7: ENDOCRINOLOGY

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CHAPTER 7 ENDOCRINOLOGY

Diabetes
Thyroid disorders
Obesity

DIABETES

A GP with a list of 2000 patients might expect to have 50 patients with diabetes, 10–15 of whom will be receiving insulin at any one time. Diabetes occurs because of lack of insulin, or resistance to its action, and is diagnosed by raised blood sugars.

Tip

Active case-finding and organised screening of selected groups is the key to diagnosis.

Risk factors in diabetes

The following factors put people at increased risk of developing diabetes:

• >65 years old
• Asian or Afro-Caribbean origin
• obesity, particularly abdominal obesity
• a family history of diabetes or cardiovascular disease
image

Diagnosis

Patients are often asymptomatic and may be diagnosed during routine or opportunistic screening.

History.

Patients with the following symptoms should be tested for diabetes:

• thirst, polyuria and weight loss
• recurrent infections, especially skin infections
• neuropathic symptoms, e.g. pain, numbness and paraesthesiae
• marked visual acuity changes
• unexplained symptoms, e.g. lassitude.

Tip

Diabetes is defined by WHO criteria, using venous samples, as:

• a fasting blood glucose level of >7.0 mmol/l, or
• a random plasma glucose level of >11.1 mmol/l.

In asymptomatic patients the measurements should be duplicated on another day before the diagnosis is made.

Investigations

Patients with a fasting plasma glucose between 6.1 and 7.0 mmol/l have impaired fasting glycaemia and need an oral glucose tolerance test.

The oral glucose tolerance test

• The patient should not have smoked and should have had a normal carbohydrate intake for the previous 3 days.

– After an overnight fast, give 75 g of oral glucose (350 ml of Lucozade can be used).
– Measure blood glucose 2 hours later.

• If >11.1 mmol/l, the patient is diabetic.
• If >7.8 and <11.1 mmol/l, the patient has impaired glucose tolerance.
• If <7.8, the patient has normal glucose tolerance.

Patients with impaired fasting glycaemia and impaired glucose tolerance should have annual follow-up with fasting blood glucose measurement.

Management

Referral.

At the time of diagnosis, if the patient is ill, ketonuria is present or if the blood glucose is more than about 25 mmol/l, immediate referral should be arranged.

Admit all children and pregnant women.

Aims of diabetic care

• To keep the patient well and symptom-free.
• To keep the fasting blood glucose below 6.7 mmol/l, the maximum blood glucose below 10 mmol/l and the level 2 hours after a meal below 6.7 mmol/l. (It is generally believed that good diabetic control prevents the development of long-term complications.)
• To avoid fasting glycosuria.
• To maintain the HbA1c below 7%.
• To minimise the risk of cardiovascular disease by vigorously treating hypertension (<130/80) and hypercholesterolaemia (reduce total cholesterol by 25% or to <4 mmol/l, whichever is the lower value) in conjunction with the diabetes. All diabetics should be prescribed aspirin 75 mg od if aged >50 and a statin, e.g. simvastatin 40 mg od if aged 40–80, or if younger and total serum cholesterol >5 mmol/l.
• To detect complications early, in order to reduce:

– angina, MI and cerebrovascular disease
– foot ulceration and limb amputation due to peripheral vascular disease and diabetic neuropathy
– visual loss due to diabetic retinopathy
– renal failure due to diabetic nephropathy.

• To offer effective education.

General management.

Practice nurses and diabetes specialist nurses have a valuable role in sharing the management of the diabetic patient. Diabetes UK is the national association for diabetes (see p. 356) and offers excellent on-line advice to both patients and professionals.

Education

• Emphasise the importance of self-management.
• Advise against smoking.
• Self-monitoring:

– All type 1 (insulin-dependent diabetes mellitus (IDDM)) patients should measure their blood glucose (and, ideally, their urine for ketonuria). Teach home glucose monitoring using a blood glucose test meter. Testing should ideally be carried out before each main meal and before bed.
– Urine testing alone is satisfactory for older type 2 diabetics. The urine should be tested 2 hours after a meal. A series of three tests on one day per week is more useful than once-daily testing.

• Intercurrent illness:

Diabetes therapy (insulin or tablets) should never be reduced or omitted during intercurrent illness. Insulin-dependent diabetics usually require more insulin during intercurrent illness.

– Non-insulin-treated patients can occasionally become ketoacidotic during intercurrent illness and may require insulin therapy.
– The frequency of self-monitoring should be increased.
– Fluid intake should be increased.
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