Brief Answer: hypoglycema episodes or migraine-induced blackouts Detailed Answer: Hi Mr. XXXXXXX Thanks for your query. Firstly, in order to PINPOINT the exact cause of generalized itching; give you a SOUND professional advice; and, TRUE VALUE FOR YOUR MONEY, I request you to kindly provide additional information as follows :- # Duration of diabetes # Does your wife get features of hypoglycemia (hunger, palpitations, dizziness, anxiety, sweating, shaking feeling of body) # Any OTHER SYMPTOMS or problems (if any). Dose she have tingling, numbness in her feet/legs? # Her latest Blood sugar levels (fasting and 2 hours after breakfast) ; HbA1c level; any other test reports (as available) # Her latest kidney function test reports : impaired kidney functions as a diabetic complication, cause increased anti-diabetic drugs levels in the blood and cause hypoglycemia # Duration of migraines and are her migraines under control with the current medications? # Her Blood Pressure readings (latest). This notwithstanding, from the details provided by you, the possibilities are :- * Episodes of hypoglycemia - in that event, the dosages her anti-diabetic drugs need to be modified. * Doses of anti-depressants need to be modified. * Also, I personally am of the opinion that she is on too many anti-depressants + anti-anxiety drugs, and probably need to be reduced/modified. However, I can do this ONLY on receipt of additional information. Pending receipt of additional information, I will strongly recommend that:- - you carry out your wife's 4 sugar levels (on a single day) : Fasting; 2hours EACH after breakfast, lunch and dinner. These four readings will give valuable information to me whether she has been having transient hypoglycemic attacks; and also help me in modifying the dose of anti-diabetic drugs so as to maintain IDEAL control throughout 24 hours. - Add a Beta-blocker such as Atenolol 25mg twice daily for control of her migraines. - A CT scan of Brain to rule out any lesion responsible for blackouts, which can be minor seizures. Consult your doctor and apprise him of my opinion. I am certain that he agrees with my opinion and clinical acumen; order required tests, and- based on the reports- will arrive at a certain diagnosis and prescribe/modifiy suitable treatment as advised. Hope I have addressed to your concerns to your complete satisfaction and you find my response helpful and informative. I will be happy to answer further queries, if any. Please revert back to me at the earliest, along with the additional details as advised. And, PLEASE BE REASSURED THAT I WILL GUIDE YOU TO THE BEST OF MY KNOWLEDGE. Fond regards and have a nice day, Dr. Rakesh Karanwal

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Brief Answer: EEG should be done to rule out epilepsy Detailed Answer: Hi Mr. XXXXXXX It’s a great pleasure hearing back from you. Thanks for the invaluable information. Firstly, the possible causes of recurrent blackouts, followed by migraine and diarrhea are :- * A type of epilepsy (which presents as a sudden blackout with post-ictal migraine and diarrhea). An EEG should therefore be carried out, since CT/MRIs have already excluded brain lesions. * Peripheral Neuropathy (constant tingling in soles and feet) with secondary autonomic neuropathy (abrupt drop in blood pressure, leading to blackouts)- as a diabetic complication. A combination of carbamezapine + Vitamin B12 (1500mcg/day) will control her tingling in feet. Also, carbamezapine would effectively control not only epilepsy (if diagnosis is confirmed), but also be very helpful in migraine. * Blood sugar is poorly controlled and hence need addition of another anti-diabetic drug, preferably Glimepiride. * The desirable BP in diabetics is <120/80. I would prefer use of ACE inhibitors (which will protect the kidneys) PLUS Beta-blockers, such as Atenolol (which will be of great help in controlling migraines. * Lastly, I feel that Mrs. XXXXXXX is on too many drugs. If I were her treating doctor, I would have discontinued amitriptyline, Lexotan and Topamax. Instead, I would have prescribed clonazepam in gradually increasing doses, which – in combination with citalopram- would curb her anxiety and depression. This combination, along with beta-blockers, would be an ideal preventive treatment for migraines. Please consult Mrs. John’s treating doctor and discuss my opinion / recommendations in great detail with him. I am sure that he will agree with me and order EEG; cardiac workup to exclude cardiac arrhythmias as the cause of blackouts; investigations to rule out/confirm autonomic neuropathy. Based on the tests reports, he will optimize the treatment. Hope you find my response as helpful and to your satisfaction. I will be happy to answer further clarifications, if any. Take Care and have a nice day

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