.30am nuts and dates
7.45am milk and puffed rice
9.45am 2u lispro insulin
9.55am rice with papaya, chayote, bitter gourd, spiny gourd, tomato, long beans, pumpkin, egg and salad
12.00noon pieces of mixed fruit ( prasad)
1.45pm blood suger 226
1.45pm 3u lispro insulin
1.55pm lunch with same previous dish except egg
4.00pm blood sugar 74
5.30pm sour curd
7.00pm banana
Narmeen Shah:
PaJR PHR Moderator: Parents described benefits of CGM use: decreased worry about glucose excursions, improved sleep, increased sense of safety with children who cannot recognize or express symptoms of hypo- or hyperglycemia, and greater comfort with other caregivers, especially using remote monitoring functionality when away from children. Challenges included painful insertions, wearing multiple devices on small bodies, disruptive alerts, data gaps due to lost signals, skin/adhesive problems, and difficulty interpreting the amount of information generated by CGM.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708264/
PaJR PHR Moderator: Inputs from global pediatric endocrinologist:
Instead of daily excursions, can we get a graph of mean daily values (pre- and post/breakfast, pre- and post-lunch, pre- and post-dinner etc): values may not be available for each time point everyday. Grouping the timings around meals is better than calendar times, and allows an assessment of responses in the fed and post-absorptive states.
15/09/24
Patient Advocate: 9.45pm 2u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 3u lantus insulin
15/09/24
7.30am blood sugar 270
7.30am nuts and dates
7.45am milk with puffed rice
9.45am 2u lispro insulin
9.55am rice with pointed gourd, chayote, papaya, long beans, pumpkin, egg and salad
Paticipant 20: My analysis is that the 2U lispro is not sufficing for both breakfast and Lunch.
Lispro for dinner appears okay.
Lantus 4U seems perfect at bedtime. However there are occasional low sugar events in the morning.
Ideally we need 2 am or 3 am blood sugars too to check if there is any nocturnal high or low blood sugars.
Narmeen Shah:
Assumptions
1. Post and Pre meal times don't mean that nothing is fed between these intervals.
2. Insulin has been given either after the meal or before the meal so the sugar levels are not independent of interventions.
https://docs.google.com/spreadsheets/d/18DeTEzBh_cm27WhVqF3dLloLw6JnEBGNl5Uj1gPv4wY/edit?usp=sharing
https://colab.research.google.com/drive/1rh2STRsbpcS4Cxihgnf0mGf75Cu7MiwT?usp=sharing
PaJR PHR Moderator: Well done 👏
Keep adding these to her online case report too
Narmeen Shah: Ok sir 🙏
Patient Advocate: 12.00noon mosambi
1.45pm 2u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
4.00pm blood sugar 298
5.30pm sour curd
PaJR PHR Moderator: Quoting from the case report our notes on 👇
06/09/24
Patient Advocate: 5.09.24
7.30am nuts and dates
7.45am milk
9.45am 2u lispro insulin
9.55am rice with pointed gourd, chayote, green banana, papaya, long beans, bitter gourd, egg and salad
12.00noon blood sugar 249
12.00noon mosambi
1.45pm 3u lispro insulin
1.55pm lunch with same previous dish except egg and include fish
4.00pm blood sugar 71
5.30pm sour curd
7.00pm banana
9.30pm pizza
9.45pm 2u lispro insulin
9.55pm rice with as same as lunch dish
10.40pm 4u lantus insulin
PaJR PHR Moderator: 2 unit of lispro appears less and 3 units appears dangerously close to hypoglycemia!
If only we could procure 2.5
Check fasting sugars to decide the suitability of the current lantus dose
Participant 20: Why not Actrapid? Slightly lesser peak than Lispro and a couple hours more duration of action.
https://drive.google.com/file/d/1_WP94jHW5P8t620REGJGX0rEmHYxdig5/view?usp=sharing
This is a document on "Dose adjustment for normal eating (DAFNE)" which allows for precise calculation of carbohydrate portion and adjust insulin doses accordingly.
The standard recommendation for 1 CP is 1 unit Lispro (Humalog). But I would advise to start with 1/2 (half) unit for each CP to see how the child responds.
16/09/24
PaJR PHR Moderator:
"Dyadic conversational inputs around this patient that would be useful for the entire team of learners here:
Pediatric Endocrinologist: Very useful! Thank you. If the stated assumptions are true (can it be checked?).
Moderator: @Narmeen Shah please see if you can verify the stated assumption/conclusion from your graph as in numbered the lines below:
1)...then, the fasting (pre-bf) is a tad too low.
The lid pro insulin at bf is not enough (bolts insulin has two jobs - to bring the pre-meal blood sugar down, if it’s high, and to cover the carbs + protein eaten at the meal).
2) In this case, the pre-bf values is on the lower end, and the post bf is very high.
So she needs more insulin at breakfast, not unexpected (“first meal effect”). The lid pro at lunch is good to cover her lunch (pre- and post-lunch are very similar, so if pre-lunch is decreased, post-lunch will also be lower).
Her dinner list spro is too much. So, I think if her breakfast lispro is increased, and dinner lispro is decreased, her sugars will even out.
This graph should be repeated every 2 weeks and adjustments need to be made.
PaJR moderator: Very valuable inputs for this patient. I guess the catch is in the dose increments and decrements as we are unable to increase it by 0.5U that would be safer?
Pediatric Endocrinologist: True, but I would reduce dinner lispro by 1 unit and increase breakfast lispro by 1
PaJR moderator: I guess that may have been done in the past if we could wade through the entire case report events documented till date since months and hence we were hung on titrating with 0.5."
Patient Advocate: 7.00,pm banana
9.45pm blood sugar 289
9.45pm 3u lispro insulin
9.55pm dinner with as same as lunch dish
10.40pm 4u lantus insulin
7.30am blood sugar 90
7.30am nuts and dates
7.42am milk and puffed rice
9.45am 2u lispro insulin
9.55am rice with pointed gourd, chayote, papaya, long beans, Spiny guard, ribbed gourd, egg and salad
12.00noon blood suger 297
12.00noon mosambi
1.45pm 3u lispro insulin
1.55pm lunch with same previous dish except egg
5.30pm sour curd
7.00pm banana
17/09/24
PaJR PHR Moderator:
"Query:
Why it is happening that sugar levels are that much low in pre breakfast and high in post breakfast and low at night. Check the above daily routine again from sep 1 - sept 13 and analyze the keen aspect.
ChatGPT said:
The pattern of blood sugar levels being low in pre-breakfast and high in post-breakfast, followed by low at night, can be analyzed in the context of the provided daily routine and insulin doses. Here’s a detailed look at the possible reasons behind this pattern:
1. Pre-Breakfast Low Blood Sugars:
- - Lantus (long-acting insulin) is administered at 10:40 pm, which peaks during the night, potentially contributing to low blood sugar in the morning (pre-breakfast).
- - The fasting blood sugars are quite low on several days (e.g., 72 on 11/09, 53 on 12/09). This suggests the night dose of Lantus (4 units) might be slightly too high, as indicated by the PaJR PHR Moderator's recommendation to reduce Lantus to 3 units.
- - Overnight hypoglycemia (unnoticed due to lack of symptoms) may occur, leading to low morning fasting levels.
- - The low pre-breakfast levels may also be due to prolonged fasting (i.e., the time gap between dinner and breakfast).
2. Post-Breakfast High Blood Sugars:
- - The Lispro dose given at breakfast (2 units) appears insufficient to handle the carbohydrates and protein in the breakfast meal.
- - On many days, the post-breakfast sugars spike (e.g., 267 on 03/09, 282 on 13/09), indicating that the insulin-to-carbohydrate ratio at breakfast is inadequate.
- - The phenomenon of "dawn phenomenon" or "first meal effect" could also be at play, where insulin resistance is typically higher in the morning, requiring more insulin at breakfast.
- - The meal composition (e.g., puffed rice, nuts, dates) likely contains high glycemic index (GI) carbs that cause rapid spikes in blood sugar, and 2 units of Lispro may not be enough to manage this.
3. Low Nighttime Blood Sugars:
- - After dinner, the pre-bedtime sugar levels (e.g., 57 on 13/09) are quite low, which suggests that the dinner Lispro dose (2 units) may be too high relative to the amount of carbs consumed at dinner.
- - The insulin sensitivity increases at night, which means the same dose of insulin might have a stronger effect, leading to low blood sugars before bed or overnight hypoglycemia.
- - The combination of long-acting Lantus and short-acting Lispro at night could be causing excessive lowering of blood sugars during the night, especially if the evening meal has fewer carbohydrates or if there is less activity.
Key Analysis Points:
1. Breakfast Lispro Dose Insufficient:
- - The post-breakfast blood sugars are significantly higher than pre-breakfast levels. The 2-unit Lispro given at breakfast may not be covering the amount of carbs/protein in breakfast or dealing with the "dawn phenomenon."
- - Increasing the Lispro dose at breakfast (e.g., from 2 units to 3 units) might help better manage these spikes.
2. Lantus Dose Too High at Night:
- - The low pre-breakfast blood sugars suggest the Lantus dose needs to be reduced at night. Reducing it from 4 units to 3 units might prevent nighttime hypoglycemia.
- - The PaJR PHR Moderator suggested this adjustment to optimize the nighttime glucose levels.
3. Dinner Lispro Needs Adjustment:
- - The 2 units of Lispro at dinner may be too much, especially if the evening meal is low in carbs. Reducing this dose to 1 or 1.5 units might prevent low post-dinner and pre-bedtime sugar levels.
4. Monitoring and Adjustments:
- - Continuous Glucose Monitoring (CGM) or frequent blood sugar checks might be necessary to track fluctuations throughout the day, especially overnight.
- - Adjusting both meal composition and insulin doses for different times of day is key to preventing these high-low swings.
Suggested Next Steps:
- - Increase Lispro dose at breakfast to 3 units to manage the morning spike.
- - Reduce Lantus to 3 units at night to prevent pre-breakfast lows.
- - Reduce Lispro at dinner (possibly to 1.5 units) to avoid low nighttime sugars.
This should help smooth out the extremes and stabilize blood sugar levels throughout the day.
Disclaimer:
The information provided in this analysis is intended for experimental and informational purposes only. It is not meant to replace professional medical advice, diagnosis, or treatment. Do not use this analysis as medical advice, as it could lead to unintended consequences or complications. Always seek the guidance of a healthcare professional before making any adjustments to your diabetes management plan.
PaJR PHR Moderator: Done by @Narmeen Shah. Please share the image showing your method too here
থাকে।
মূল বিশ্লেষণের বিষয়:
১. প্রাতঃরাশের লিসপ্রো ডোজ অপর্যাপ্ত:
- প্রাতঃরাশের পরে রক্তে শর্করা প্রাক-নাস্তার মাত্রার তুলনায় উল্লেখযোগ্যভাবে বেশি। প্রাতঃরাশের সময় দেওয়া 2-ইউনিট লিসপ্রো প্রাতঃরাশের কার্বোহাইড্রেট/প্রোটিনের পরিমাণকে কভার করে না বা "ভোরের ঘটনা" নিয়ে কাজ করতে পারে না।
- প্রাতঃরাশের সময় Lispro ডোজ বাড়ানো (যেমন, 2 ইউনিট থেকে 3 ইউনিট) এই স্পাইকগুলিকে আরও ভালভাবে পরিচালনা করতে সহায়তা করতে পারে।
প্রশ্ন*
কেন এমন হচ্ছে যে সকালের নাস্তায় চিনির মাত্রা অনেক কম এবং সকালের নাস্তায় বেশি এবং রাতে কম। 1 সেপ্টেম্বর থেকে 13 সেপ্টেম্বর পর্যন্ত উপরের দৈনিক রুটিনটি আবার পরীক্ষা করুন এবং প্রখর দিকটি বিশ্লেষণ করুন।
চ্যাটজিপিটি বলেছেন:
প্রাক-নাস্তায় রক্তে শর্করার মাত্রা কম এবং প্রাতঃরাশের পরে উচ্চতর হওয়ার ধরণ, রাতে কম হওয়ার পর, প্রদত্ত দৈনিক রুটিন এবং ইনসুলিনের মাত্রার পরিপ্রেক্ষিতে বিশ্লেষণ করা যেতে পারে। এখানে এই প্যাটার্নের পিছনে সম্ভাব্য কারণগুলির একটি বিশদ চেহারা রয়েছে:
১. প্রাতঃরাশের লো ব্লাড সুগার:
- ল্যান্টাস (দীর্ঘ-অভিনয় ইনসুলিন) রাত্রি 10:40 টায় পরিচালিত হয়, যা রাতের মধ্যে সর্বোচ্চ পর্যায়ে পৌঁছায়, সম্ভাব্যভাবে সকালে (প্রাক-খাওয়া) কম রক্তে শর্করার ক্ষেত্রে অবদান রাখে।
- উপবাসের রক্তে শর্করার পরিমাণ বেশ কয়েকদিনে কম থাকে (যেমন, 11/09 তারিখে 72, 12/09 তারিখে 53)। এটি পরামর্শ দেয় যে ল্যান্টাস (4 ইউনিট) এর রাতের ডোজ কিছুটা বেশি হতে পারে, যেমনটি ল্যান্টাসকে 3 ইউনিটে কমানোর জন্য PaJR PHR মডারেটরের সুপারিশ দ্বারা নির্দেশিত হয়েছে।
- রাতারাতি হাইপোগ্লাইসেমিয়া (লক্ষণের অভাবের কারণে অলক্ষিত) ঘটতে পারে, যার ফলে সকালের উপবাসের মাত্রা কম হয়।
- প্রাক-নাস্তার কম মাত্রা দীর্ঘায়িত
উপবাসের কারণেও হতে পারে
(অর্থাৎ, রাতের খাবার এবং
প্রাতঃরাশের মধ্যে সময়ের ব্যবধান)
2. সকালের নাস্তার পরে উচ্চ রক্তে শর্করা:*
- প্রাতঃরাশে দেওয়া লিসপ্রো ডোজ (2 ইউনিট) প্রাতঃরাশের খাবারে কার্বোহাইড্রেট এবং প্রোটিন পরিচালনা করার জন্য অপর্যাপ্ত বলে মনে হয়।
- অনেক দিন, সকালের নাস্তার পর শর্করার পরিমাণ বেড়ে যায় (যেমন, 03/09 তারিখে 267, 13/09 তারিখে 282), ইঙ্গিত করে যে সকালের নাস্তায় ইনসুলিন-থেকে-কার্বোহাইড্রেট অনুপাত অপর্যাপ্ত।
- "ভোরের ঘটনা" বা "প্রথম খাবারের প্রভাব" এর ঘটনাটিও খেলতে পারে, যেখানে ইনসুলিন প্রতিরোধ সাধারণত সকালে বেশি হয়, প্রাতঃরাশের সময় আরও ইনসুলিনের প্রয়োজন হয়।
- খাবারের সংমিশ্রণে (যেমন, পাফ করা ভাত, বাদাম, খেজুর) সম্ভবত উচ্চ গ্লাইসেমিক ইনডেক্স (GI) কার্বোহাইড্রেট রয়েছে যা রক্তে শর্করার দ্রুত বৃদ্ধি ঘটায় এবং এটি পরিচালনা করার জন্য লিসপ্রোর 2 ইউনিট যথেষ্ট নাও হতে পারে।
3. কম রাতের রক্তে শর্করা:*
- রাতের খাবারের পরে, ঘুমানোর আগে শর্করার মাত্রা (যেমন, 13/09 তারিখে 57) বেশ কম, যা পরামর্শ দেয় যে রাতের খাবারে খাওয়া কার্বোহাইড্রেটের পরিমাণের তুলনায় ডিনার লিসপ্রো ডোজ (2 ইউনিট) খুব বেশি হতে পারে।
- রাতে ইনসুলিনের সংবেদনশীলতা বৃদ্ধি পায়, যার অর্থ ইনসুলিনের একই ডোজ আরও শক্তিশালী প্রভাব ফেলতে পারে, যার ফলে শোবার আগে বা রাতারাতি হাইপোগ্লাইসেমিয়া রক্তে শর্করার পরিমাণ কম হতে পারে।
- রাতে দীর্ঘ-অভিনয়কারী ল্যান্টাস এবং স্বল্প-অভিনয় লিসপ্রোর সংমিশ্রণ রাতের বেলা রক্তে শর্করার অত্যধিক হ্রাস ঘটাতে পারে, বিশেষ করে যদি সন্ধ্যার খাবারে কম কার্বোহাইড্রেট থাকে বা যদি কম কার্যকলাপ থাকে।
মূল বিশ্লেষণের বিষয়:
১. প্রাতঃরাশের লিসপ্রো ডোজ অপর্যাপ্ত:
- প্রাতঃরাশের পরে রক্তে শর্করা প্রাক-নাস্তার মাত্রার তুলনায় উল্লেখযোগ্যভাবে বেশি। প্রাতঃরাশের সময় দেওয়া 2-ইউনিট লিসপ্রো প্রাতঃরাশের কার্বোহাইড্রেট/প্রোটিনের পরিমাণকে কভার করে না বা "ভোরের ঘটনা" নিয়ে কাজ করতে পারে না।
- প্রাতঃরাশের সময় Lispro ডোজ বাড়ানো (যেমন, 2 ইউনিট থেকে 3 ইউনিট) এই স্পাইকগুলিকে আরও ভালভাবে পরিচালনা করতে সহায়তা করতে পারে।
২। ল্যান্টাস ডোজ রাতে খুব বেশি:
- প্রাতঃরাশের কম রক্তে শর্করা পরামর্শ দেয় যে ল্যান্টাস ডোজ রাতে কমাতে হবে। এটি 4 ইউনিট থেকে 3 ইউনিটে কমিয়ে রাতের হাইপোগ্লাইসেমিয়া প্রতিরোধ করতে পারে।
- PaJR PHR মডারেটর রাতের গ্লুকোজ মাত্রা অপ্টিমাইজ করার জন্য এই সমন্বয়ের পরামর্শ দিয়েছেন।
৩. ডিনার লিসপ্রোর সামঞ্জস্য প্রয়োজন:
- রাতের খাবারে লিসপ্রোর 2 ইউনিট খুব বেশি হতে পারে, বিশেষ করে যদি সন্ধ্যার খাবারে কার্বোহাইড্রেট কম থাকে। এই ডোজটি 1 বা 1.5 ইউনিটে কমিয়ে রাতের খাবারের পরে এবং ঘুমানোর আগে চিনির মাত্রা কম হওয়া প্রতিরোধ করতে পারে।
4. পর্যবেক্ষণ এবং সমন্বয়:
- ক্রমাগত গ্লুকোজ মনিটরিং (CGM) বা ঘন ঘন রক্তে শর্করার পরীক্ষা সারা দিন, বিশেষ করে রাতারাতি ওঠানামা ট্র্যাক করার জন্য প্রয়োজন হতে পারে।
- দিনের বিভিন্ন সময়ের জন্য খাবারের সংমিশ্রণ এবং ইনসুলিনের ডোজ উভয়ই সামঞ্জস্য করা এই উচ্চ-নিম্ন দোল রোধ করার মূল চাবিকাঠি।
প্রস্তাবিত পরবর্তী পদক্ষেপ:
- সকালের স্পাইক পরিচালনা করতে সকালের নাস্তায় লিসপ্রোর ডোজ 3 ইউনিটে বৃদ্ধি করুন।
- প্রাতঃরাশের কম হওয়া রোধ করতে রাতে ল্যান্টাসকে 3 ইউনিটে কমিয়ে দিন।
- রাতে কম শর্করা এড়াতে রাতের খাবারে লিসপ্রো কমিয়ে দিন (সম্ভবত 1.5 ইউনিট)।
এটি চরমগুলিকে মসৃণ করতে এবং সারা দিন রক্তে শর্করার মাত্রা স্থিতিশীল করতে সহায়তা করবে"
Narmeen Shah: Sir
1. I first copy pasted the complete data of the case report from sept 1 - sept 13.
2. Excel data that I created to calculate the pre- post- mean blood sugar values for the graph.
3. Wrote my two assumptions and ask to verify the stated assumptions.
- Post and Pre meal times don't mean that nothing is fed between these intervals.
- Insulin has been given either after the meal or before the meal so the sugar levels are not independent of interventions.
4. Chatgpt broke down the assumptions and reponded about it in four points.
5. After that I gave the query/prompt:
- - Why it is happening that sugar levels are that much low in pre breakfast and high in post breakfast and low at night. Check the above daily routine again from sep 1 - sept 13 and analyze the keen aspect.
Lispro - action starts by 30 minutes, peaks 1-2 hours, gone by 3 hours; Regular - action starts by 60 minutes, peaks 3-5 hours, gone by 8 hours - etc. Lantus - pretty flat with repeated use, especially if dose is >10 units. Hypos less with Lantus and degludec.
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