Clinical Focus
15 SEPTEMBER 2023 ausdoc . com . au
AUSDOC ’ S TOP FIVE CLINICAL ARTICLES
Case Report
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Source : AusDoc website ; 1 Aug 1 to 3 Sept .
A patient with type 2 diabetes and comorbidities successfully swaps insulin for carbohydrate restriction , wavering only when in hospital .
Dr Liz Fraser GP in Canberra , ACT .
AT age 55 , Frankie has multiple health problems . Long-term mental illness has been managed with polypharmacy for many years . Clozapine therapy has contributed to weight gain , type 2 diabetes and profound constipation .
She has quit smoking but remains prone to chest infections and frequent hospitalisations . Her medications include five psychotropics , simvastatin , two antihypertensives , two inhalers , opiates for chronic pain and multiple laxatives .
Despite metformin and mixed rapid- and longer-acting insulin aspart 26 units mane and 22 units nocte , her diabetes is poorly controlled , with an HbA1c of 10 % and usual blood glucose levels between 15mmol / L and 20mmol / L .
Frankie ’ s mobility is poor as a result of deconditioning and debilitating leg , back and abdominal pain . She sees her usual GP most weeks to manage her multiple comorbidities .
Examination
Frankie weighs 77kg , with marked abdominal adiposity . Her BMI is 33kg / m2 , waist circumference is 110cm and blood pressure is 160 / 90mmHg . She uses a wheelie walker and is unsteady on her feet .
Progress
Faced with potentially complicated surgery , Frankie asks a friend ( a GP with an interest in low-carbohydrate medicine and a colleague of her usual GP ) to support her during a telehealth consultation with a surgeon .
While they are waiting for the appointment , the friend looks in Frankie ’ s fridge . Noticing eggs and cheese , the GP friend offers to make Frankie an omelette , which she enjoys . They discuss the importance of better blood glucose control should the proposed surgery go ahead . Frankie agrees to try therapeutic carbohydrate restriction , with her GP friend providing advice to her regular GP regarding her insulin regime . Frankie ’ s regular GP supports this approach and is glad for the insights of the GP friend .
Over the next few weeks , as Frankie changes her usual carbohydrate-rich diet to one based on meat , vegetables , berries and Greek yoghurt , her blood glucose drops rapidly . At first , the insulin is reduced to 14 units daily and then stabilises at around 8 units .
A few months later , Frankie has the surgery and , despite some postoperative challenges , recovers well . In hospital , Frankie ’ s blood glucose shoots back up to 15-20mmol / L on high-carbohydrate hospital fare . Her insulin requirements correspondingly increase .
Back home , Frankie resumes the lowcarb approach , and within two days , her blood glucose levels drop below 10mmol / L and insulin returns to 8 units daily .