Question of the Week # 83, 84 and 85

Q83) 35-year-old man with a 10-year history of type 1 diabetes mellitus is evaluated because of recent onset of morning hyperglycemia. His home blood sugar logs over the last 10 days have consistently been showing elevated sugars in the range of 220 to 300 mg% in the early morning ( pre-breakfast).  He has also experienced nightmares recently. He has been compliant with his diet instructions and has  not changed his dinner potions recently.  He takes mixed insulin regimen :  NPH/Regular  insulin 70/30 mix at  30 units in the AM before breakfast and 20 units in PM 30 minutes before dinner. Which of the following best explains this patient’s morning hyperglycemia?

( A ) Diabetic nephropathy

( B ) Undertreatment with insulin

( C ) Overtreatment with insulin

( D ) Insulinoma

(E) Non compliance with Insulin

Q84) The best diagnostic study in establishing the diagnosis in this patient :

A) C-Peptide level

B) Urine 24 hour catecholamines

C) Check pre-dinner blood sugar level

D) Check blood sugar level 30 minutes post – dinner

E) Check blood sugar level between 2:00 AM and 3:00 AM

Q85) Next best step in managing this patient’s pre-breakfast hyperglycemia :

A) Increase pre-breakfast regular insulin dosage in AM

B) Increase pre-dinner regular insulin dose

C) Reduce pre-dinner NPH insulin dose

D) Decrease the carbohydrate consumption in the night

E) Discontinue Pre-dinner insulin

5 Responses

  1. C

  2. concur

  3. C,E,C

    Dawn phenomenon. The dawn phenomenon is the end result of a combination of natural body changes that occur during the sleep cycle and can be explained as follows. Between 3:00 a.m. and 8:00 a.m., your body starts to increase the amounts of counter-regulatory hormones (growth hormone, cortisol, and catecholamines). These hormones work against insulin’s action to drop blood sugars. The increased release of these hormones, at a time when bedtime insulin is wearing out, results in an increase in blood sugars. These combined events cause your body’s blood sugar levels to rise in the morning.
    Somogyi effect. Named after the doctor who first wrote about it, this condition is also called “rebound hyperglycemia.” Although the cascade of events and end result — high blood sugar levels in the morning — is the same as in the dawn phenomenon, the cause is more “man-made” (a result of poor diabetes management) in the Somogyi effect. The term refers to pattern of high morning sugars preceded by an episode of hypoglycemia (with no symptoms). Your blood sugar may drop too low in the middle of the night, so your body counters by releasing hormones to raise the sugar levels. This could happen if you took too much insulin earlier or if you did not have enough of a bedtime snack.

    Somogyi Effect= rebound hyperglycemia because the body was in hypoglycemia (too much insulin)….so the stress hormones epinephrine and glucagone will kick in and there u have hyperglycemia in the morning………so the PT is hypoglycemic at 3 AM and he is hyperglycemic at 7-8 AM for example.
    Mx= give NPH at bed time instead at dinner time and give LOWER dose.

    Dawn Phenomenon:
    – high sugar at 3 a.m. and also at 7 a.m. b/c there’s increased insulin resistance between 5-8 a.m. caused by growth hormone
    Mx = INCREASE dose of NPH at dinner time.

    So if we are not sure if the morning hyperglycemia is due to the Dawn or Somogyi effect, what do we do? how do we modify the Insulin dose?
    -Answer is to DECREASE the insulin at night.
    Then check am glucose:
    -If the glucose is increased in the am, it was Dawn Phenomenon. (not enough Insulin or not the right type at pm)..
    -If the glucose is normal or decreased in am, it was Somogyi. (rebound hyperglycemia due to the body’s counterregulatory hormones).
    (NEVER INCREASE the Insulin dose, because if the patient has Somogyi, we could end up putting him in a coma)

    Once we have determined which one it is we can modify the Insulin accordingly.
    For Dawn effect we can break down the pm dose to regular (rapid acting) in the pm and NPH (intermediate acting) right before bedtime.

  4. C,E,C

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