In this second part of his exclusive series on difficult diabetes, Dr. Sanjay Kalra discusses hyperglycaemia and its causes among diabetes patients reiterating that many a times the culprit may be a non-pharmacological one.

Think beyond glucose

Diabetes management is possible only if one has a comprehensive knowledge of the medical, surgical, psychological and treatment history of the patient. The alliterative 'I' checklist:

• Infection,
• Inflammation,
• Invasion,
• Injury,
• Irritability [psychogenic], and
• Iatrogenic [drug induced]

helps remind one of the various causes of hyperglycaemia. Improper intake of food, inadequate physical activity, and incorrect insulin technique can be added to this list.

Concomitant illnesses

Many concomitant illnesses can lead to intractable hyperglycaemia. These may be medical, such as infections and inflammations; surgical, including infections, invasive tumours and injuries; endocrine (e.g. acromegaly, Cushing’s syndrome, hyperthyroidism and pheochromocytoma) and psychiatric (including depression, anxiety neurosis and schizophrenia).

While the source of infection, site of inflammation/invasion, cause of endocrine dysfunction, or reason for stress may be obvious at times, this is not always the case. The astute physician should search for occult or asymptomatic infections which may be the cause of hyperglycaemia. Urinary tract infections, genital tract infections and otitis media are commonly encountered conditions in persons with poorly-controlled diabetes. Identification and resolution of these diseases help achieve good glucose control as well.

Improper lifestyle

Simpler causes, however, are more frequently encountered in clinical practice. Lack of adherence to suggested dietary restrictions and physical activity; stress (diabetes distress); and improper administration or storage of prescribed medication are common reasons for poor control.

Patience is required while taking a dietary recall history. The most frequent reason for poor control that I have encountered in my practice is excessive use of ghee [clarified butter] in cooking. Special focus must be paid to reducing the quantity of visible fats and simple sugars while counselling persons with diabetes.

Domestic and professional stress are another cause of poor diabetes control. Lending an empathic ear is usually enough to solicit issues such as family discord, financial challenges or other psychological burdens. These can be addressed, as required, by counselling and pharmacotherapy.

Inappropriate drug usage

A detailed drug history must be taken while evaluating persons with diabetes. Hyperglycaemia may be due to iatrogenic causes such as glucocorticoids or immunosuppressants. It may also be possible that an inappropriate insulin regimen, preparation, delivery device or dosage has been prescribed, or that the insulin technique is incorrect. An examination of the insulin injection site may reveal lipohypertrophy, which can impact insulin absorption.

Despite repeated counselling and education, we often find that patients inject at the wrong site, or inject repeatedly at the same site [without rotation], or reuse needles multiple times. Another common cause of poor control may be a mismatch between syringes and vials [40 U/ml and 100 U/ml] or pens and cartridges [different manufacturers].

One must spare time to see the medicines actually being consumed by the patient. Many a times, the actual intake may be different from the prescribed medication. Patients can be asked to bring their medicines, or pictures of the tablets and injections that they are taking, to avoid such errors.

Summary

To summarise, a methodical and systematic clinical approach helps manage the most difficult diabetes. A history, physical examination and relevant investigations are enough to diagnose the cause of poor control. Once the aetiology is identified, managing it becomes much easier.