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Case Report
Difficult to stomach
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An emergency presentation leads to the diagnosis of a gastric complication of type 1 diabetes .
Emma Armstrong Senior diabetes and endocrinology dietitian , Royal Melbourne Hospital ; founder of Endocrine Nutrition , where she provides one-on-one dietitian telehealth ( phone or video ) consults .
JAMILLA , 41 , presents to hospital with epigastric pain , nausea and vomiting on a background of type 1 diabetes , diagnosed 11 years ago . During admission , she undergoes a gastric emptying study and is diagnosed with gastroparesis . This is presumed secondary to autonomic neuropathy , although she has no other complications of diabetes . Her symptoms are managed with dietary modification and prokinetics : metoclopramide 10mg , domperidone 10mg and erythromycin 50mg — all taken before meals , three times a day .
Jamilla ’ s diabetes is usually managed with a basal / bolus insulin ( insulin detemir and insulin aspart ) regimen , and she is reported to be proficient in carbohydrate counting , implementing flexible insulin dosing with meals . Her most recent HbA1c was 8.1 %. Jamilla is referred to the dietitian during her admission for nutritional assessment and management .
Assessment
Jamilla currently weighs 52kg ( BMI 20.3kg / m2 ). She reports she has lost 4kg unintentionally over the past month . Her symptoms of nausea , pain and vomiting were initially intermittent but have worsened and become more regular . She reports she has been vomiting 10-15 minutes after ingestion of all food and fluids prior to admission .
At home , Jamilla eats three meals a day . These include toast , cereal or eggs for breakfast and lentil , chickpea or meat-based stews served with rice , wholemeal bread or injera ( an Ethiopian flatbread ) for lunch and dinner . Jamilla reports she has recently been taking her prandial insulin after eating , trying to account for her delayed digestion and possible vomiting . She has been finding it difficult to predict her required insulin doses .
Management
In hospital , Jamilla is initially made nil by mouth while her symptoms settle . She is then able to manage a liquid diet , which includes several oral nutrition supplements a day and eventually progresses to soft foods . Upon discharge , the dietitian discusses dietary changes she could trial to manage her gastroparesis symptoms . These include avoiding high-fat foods , limiting foods high in fibre and opting for liquids or puree foods if required .
Discussion
Gastroparesis is delayed gastric emptying without mechanical obstruction of the stomach . 1 , 2 Cardinal symptoms include postprandial abdominal pain , nausea and vomiting , bloating and early satiety . 1 , 3 Symptoms are
ESTROGEL ® PRO PRIMARY ADVERTISEMENT For her .
Medicine co-pack containing one pack of Estrogel ® ( estradiol hemihydrate ) plus one pack of Prometrium ® ( micronised progesterone ) for women with a uterus
PBS Information : These products are not available on the PBS .
Please review Product Information before prescribing , accessible at besins-healthcare . com . au / PI or 1800 BESINS ( 237 467 ), or by scanning the QR code :
Minimum Product Information Estrogel ( estradiol hemihydrate ) gel . Indications : Hormone replacement therapy ( HRT ) for estrogen deficiency symptoms in postmenopausal women . Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of , or contraindicated for , other medicinal products approved for the prevention of osteoporosis . The lowest effective dose should be used for the shortest duration . Contraindications : Known , past or suspected breast cancer ; Known or suspected estrogen-dependent malignant tumours ( e . g . endometrial cancer ); Undiagnosed genital bleeding ; Untreated endometrial hyperplasia ; Previous or current venous thromboembolism ( e . g . deep venous thrombosis , pulmonary embolism ); Known thrombophilic disorders ( e . g . protein C , protein S , or antithrombin deficiency ); Active or recent arterial thromboembolic disease ( e . g . angina , myocardial infarction ); Acute liver disease , or a history of liver disease as long as liver function tests have failed to return to normal ; Known or suspected pregnancy ; Lactation ; Known hypersensitivity to the active substances or to any of the excipients ; Porphyria . Precautions : Appraisal of the risks and benefits should be undertaken at least annually . Refer to full Product information ( PI ) for conditions which require supervision during treatment with Estrogel . Treatment should be withdrawn if the following occur , jaundice or deterioration in liver function ; significant increase in blood pressure ; new onset of migraine type headache ; pregnancy . Caution : endometrial hyperplasia and carcinoma , breast cancer , ovarian cancer , venous thromboembolism , coronary artery disease ( CAD ), ischaemic stroke , thyroid function , elderly , ALT elevations , paediatric use ( see full PI ). Interactions : use of concomitant skin medications , surface active agents or strong skin cleansers and detergents should be avoided at site of application , metabolism of estrogens may be increased by concomitant use of inducers of hepatic enzymes such as anticonvulsants ( phenobarbital , phenytoin , carbamezapine ) and anti-infectives ( rifampicin , rifabutin , nevirapine , efavirenz , ritonavir and nelfinavir ) and some herbal preparations ( St John ’ s wort ) reducing the effectiveness of estrogen . Estrogel as a transdermal administration might be less affected than other oral hormones by enzyme inducers . Concomitant use of estrogens with lamotrigine may decrease lamotrigine plasma concentrations . Caution is warranted for co-administration with hepatitis C virus ( HCV ) combination regimens ombitasvir / paritaprevir / ritonavir with or without dasabuvir and the regimen glecaprevir / pibrentasvir may cause greater than usual ALT elevations . Pregnancy Category B3 ; not for use in lactation . Adverse Effects : headache , nausea , abdominal pain , breast swelling / pain , breast enlargement , dysmenorrhea , menorrhagia , metrorraghia , leucorrhoea , endometrial hyperplasia , weight gain ( increase or decrease ), water retention with peripheral edema ( see full PI ). Dosage and Administration : Estrogel should be used daily on a continuous basis . Estrogel as an estrogen only product is indicated only for women without a uterus . In women with an intact uterus it is recommended to add a progestogen for at least 12 days of each month . Although some women will respond to 1.25 g daily ( 1 pump ), the usual starting dose is 2.5 g per day ( 2 pumps ). If after one month of treatment , effective relief of menopausal symptoms is not obtained the dosage may be increased to a maximum of 5 g ( 4 pumps ) ( see full PI ). The lowest effective dose should be used for maintenance therapy . The optimal daily maintenance dose needs to be reevaluated regularly ( e . g . annually ). Estrogel should only be continued for as long as the benefit outweighs the risk . The correct dose of gel should be dispensed and applied to clean , dry , intact areas of skin e . g . on the arms and shoulders , and / or inner thighs . The area of application should be as large as possible . Refer to Full Product Information before prescribing .
Minimum Product Information Prometrium ( oral , micronised progesterone ) Indications : menstrual irregularities ; adjunctive use with an estrogen in postmenopausal women with an intact uterus . Contraindications : known allergy / hypersensitivity to progesterone or excipients ; severe hepatic dysfunction ; undiagnosed vaginal bleeding ; known missed abortion / ectopic pregnancy ; mammary / genital tract carcinoma ; thromboembolic disorders ; thrombophlebitis ; cerebral haemorrhage ; porphyria . Clinically Significant Precautions : not a treatment for premature labour ; not a contraceptive ; discontinue if unexplained visual loss / changes , proptosis , diplopia , papilloedema , retina vascular lesions or migraine ; use caution in conditions affected by fluid retention and history of depression , diabetes , hepatic dysfunction , migraine , photosensitivity and during lactation ; increased risk of breast cancer and venous thromboembolism with estrogen concomitant therapy ( refer estrogen PI ); may cause drowsiness ; may affect laboratory test results . Clinically Significant Interactions : caution with P450 enzyme inducers and inhibitors ; may increase antidiabetic medication ; bioavailability may be reduced by smoking and increased by alcohol abuse . Very Common and Common Adverse Effects : menstrual disturbances ; headache . d1 – d25 . Secondary amenorrhoea : 400mg / d for 10d . Ovulation disorders / anovulation : 200 – 300mg for 10d ( d17 – d26 , inclusive ).
Estrogel ® and Prometrium ® are registered trademarks of Besins Healthcare . Besins Healthcare Australia Pty Ltd ABN 68 164 882 062 . Suite 5.02 , 12 Help Street , Chatswood NSW 2067 . Office phone ( 02 ) 9904 7473 . For medical information call 1800 BESINS ( 237 467 ). www . besins-healthcare . com . au EPR-EST-PRM-1969 January 2024