Q: I am a 46 years old diabetic for the last three years. Earlier, I used to take Zoryl M2 and Cardace H 5 but my sugar levels were always high. Some time ago I underwent the following test and met a new doctor. He prescribed the following medicines for my condition: Glizid M TDS, Mignar 25 TDS, Cardace H 5 OD and Udiliv 300 BD. Will these improve my condition? My test results are: Serum urea – 22, Serum creatinine - 0.77, SGOT – 70, SGPT – 175, HBA1C - 11.00 %. The urine test highlighted proteins; S.G > 1.030, Proteins - present 1+ (30.0 mg/dl), Glucose - present 4+ (>2.0 g/dl), Leucocyte esterase – positive, Pus cells - 25 wbc/ul and Epithelial cells – few. Please advise.

A:A review of your lab tests shows that there is proteinura (i.e. protein in urine). Any amount more than trace (trace means less than 15mg/dL) shows that significant amount of protein is being filtered through kidney. If not checked at early stage, it can lead to chronic renal failure (CRF), which is a very serious problem. Fortunately your kidney, as of now, is functioning well with both blood urea and creatinine of normal values. However, please keep in mind that by the time blood urea and creatinine go up, significant kidney damage has taken place; hence one must not wait for these tests to become abnormal. Your urine shows that there is urinary tract infection (pus cells, leucocyte esterease). This is rather common in diabetics and can lead to protein (albumin) in the urine. At this stage, it is a little bit difficult to determine whether the protein in urine is due to kidney dysfunction or urinary tract infection. Besides, kidney impairment develops after many years of suffering from diabetes (5-10 years). However, as an abundant precaution one should assume that proteinuria is due to early stage of kidney impairment unless proved otherwise. You make no mention of blood pressure and yet you have been prescribed Cardace-H a combination of ramipril and hydrochlorothiazide, which is used exclusively in blood pressure. Even in the new therapy suggested by your doctor, these medicines are being prescribed. If you have blood pressure also in addition to diabetes, it needs to be controlled aggressively and ideally should be brought down to 130/80 or less, if possible. It is known that diabetics with high blood pressure can quickly develop kidney failure compared to those who do not have blood pressure. Your HbA1c at 11 shows that in the previous 10-12 weeks, your blood sugar level has consistently remained quite high. It must be brought down to 8 or lower. Your liver function tests (called liver enzymes such as SGPT, SGOT) are a little bit abnormal and are most likely due to side effect of Zoryl-M which contains two medicines: metformin and glimepiride. It is well known that glimepiride causes increase in liver enzymes (SGOT/SGPT). Glizid-M (metformin + gliclazide) is just like Zoryl-M, if not inferior. There is hardly any scientific reason to replace glimepiride with gliclazide since metformin is common to both. The mechanism of action of both glimepiride and gliclazide is similar and replacement will give little benefit. Udiliv is indicated in the specific treatment of dissolution of certain specified types of gall bladder stones and Chronic Cholestatic Liver Disease. Due to aggressive commercial promotion, it is being wrongly used for all sorts of liver disorders. It is of little use in your case if the increase in your liver enzymes is due to a side effect of glimepiride. Mignar is the brand name. The name of the medicine is called miglitol. It should not be given to patients with kidney disorder/impairment. Most cases of Type II diabetes have some element of insulin resistance. Insulin resistance is more common in over-weight patients (you are over-weight by about 10 kg). Metformin is ideal in such cases since it increases the utilisation of available insulin secreted by the body and/or given by injection. You can take the following steps: (a) Reduce your weight by exercise and diet management. This will help in the control of diabetes and high blood pressure (if you are hypertensive). (b) Shift to insulin since oral agents are most unlikely to be of help at this stage. Even otherwise you should shift to insulin at least for a few months till your blood sugar is brought down to normal values and the issue of protein in urine is sorted out. There is a widespread misconception, that once on insulin, always on insulin. You can go back to oral anti-diabetics once the issue of protein in urine is sorted out. The suggested initial dose will be Huminsulin (Lilly) - R (i.e. Regular - 40 units/ml pack) 10 units with lunch and 8 units with dinner. Based on glucose estimations and response, the dose will need to be adjusted, if necessary. (c) Along with Huminsulin, Glyciphage (metformin) 500 mg 2-3 times daily (with principal meals). (d) Cardace-H to be continued if you are hypertensive. Even otherwise ramipril (one ingredient of Cardace-H) is highly beneficial in diabetics and slows the development of kidney impairment. However in patients with normal blood pressure, only plain Cardace is to be taken, not Cardace-H. (e) Urine culture and if positive antibacterial therapy. Also determine lipid levels (cholesterol, triglycerides) in the blood. In most diabetics, they are raised. (f) Once protein disappears in the urine; brisk walk atleast 5 days a week for 45 minutes to cover no less than 4.5 km. This will help in reduction of weight and medication both. Please keep in mind that exercise can give rise to protein in the urine. (f) Diabetic diet and no alcohol.