CME INDIA Presentation.
How you approach to the following case?
One 22-year old female, diagnosed as Type-1 diabetes 5 year back (GAD65 positive). She was trying to reduce weight, so started working out twice daily. Reduced her diet and had a very well controlled blood sugar on 14 u of Tresiba (Degludec) and 2-4-4 u of Novorapid. But now from past 3-4 days her blood sugar levels went on rising too much. She increased Tresiba from 14 to 18 U and Novorapid to 6-6-6. Still fasting glucose values are more than 150 mg random or pp always exceeds 250mg.
CME INDIA Discussion:
Dr N K Singh: There must be some factors, stress, food related, etc. All to be explored. Insulin doses to be increased as per guidelines. CGM may be done.
Input by Patient: There is no mental stress, all stress is due to increased glucose level. In lockdown, at home. My diet and exercises are as before.
Patients asks a very important question:
Is it related to the phases of menstrual cycle? Because the day before i entered ovulatory phase of the cycle, it started increasing.
Dr N K Singh: Just temporarily, increase doses.
Dr Manoj Chawla, Diabetologist, Mumbai: If it’s menses, it would be affected with most cycles. One needs to review the injection site and technique and a CGM(continuous glucose monitoring) is possible if course. Tresiba does have good 24 hr and beyond control.
Dr N K Singh: Glucose control seems to differ in the follicular and luteal phases, probably due to a hormonal effect or additionally to the presence of premenstrual symptoms or premenstrual syndrome indicating that in women with type-1 diabetes the two phases of the menstrual cycle should be taken into consideration when planning insulin therapy.
Dr Manoj Chawla, Mumbai: Yes. So, a lot of women especially type 1 have the disruption of sugars during the cycle time. Hence planning different regimes for insulin is helpful. A few of my patients with this issue who use the insulin pump have a separate temporary basal set up for the menses time. But coming back to this patient in question, we have to evaluate other factors before reaching to this conclusion.
Dr Prasun Dev, Dm Endo Kims, Hyderabad: Luteal phase progesterone causes sugars to increase. Many type 1 diabetics need slightly higher doses in the second half of the periods. Though recent increase might have other underlying causes.
CME INDIA Learning Points:
- Menstrual cycle is a physiological phenomenon during reproductive life of women. Its phases are influenced by alteration in the concentration of hormones such as estrogen and progesterone. Therefore, certain physiological parameters, such as blood glucose is affected during menstrual cycle
- Glucose control seems to differ in the follicular and luteal phases, probably due to a hormonal effect or additionally to the presence of premenstrual symptoms or premenstrual syndrome
- In women with type 1 diabetes the two phases of the menstrual cycle should be taken into consideration when planning insulin therapy. (Diabetes Care. 2013 May; 36(5): e70)
- Menstrual cycle is characterized by three phases; occur due to alteration in concentration of hormones such as estrogen and progesterone. Estrogen and progesterone levels will be very low in menstrual phase. During the proliferative phase, there is an increased level of estrogen and the secretory phase is characterized by raised levels progesterone and also estrogen.
- During the Secretory phase, there is slight rise in Fasting Blood sugar comparing to, proliferative phase and menstrual phase, but it is not significant statistically. Post Prandial Blood sugar is raised in secretory phase comparing with proliferative phase and menstrual phase, and it is significant statistically.
- Alterations in insulin receptor binding and affinity at different times during the menstrual cycle have been reported as a potential explanation for his phenomenon.
(Bennal AS et al. Int J Reprod Contracept Obstet Gynecol. 2013 Sep;2(3):284-287)
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