Case

A 75 year old female known to have Diabetes Mellitus since 13 years ago on insulin therapy, presented to the out patient consultation clinic saying that her insulin requirement has decreased, she explains saying that she used to take 10 units of soluble insulin preprandially and know she takes 5 units preprandially giving the same results as indicated by the glucometer. The patient assumes that she will be disease free by the end of the year.

How can you explain this? and what investigations do u recommend and Y?

well i thihnk the life style has resulted in increase of sensitivity of receptors to the insulin......am i even close??

we are having a great benefit with u SAMER.

ali

U r welcome 3allawi.

The patient has not changed her lifestyle, she is on the same diet, no exercises or other factor modifications. The patient didnt even change the brand of the insulin.

everything clinically is the same, except that she needs less insulin than before and that she thinks she will be disease free.

its a bit tricky

OK, take this hint:
Think about Insulin pharmacokinetics.

Guys, u gotta at least give some suggestions.

come on.

ITs DM. bcmf/secret.gif

I think it is the " Honey Moon " period .. !!??
But I'm so sure ..

i was thinking about (honey moon period ) just like ahmed but i think this will happen with DM type 1 and in kids not in the case you gave.

so the possible thing would be -transient remission -?!!!!!!!!!!!!!!

will she be disease free ? no not now not ever

my advice for her? keep monitering your blood sugar level and try to adjust the dose of insulin in order to avoid hypoglycemia from large insulin dose and also to avoid hyperglycemia from small dose since the disease sooner or later will revet to it is previous behaviour.

or even easier thinking maybe the glucometer is not functioning properly bcmf/thinking.gif

i will be thankful if you can explain the pathophysiology for me

Regards
Farah Baha

well since u mentioned the pharmacokinetics . then i will say because of the old age of the patient ,so the clearance of insulin decreased ,as it is slightly affected my circulating peptid hormones.

tere ani akteb ta2leef 5orafee.

ali

simply, it is a miracle!!!!!!!!!

My guess goes with Farah,I was thinking slightly the same .

Thank you.

Ok,

Ahmed, Honey moon period occurs in newly diagnosed Type 1 DM.

DM is a chronic non-remitting disease.

Luay, I wish that this was a miracle but its not.

Slowly progressing Chronic Renal Failure does not show symptoms until the Glomerular Filtration Rate is very low reaching 20 ml/min or even lower [normal 80-120] and even when it develops symptoms, the first of which would probably be nocturia, nocturia is a feature often already present in diabetic patients.

You have to bear in mind that insulin is mainly metabolized by the renal tubules, and this patient is developing slowly progressive chronic renal failure due to diabetes which makes insulin metabolism less, therefore the patient will present with reduced insulin requirement giving patients the false impression that they are getting better and that they will be cured. Another presentation would be hypoglycemic attacks if the patient was not monitoring his blood glucose levels.
This also applies to metformin which is contraindicated in Chronic Renal Failure.

The investigations order should be the Renal Function Tests.

As Farah said, the patient should monitor the glucose level and adjust the doese accordingly, but the disease will not revert since it is a chronic renal failure which indicates permanent damage of the kidney, so the insulin dose will definitely be less than before.

Ali, your second answer was the nearest one. Congrat...

Hope this case was refreshing, Thank you guys for ur patience.