DIABETES and ENDOCRINE CASES
Dr Sunil Zachariah
Consultant Endocrinologist
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%
• 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
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.
• 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
• 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
• 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.
Case 2
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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
• 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
CASE-3
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23 year old lady
3 months post delivery
Presents with palpitations and loose stools
FT4=32.6 pmol/L
TSH<0.01 mU/L
POSTPARTUM THYROIDITIS
• Incidence varies from 5-11%
• More common in women with a family history
of hypothyroidism and positive TPO
antibodies
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
POSTPARTUM THYROIDITIS
• Incidence varies from 5-11%
• More common in women with a family history
of hypothyroidism and positive TPO
antibodies
Pathogenesis
• Destructive autoimmune thyroiditis causing
first release of thyroxine and then
hypothyroidism as the thyroid reserve is
depleted
• FNAC shows lymphocytic thyroiditis
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
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?
• For women who have had previous gestational
diabetes, NICE guidance recommends early
self monitoring of blood glucose or GTT at 1618 weeks of gestation.
• Screening for gestational diabetes should not
be performed using fasting blood glucose,
random blood glucose or urine analysis
Case-5
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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?
Case-6
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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?
Case-7
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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?
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
Case Study-8
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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
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
• 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
Case Study 10
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27 year old female
Follicular Cancer of Thyroid
Post surgery, post radioiodine ablation
On Thyroxine replacement (175 mcg)
FT4 19.8
TSH 0.05
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
Case 11
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50 year old man
Ventricular tachycardia with poor LV function
Controlled on Amiodarone
FT4 50
FT3 7
TSH<0.01
Amiodarone and Thyroid
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Inhibits thyroidal iodide uptake
Inhibits conversion of T4 to T3 intracellularly
Inhibits T4 entry into cells
Direct T3 antagonism at level of cardiac tissue
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)