DIABETES and ENDOCRINE CASES

1. DIABETES and ENDOCRINE CASES Dr Sunil Zachariah Consultant Endocrinologist

2. Case 1 • 28 year old man with newly diagnosed type 1 diabetes attends clinic. He is accompanied by his female partner who does not have diabetes. They are planning to start a family and want to know the risk of their offspring having type 1 diabetes in the future? • A)0.4% • B) 2 % • C) 6% • D) 8% • E) 10%

3. Answer: 6% • The overall lifetime risk in a caucasian developing type 1 diabetes is 0.4% • However this rises to • 4% if the mother has it • 5-6% if the father has it • 10-25% if both parents have it

4. DVLA and Diabetes • Group 1 assessments: • Most important change is that where a patient has had 2 episodes of hypoglycemia requiring assistance from a third party at anytime (including when sleeping) in a year, they must inform DVLA. • The requirement of assistance would include admission to A/E, treatment from paramedics, or from a partner/friend who has to administer glucagon or glucose because the patient cannot do so themselves.

5. It does not include a third party offering assistance, but the patient not requiring it. • Therefore when filling the questionnaire, great care should be taken to elicit the exact history of each episode. • Doctor must inform the patient that they need to tell the DVLA

6. In some cases, it may be suspected that severe nocturnal hypoglycemia is present in a patient sleeping on their own, but when not witnessed, this would not constitute an episode for reporting. • Also biochemical or CGMS evidence of hypoglycemia does not constitute evidence to stop driving in the absence of symptoms • If patient does not inform DVLA and continues to drive, according to GMC, the doctor should inform the medical advisor of DVLA

7. Group 2 Drivers: • Further change in regulation enables insulin treated diabetes patients to apply for Group 2 driver permission. • Group 2 vehicles are large goods vehicles (LGV) and passenger carrying vehicles (PCV). These are vehicles in excess of 7.5 metric tonnes laden weight or minibuses with more than 8 seats if driven for hire or reward. • DVLA is seeking network of diabetes assessors to help with these applications.

8. Case 2 • 22 year old girl • Routine blood testing • Free T4 of 13.6 pmol/L (11.5-21) • TSH of 8 mU/L (0.45-4) • TPO antibodies positive • Family history of thyroid illness • Patient feels well in herself

9. Patient has subclinical hypothyroidism • In women, the annual risk of spontaneous overt hypothyroidism is 4% in those who have both high TSH and positive TPO antibodies • If TSH>10, treatment is indicated • If TSH between 4-10, depending on symptoms, TPO antibodies, family history etc • Low threshold if trying for pregnancy • Spontaneous recovery has been described in subjects with mildly raised TSH. In one study 37% of patients normalised TSH over 30 months

10. CASE-3 • 23 year old lady • 3 months post delivery • Presents with palpitations and loose stools • FT4=32.6 pmol/L • TSH<0.01 mU/L

11. POSTPARTUM THYROIDITIS • Incidence varies from 5-11% • More common in women with a family history of hypothyroidism and positive TPO antibodies

12. CLINICAL FEATURES • Presentation is usually 3-4 months postpartum • Can be hypothyroidism (40%), hyperthyroidism (40%) or biphasic(20%) • Goiter is present in 50% of patients • To distinguish from Graves disease use thyroid isotope scan and TSH receptor Ab

13. POSTPARTUM THYROIDITIS • Incidence varies from 5-11% • More common in women with a family history of hypothyroidism and positive TPO antibodies

14. Pathogenesis • Destructive autoimmune thyroiditis causing first release of thyroxine and then hypothyroidism as the thyroid reserve is depleted • FNAC shows lymphocytic thyroiditis

15. Management • Most patients recover spontaneously without requiring treatment • If hyperthyroid use beta blockers rather than antithyroid drugs as the problem is increased release, not synthesis • Hypothyroid phase is more likely to require treatment • Only 3-4% remain permanently hypothyroid • 10-25% will recur in future pregnancies

16. Case-4 • 28 year old lady attends surgery in her second pregnancy at 16 weeks gestation. She had gestational diabetes in her previous pregnancy and was treated with insulin. She has not attended fasting blood glucose tests annually. What should be the next step in management?

17. For women who have had previous gestational diabetes, NICE guidance recommends early self monitoring of blood glucose or GTT at 16-18 weeks of gestation. • Screening for gestational diabetes should not be performed using fasting blood glucose, random blood glucose or urine analysis

18. Case-5 • 58 year old with type 2 diabetes attends clinic • BMI=36.5 kg/m2 • Last HbA1c=10% (86 mmol/mol) • Maintains he takes all his tablets and insulin regularly • Presently on metformin 1 gm bd, gliclazide 160 mg bd, lantus 100 units once daily • Already tried changing injection sites and needles • What is your next step?

19. Case-6 • 60 year old male with type 2 diabetes • BMI=27 • Presently taking metformin 500 mg once daily • Last HbA1c=8.8% • Creatinine=256, GFR=28 • What are your treatment options?

20. Case-7 • 65 year old male • History of type 2 diabetes • Comes for annual review • HbA1c=7.1% • On metformin and pioglitazone • Previous history of bladder cancer • Any Action needed?

21. Pioglitazone and Bladder Cancer • Data from 5 year interim analysis of an ongoing 10-year epidemiological study • FDA calculated that duration of pioglitazone therapy for more than 12 months was associated with 27.5 excess bladder cancer per 100000 person years follow up relative to pioglitazone naive patients • FDA has therefore recommended pioglitazone should be prescribed with caution in patients with previous bladder cancer and avoided in patients with active bladder cancer

22. Case Study-8 • 60 year old Type 2 Diabetes • Last HbA1c=8%(64 mmol/mol) • Presents with erectile dysfunction • Not much benefit from Viagra • Testosterone level 8 nmol/L

23. Hypogonadism in Type 2 Diabetes • Low testosterone levels are common in people with type 2 diabetes • Effect of testosterone replacement on glycaemic control remains uncertain • If androgen deficiency is suspected then do at least two 9 am testosterone levels. If first sample is low , then check LH, FSH, SHBG, ferritin and prolactin as well in the 2nd sample

24. If testosterone level is between 8 and 12 nmol/L in a symptomatic individual, then a trial of testosterone replacement is warranted • If the man has tried a phosphodiesterase inhibitor without success and has a total testosterone of <12 nmol/L, then a 6 month trial of testosterone is warranted

25. Case Study 10 • 27 year old female • Follicular Cancer of Thyroid • Post surgery, post radioiodine ablation • On Thyroxine replacement (175 mcg) • FT4 19.8 • TSH 0.05

26. Follow up of thyroid Cancer • Original diagnosis and treatment • If total thyroidectomy and ablative radioiodine, thyroglobulins usually undetectable if TSH unrecordable • Maintain TSH<0.05

27. Case 11 • 50 year old man • Ventricular tachycardia with poor LV function • Controlled on Amiodarone • FT4 50 • FT3 7 • TSH<0.01

28. Amiodarone and Thyroid • Inhibits thyroidal iodide uptake • Inhibits conversion of T4 to T3 intracellularly • Inhibits T4 entry into cells • Direct T3 antagonism at level of cardiac tissue

29. Amiodarone induced hyperthyroidism • 2-12% • Type 1: Iodine overload in abnormal gland, treat with carbimazole or lithium • Type 2: Glandular damage, release of preformed hormones, treat with prednisolone 0.5-1.25 mg/kg for 3-6 weeks • Management of tachyarrhythmia's: beta blockers if not in CCF • ?total thyroidectomy (not radioiodine)