dr karen greenhorn bingley medical practice. see cases

Endocrine ProblemsDr Karen Greenhorn

Bingley medical Practice

Diagnosing DiabetesSee Cases

Aims and ObjestivesAccurately Diagnose DiabetesKnow Management options for treating Type

2 DiabetesKnow the DVLA Guidance for DiabetesAware of other endocrine problems and how

to management them.

HBA1c >6.5% Can be used to Diagnose Diabetes BUT WHO states ‘The diagnosis of diabetes in an asymptomatic person should

not be made on the basis of a single abnormal plasma glucose or HbA1c value.’

At least one additional HbA1c > 6.5% or a fasting plasma glucose > 7.0 or a random (casual) sample > 11.1 or from the oral glucose tolerance test (OGTT) It is advisable to use one test or the other but if both glucose and HbA1c aremeasured and both are “diagnostic” then the diagnosis is made. If one only isabnormal then a further abnormal test result, using the same method, isrequired to confirm the diagnosis.’ A value of less than 6.5% does not exclude diabetes 

Interpreting the Oral Glucose Tolerance Test

Impaired fasting glycaemiafasting sample of 6.1mmol/l to 6.9 mmol/l Impaired Glucose Tolerance2–hour plasma glucose ≥7.8 and <11.1mmol/lBeware this comes back as normal in the pathology

links

Diabetic2-hour plasma glucose >11.1mmol/l 

Newly Diagnosed Type 2 DiabeticThe 42 year old Asian gentleman with a

random glucose of 11.6 and a fasting of 7.2

ManagementBPBMIBloods (U+E, LFT, HBA1c, Lipids, TFT’s)Urine (ACR)Referral for retinal ScreeningReferral to EXPERT or dietitianPulses, 10g monofilament testing and referral

to podiatrist

ResultsBP 168/92mmHgBMI 37HBA1c 75mmol/mol (9.0%)Cholesterol 6.7ACR 4.7

NICE TargetsHbA1c <6.5% BP <140/80 mmHg, but if kidney, eye

or cerebrovascular disease <130/80Lipids Cholesterol <4.0 mmol/l, LDL

<2.0mmol/l

Metformin and Renal Impairment>60, continue60-45, continue but monitor renal function

more frequently (3-6/12)30-44, prescribe with caution and use 50% of

the dose, monitor renal function every 3/12, don’t initiate.

<30 absolute contraindication. Stop if on it.

Management Case 2A 67 year old lady with a BMI of 37 is taking

maximum doses of metformin and ramipril and she is unable to exercise due to osteoarthritis of both her knees, comes to the diabetic clinic for the results of her blood tests.

HBA1c 62mmol/mol (7.8%)BP 156/88Other bloods OKWhat are her options?

Incretin EffectIncretin hormones (GLP1 and GIP) produced

by GI tract in response to nutrient entry.Stimulates post-prandial secretion of insulinSuppresses post-prandial secretion of

glucogon (reduces gluconeogenesis)Promotes satiety and reduces appetite.

DPP4 Inhibitors(Sitagliptin, Vildagliptin, saxagliptin)

Inhibits the breakdown of GIP by inhibiting the enzyme DPP4

Licensed for any triple therapy. And can be used with insulin.

Once daily tablet. (up to bd with vildagliptin)More effective if used early in the course of diabetes. Avoid if eGFR <50S/E Headache. URTI. Weight neutral.

Incretin Mimetics(Exenatide and Liraglutide)GLP 1 AnalogueIt interacts with a specific receptor on the

beta cell.Helps weight lossSub cut injection (as rapidly degraded in the

circulation) 60 minutes before meals. BD for exenatide, and (new once weekly), OD for Liraglutide

GLP1 Analogues(Exenatide, Liraglutide)Exenatide licensed triple therapy with

sulphonylurea and metformin, Liraglutide triple therapy can also include a Glitazone.

NOT licensed for monotherapy. NICE : HbA1c >7.5% and BMI > 35 in people of

European decent or lower BMI (>30) if other ethnicity or weight loss would benefit other co-morbidities.

eGFR avoid if <30 exenatide, <60 Liraglutide. S/E nausea very common. Hypoglycaemia more

common if taken with a sulphonylurea. Acute pancreatitis.

Weight Loss SurgeryReuxen-Y-Bipass better than banding (can

now be done laparoscopically)On average 82% REMISSION FROM

DIABETES 14 years post surgeryThe greater the BMI the greater the benefitBUT Leads to malabsorption problems (B12,

Calcium, anaemia), gastric dumping syndrome and rarely hypoglycaemia

Case 348 year old gentleman recently diagnosed

with type 2 diabetes and has been to see the dietician who is concerned with the amount he is having to eat to maintain his weight and is concerned that he is actually a type 1 diabetic. He is on the maximum dose of glimepiride and HBA1c is 90mmol/mol (10.4).

He feels well, what do you do?

Blood Glucose monitoringType 1 or type 2 on intensive insulin regime.Pregnancy on insulin.

QDS

Type 2 on conventional insulin therapy.

2-3 times a week, more if not stable or unwell.

Type 2 on insulin and Oral hypoglycaemics.

At least OD varying the times.

Type 2 on sulphonyluria. Only to identify hypo’s

Diet alone or metformin or glitazone.

DO NOT NEED. In motivated can be used to monitor lifestyle changes.

Case 4A 28 year old Type 1 Diabetic has come for a

medication review as he has been ordering a lot more strips recently, 2 boxes of 50 a week. On discussion he had become obsessed about having a hypo having been in hospital recently with a hypoglycaemic episode. His partner had treated it using hypostop gel and he was admitted for a few hours observation in hospital. He drives to work, what conversation should you have with him?

Severe hypoglycaemiaDefined as requiring the assistance of another person.Changes to the standards for driving Group 1

vehicles (cars and motorcycles)

The following changes introduced by the European Union have applied since September 2010. Must NOT have had more than one episode of severe hypoglycaemia within the preceding 12 months

Must NOT have impaired awareness of hypoglycaemia which has been defined by the Diabetes Panel for Group 1 vehicles as an inability to detect the onset of hypoglycaemia because of a total absence of warning symptoms

Further information can be obtained from the DVLA website – www.dft.gov.uk/dvla/medical

Driving and HypoglycaemiaMust Test Blood Glucose before DrivingIf <4.0 MUST NOT DRIVEIf <5.0 Have a snack before drivingCheck Blood Glucose every 2 hours when

drivingIf having a Hypo must pull over, take keys out

of ignition and sit in passenger seat for 45 minutes after it has been corrected.

Case 5This 70 year old gentleman has recently been diagnosed with diabetes, what investigations should you do?

Cushing Syndrome

Cushings SyndromeGlucocorticoid excessPrimary excess due to Adrenal

adenoma/carcinomaIncreased ACTH due to Pituitary or ectopic

source.TEST U+E, Dexamethasone suppression test

(1mg Dex at 11pm, no suppression), 24 hour free cortisol, CXR.

Case 6A 32 year old lady has been complaining of

being tired all the time! But also legs feel very weak, as though is going to pass out all the time and been loosing weight. What blood tests would you do if any?

Blood resultsFBC normalGlucose 4.2mmol/lSodium 125mmol/lPotassium 6.2mmol/lUrea 10mmol/lNormal creatinineWhat is the diagnosis and what do you do?

Addison’s DiseasePrimary Hypoadrenalism and ACTH excess

Secondary HypoadrenalismLong term steroid useInadequate ACTH production

(panhypopituitarism)

Case 7A 48 year old lady is complaining of feeling

tired all the time, difficulty loosing weight and dry skin.

You do some blood tests which are all normal apart from a TSH of 7.8 and normal T4

What do you do?

Overt HypothyroisimSymptomaticTSH >10Reduced serum free or total thyroxine

Sub-clinical HypothyroidismTSH 5-10Normal Thyroxine levelsWhether to treat is controversialEXCEPT IN PREGNANCY or trying to

conceive.Risk of progression to overt is small (5% pa

with antibodies, 2% pa without)

When to TreatIF SYMPTOMS trial of thyroxine for 6

months, if feel better can continue (50%).NO SYMPTOMS BUT ANTIBODIES not to

treat but yearly surveillance.