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A patient ’ s poor diabetes control is thought to be linked to a red patch on his shin , though not via mechanisms that first glance might suggest .
Timothy Hui Senior medical student , Curtin Medical School , Curtin University , Perth , WA .
Dr Daniel Xu Academic co-ordinator , general practice research and international collaboration , Curtin Medical School , Curtin University , Perth , WA .
MIKE , a 51-year-old Caucasian male , presents to his GP with a two-week history of right lower leg rash ( see figure 1 ). He has no other symptoms .
Mike has type 2 diabetes ( T2DM ), which is poorly controlled on insulin glargine . HbA1c one month ago was 10.1 %, self-monitored fingerprick fasting glucose is typically 10-14mmol / L and postprandial glucose 16-22mmol / L .
His past medical history includes previous alcohol dependence now in remission , GORD , alcoholic hepatitis , depression , and diffuse idiopathic skeletal hyperostosis ( Forestier ’ s disease ). His current medications in addition to insulin are esomeprazole 20mg daily and sertraline 50mg daily .
Examination
On examination , Mike appears systemically well . Vital signs are within normal limits . There is a 2x3cm red patch , which is uniformly pigmented , with a regular , well-defined edge . The lesion is mildly scaly , non-tender and not associated with any discharge . Random glucose is 22mmol / L and urine dipstick reveals ketonuria . There are no other remarkable findings on skin and general examination .
Provisional diagnosis
The serum glucose and ketonuria meet the biochemical criteria for diabetic ketoacidosis so Mike is urgently transferred to hospital . It is thought the lesion may represent early localised infection , and topical triamcinolone acetonide , nystatin , gramicidin and neomycin ointment are applied to the lesion . His insulin glargine dose is increased by six units and dietary adherence is reinforced . Mike is afebrile throughout his admission , with normal inflammatory markers , and on discharge the lesion is unchanged .
Further management
Mike returns to his GP four weeks later and the lesion shows no signs of improvement ( see figure 2 ). A punch biopsy is performed . Histology shows slight superficial and deep perivascular inflammatory lymphocyte infiltrate with thickened subcutaneous fat , consistent with erythema nodosum ( EN ).
Figure 1 . The 2x3cm lesion developed on the patient ’ s shin .
Discussion
EN , the most common form of panniculitis , is characterised by erythematous , tender nodules , typically on the shins . 1 , 2 The aetiology is usually idiopathic , although secondary
PBS Information : FORXIGA ® : Authority Required ( STREAMLINED ): Type 2 Diabetes , Chronic Heart Failure and Chronic Kidney Disease . Refer to PBS Schedule for full Authority Required Information .
BEFORE PRESCRIBING PLEASE REVIEW FULL PRODUCT INFORMATION AVAILABLE ON REQUEST FROM ASTRAZENECA ON 1800 805 342 OR www . astrazeneca . com . au / PI
MINIMUM PRODUCT INFORMATION . FORXIGA ( dapagliflozin ) 10mg tablets . INDICATIONS : Type 2 diabetes mellitus - Glycaemic control in adults as : monotherapy as an adjunct to diet and exercise where metformin is otherwise indicated but was not tolerated ; initial combination with metformin , as an adjunct to diet and exercise , to improve glycaemic control when diet and exercise have failed and there are poor prospects for response to metformin monotherapy ; in combination with other anti-hyperglycaemic agents to improve glycaemic control , when these together with diet and exercise do not provide adequate control . Type 2 diabetes mellitus - Prevention of hospitalisation for heart failure in adults with established cardiovascular disease or risk factors for cardiovascular disease to reduce the risk of hospitalisation for heart failure . Heart failure in adults for the treatment of symptomatic heart failure independent of left ventricular ejection fraction , as an adjunct to standard care of therapy . Chronic Kidney Disease to reduce the risk of progressive decline in kidney function in adults with proteinuric chronic kidney disease ( CKD Stage 2 , 3 or 4 and urine ACR ≥ 30 mg / g ). DOSAGE AND ADMINISTRATION : For all indications , 10mg once daily at any time of the day regardless of meals . CONTRAINDICATIONS : hypersensitivity to any of the ingredients . PRECAUTIONS : Not for type 1 diabetes mellitus or treatment of diabetic ketoacidosis . Renal impairment : no dose adjustment is required based on renal function ; initiating treatment in patients with eGFR < 25 mL / min / 1.73 m 2 is not recommended ; glucose lowering efficacy of Forxiga is reduced where eGFR is < 45mL / min / 1.73 m 2 , additional glucose lowering treatment should be considered in patients with diabetes mellitus . Forxiga should not be used in severe hepatic impairment . Volume depletion , and / or hypotension - caution in patients for whom dapagliflozin induced blood pressure drop could pose a risk . Ketoacidosis in patients with diabetes mellitus ; surgery ; urinary tract infections ; necrotising fasciitis of the perineum ( Fournier ’ s gangrene ); lower limb amputations , counsel patients with on routine preventative foot care ; use with medications known to cause hypoglycaemia ; children ; elderly ; cardiac failure – limited clinical experience in patients with NYHA class IV . Pregnancy - Category D ; not to be used by breastfeeding women . Interference with 1,5-anhydroglucitol ( 1,5-AG ) assay ; risk of hypoglycaemia while driving or using machinery if used with sulfonylurea or insulin . INTERACTIONS WITH OTHER MEDICINES : Concomitant use with lithium may lead to a reduction in serum lithium concentrations . Lithium dose may need to be adjusted . ADVERSE EFFECTS : common adverse reactions ( ≥2 %) in clinical trials : genital infections , urinary tract infections , back pain , polyuria , hypoglycaemia , headache , diabetic ketoacidosis , volume depletion , events related to decreased renal function . See full PI . REFERENCE : 1 . FORXIGA ® Approved Product Information . FORXIGA ® is a registered trademark of the AstraZeneca group of companies . Registered user AstraZeneca Pty . Ltd . ABN 54 009 682 311 . 66 Talavera Road , Macquarie Park , NSW 2113 . www . astrazeneca . com . au . For Medical Information enquiries or to report an adverse event or product quality complaint : Telephone 1800 805 342 or via https :// contactazmedical . astrazeneca . com . AU-19328 . April 2024 .
FORXIGA ® . SIMPLE DOSING 1
ONE TABLET ONCE A DAY NO TITRATION