To avoid reduced absorption of levothyroxine, iron/calcium carbonate tablets should be administered four hours apart.

Managing Hypothyroidism: Dosage, Goals, and Side-Effects

Hypothyroidism is a condition where the thyroid gland doesn’t produce enough thyroid hormone. The management of hypothyroidism involves the use of levothyroxine, a synthetic form of thyroid hormone. The initial starting dose of levothyroxine should be lower in elderly patients and those with ischaemic heart disease. For patients with cardiac disease, severe hypothyroidism, or patients over 50 years, the initial starting dose should be 25mcg od with dose slowly titrated. Other patients should be started on a dose of 50-100 mcg od. After a change in thyroxine dose, thyroid function tests should be checked after 8-12 weeks. The therapeutic goal is to achieve a ‘normalisation’ of the thyroid stimulating hormone (TSH) level, with a TSH value of 0.5-2.5 mU/l being the preferred range.

Women with established hypothyroidism who become pregnant should have their dose increased ‘by at least 25-50 micrograms levothyroxine’* due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. There is no evidence to support combination therapy with levothyroxine and liothyronine.

Levothyroxine therapy may cause side-effects such as hyperthyroidism due to over-treatment, reduced bone mineral density, worsening of angina, and atrial fibrillation. Interactions with iron and calcium carbonate may reduce the absorption of levothyroxine, so they should be given at least 4 hours apart.

In summary, the management of hypothyroidism involves careful dosage adjustment, regular monitoring of thyroid function tests, and aiming for a TSH value in the normal range. Women who become pregnant should have their dose increased, and combination therapy with levothyroxine and liothyronine is not recommended. Patients should also be aware of potential side-effects and interactions with other medications.

*source: NICE Clinical Knowledge Summaries

If the TSH level is between 5.5 – 10mU/L indicating subclinical hypothyroidism, it is recommended to conduct two separate tests with a 3-month interval. If the TSH level remains at the same level, a 6-month trial of thyroxine should be offered.

Understanding Subclinical Hypothyroidism

Subclinical hypothyroidism is a condition where the thyroid-stimulating hormone (TSH) is elevated, but the levels of T3 and T4 are normal, and there are no obvious symptoms. However, there is a risk of the condition progressing to overt hypothyroidism, especially in men and those with thyroid autoantibodies.

The management of subclinical hypothyroidism depends on the TSH levels and the presence of symptoms. According to the NICE Clinical Knowledge Summaries, patients with a TSH level greater than 10mU/L and normal free thyroxine levels should be considered for levothyroxine treatment. For those with a TSH level between 5.5-10mU/L and normal free thyroxine levels, a 6-month trial of levothyroxine may be offered if the patient is under 65 years old and experiencing symptoms. However, for older patients, a ‘watch and wait’ strategy is often used, and asymptomatic patients should have their thyroid function monitored every 6 months.

In summary, subclinical hypothyroidism is a condition that requires careful monitoring and management to prevent it from progressing to overt hypothyroidism. The decision to treat or not depends on the patient’s age, symptoms, and TSH levels.

If a patient with T2DM cannot take metformin due to contraindications and has a risk of CVD, established CVD, or chronic heart failure, the recommended initial therapy is SGLT-2 monotherapy.

NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.

Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.

Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.

SIADH is a well-known side effect of sulfonylureas like glimepiride.

SIADH is a condition where the body retains too much water, leading to low sodium levels in the blood. This can be caused by various factors such as malignancy (particularly small cell lung cancer), neurological conditions like stroke or meningitis, infections like tuberculosis or pneumonia, certain drugs like sulfonylureas and SSRIs, and other factors like positive end-expiratory pressure and porphyrias. Treatment involves slowly correcting the sodium levels, restricting fluid intake, and using medications like demeclocycline or ADH receptor antagonists. It is important to correct the sodium levels slowly to avoid complications like central pontine myelinolysis.

Managing Incidental Findings of Hypercalcaemia

It is crucial to consider the differential diagnosis when an incidental finding of hypercalcaemia is discovered. Immediate hospital review is necessary for severe hypercalcaemia (>3.40mmol/L) or those with symptoms. Further investigations may be required for mild hypercalcaemia, depending on the clinical context, such as chest x-ray, serum and urine protein electrophoresis, and serum cortisol.

NICE recommends referring patients suspected of having primary hyperparathyroidism to endocrinology. They will exclude other causes of hypercalcaemia and assess whether a parathyroidectomy is appropriate. Calcimimetic drug treatments and bisphosphonate therapy are potential treatments, but these would be considered in secondary care initially. A normal dietary intake of calcium is usually advised.

A patient with diabetes who has experienced two severe hypoglycaemic episodes requiring assistance must surrender their driving licence and inform the DVLA. Insulin-treated individuals must meet specific criteria to be licensed, including adequate hypoglycaemia awareness, no more than one severe episode in the past 12 months, appropriate glucose monitoring, not being a risk to the public while driving, meeting visual standards, and undergoing regular review. Increasing blood glucose monitoring before and during driving or informing the DVLA for monitoring purposes will not permit the patient to resume driving. If the patient experiences another hypoglycaemic episode within the next two months, they must notify the DVLA, but they would not meet the criteria for licensing if they have had two severe episodes in the past 12 months.

DVLA Regulations for Drivers with Diabetes Mellitus

The DVLA has recently changed its regulations for drivers with diabetes who use insulin. Previously, these individuals were not allowed to hold an HGV license. However, as of October 2011, the following standards must be met for all drivers using hypoglycemic inducing drugs, including sulfonylureas: no severe hypoglycemic events in the past 12 months, full hypoglycemic awareness, regular blood glucose monitoring at least twice daily and at times relevant to driving, an understanding of the risks of hypoglycemia, and no other complications of diabetes.

For those on insulin who wish to apply for an HGV license, they must complete a VDIAB1I form. Group 1 drivers on insulin can still drive a car as long as they have hypoglycemic awareness, no more than one episode of hypoglycemia requiring assistance within the past 12 months, and no relevant visual impairment. Drivers on tablets or exenatide do not need to notify the DVLA, but if the tablets may induce hypoglycemia, there must not have been more than one episode requiring assistance within the past 12 months. Those who are diet-controlled alone do not need to inform the DVLA.

To demonstrate adequate control, the Honorary Medical Advisory Panel on Diabetes Mellitus recommends that applicants use blood glucose meters with a memory function to measure and record blood glucose levels for at least three months prior to submitting their application. These regulations aim to ensure the safety of all drivers on the road.

Possible Causes of Hyperthyroidism with Normal TSH Levels

Hyperthyroidism with normal TSH levels can be caused by various factors. One possible cause is a TSH-secreting pituitary tumour, which is a rare condition that can lead to excessive secretion of TSH and growth hormone. Another possible cause is self-administration of thyroxine, but this can be ruled out if TSH secretion is still suppressed. Graves’ disease, a common cause of hyperthyroidism, is less likely as it typically results in unmeasurable TSH concentrations. Heterophilic antibodies in the patient’s serum can cause bizarre results, but this is unlikely to be the cause in a patient with classic symptoms of thyrotoxicosis. Finally, thyroid hormone resistance (Refetoff syndrome) is a rare syndrome where thyroid hormone levels are elevated but TSH levels are not suppressed. However, this is unlikely if the patient is symptomatic.

Emergency Treatment for Hypoglycaemia: Administering Glucagon and Arranging Hospital Admission

Hypoglycaemia is a medical emergency that can cause neurological and cardiac manifestations, including coma, convulsions, and arrhythmias. If the patient loses consciousness, administering glucagon 1 mg by subcutaneous or intramuscular injection is necessary to increase plasma glucose concentration. Once the patient regains consciousness, oral glucose should be given, and hospital admission should be arranged urgently. Administering a soluble aspirin or sugar in water orally would not be appropriate in this scenario. It is crucial to act quickly and seek medical attention to prevent further complications.

If a patient experiences gastrointestinal side-effects with metformin, it is recommended to try a modified-release formulation before considering switching to a second-line agent. While sulphonylurea, pioglitazone, and sitagliptin are potential second-line agents for those who cannot tolerate metformin, NICE advises trying modified-release metformin before considering these alternatives.

Metformin is a medication commonly used to treat type 2 diabetes mellitus, as well as polycystic ovarian syndrome and non-alcoholic fatty liver disease. Unlike other medications, such as sulphonylureas, metformin doesn’t cause hypoglycaemia or weight gain, making it a first-line treatment option, especially for overweight patients. Its mechanism of action involves activating the AMP-activated protein kinase, increasing insulin sensitivity, decreasing hepatic gluconeogenesis, and potentially reducing gastrointestinal absorption of carbohydrates. However, metformin can cause gastrointestinal upsets, reduced vitamin B12 absorption, and in rare cases, lactic acidosis, particularly in patients with severe liver disease or renal failure. It is contraindicated in patients with chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and those undergoing iodine-containing x-ray contrast media procedures. When starting metformin, it should be titrated up slowly to reduce the incidence of gastrointestinal side-effects, and modified-release metformin can be considered for patients who experience unacceptable side-effects.

Premature Ovarian Insufficiency: Causes and Symptoms

Premature ovarian insufficiency (POI) is a condition that affects at least 1% of women under the age of 40 years. It is characterized by elevated follicle-stimulating hormone (FSH), low oestradiol, and prolonged amenorrhoea. In most cases, no underlying cause is identified, but familial history, autoimmune lymphocytic oophoritis, infections, and iatrogenic causes such as surgery, radiotherapy, and chemotherapy may contribute to the condition. Spontaneous recovery of fertility is unlikely.

Androgen-secreting adrenal tumour, hypopituitarism, polycystic ovarian syndrome (PCOS), and thyrotoxicosis are incorrect diagnoses for POI. Androgen-secreting adrenal tumour is rare and presents with hirsutism, acne, and clitoral enlargement. Hypopituitarism is caused by anterior pituitary tumours and may result in pressure features, ACTH deficiency, TSH deficiency, GH deficiency, ADH deficiency, and gonadotrophin deficiency. PCOS is unlikely due to the raised FSH and lack of hyperandrogenism. Thyrotoxicosis is ruled out by the normal TSH levels.

Options for Testosterone Replacement Therapy

Testosterone replacement therapy is a common treatment for men with low testosterone levels. There are several options available, including testosterone undecanoate for oral use, injections, implants, patches, and gels. However, intramuscular depot preparations of testosterone esters are preferred for replacement therapy, according to the British National Formulary. One long-acting injectable formulation of testosterone undecanoate needs to be used only every 10–14 weeks.

Regular injections of human chorionic gonadotrophin and pulsatile subcutaneous administration of gonadotrophin-releasing hormone (GnRH) are not recommended for testosterone replacement therapy. While chorionic gonadotrophin has been used in delayed puberty in males, it has little advantage over testosterone. GnRH stimulates the release of FSH and LH from the anterior pituitary in normal subjects and is used to check whether the pituitary gland can produce LH and FSH in the correct levels.

Cyproterone acetate is an anti-androgen and is not used for testosterone replacement therapy. Regular injections of human menopausal gonadotrophin (HMG) have been replaced by recombinant gonadotrophins in fertility treatments.

It is important to monitor calcium levels when starting vitamin D as it can reveal any underlying hyperparathyroidism and lead to hypercalcaemia. Therefore, patients with renal calculi, granulomatous disease, or bone metastases may not be suitable for vitamin D. The National Osteoporosis Society recommends checking serum calcium after one month. However, there is no need to regularly check vitamin D levels once replacement therapy has begun.

Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society’s 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.

Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.

Common Mistakes in AKT Exams

A common mistake made by candidates in RCGP AKT exams is making silly errors when performing simple calculations. This often results in incorrect answers. However, at onExamination, we have noticed that candidates also tend to misread questions, leading to incorrect answers.

For instance, in a dose conversion question, candidates were asked to convert mcg to IU, but some failed to notice this and divided the 10 mcg dose by 40, resulting in an incorrect answer of 0.25. The correct method would have been to multiply the 10 mcg dose by 40 to convert to IU, giving the correct answer of 400.

To avoid such errors, the RCGP advises candidates to do a reality check after their calculation. For example, if you are familiar with the CKS NICE recommended adult intake of Vitamin D (which is 400 IU), you should be able to recognize that 0.25 is not the correct answer and double-check your calculation. By paying attention to details and doing a reality check, candidates can avoid making common mistakes in AKT exams.

Placing any object in the mouth of an unconscious patient can be risky as they may not be adequately safeguarding their airway.

In cases of heparin overdose, protamine sulfate is administered.

Insulin therapy can have side-effects that patients should be aware of. One of the most common side-effects is hypoglycaemia, which can cause sweating, anxiety, blurred vision, confusion, and aggression. Patients should be taught to recognize these symptoms and take 10-20g of a short-acting carbohydrate, such as a glass of Lucozade or non-diet drink, three or more glucose tablets, or glucose gel. It is also important for every person treated with insulin to have a glucagon kit for emergencies where the patient is not able to orally ingest a short-acting carbohydrate. Patients who have frequent hypoglycaemic episodes may develop reduced awareness, and beta-blockers can further reduce hypoglycaemic awareness.

Another potential side-effect of insulin therapy is lipodystrophy, which typically presents as atrophy or lumps of subcutaneous fat. This can be prevented by rotating the injection site, as using the same site repeatedly can cause erratic insulin absorption. It is important for patients to be aware of these potential side-effects and to discuss any concerns with their healthcare provider. By monitoring their blood sugar levels and following their treatment plan, patients can manage the risks associated with insulin therapy and maintain good health.

Management of Subclinical Hypothyroidism

Subclinical hypothyroidism is a common condition in middle-aged and older women, characterized by normal serum T4 and T3 levels but raised TSH concentration without specific symptoms or signs of thyroid dysfunction. The condition may result from previous hyperthyroidism or nonspecific symptoms such as tiredness or weight gain. In cases where patients have detectable levels of microsomal thyroid peroxidase antibodies, they are more likely to develop overt hypothyroidism.

Treatment with thyroxine is recommended for patients with a TSH > 10 μU/l and those with clinical features. The aim of therapy is to restore TSH concentration to within the reference range. However, a serum TSH concentration of less than 10 μU/l in patients who are antibody negative warrants observation rather than immediate treatment, as it may be a transient phenomenon.

It is not clear whether subclinical hypothyroidism contributes to the development of ischaemic heart disease. Therefore, prescribing simvastatin is not recommended without further information on the patient’s QRISK. Similarly, referring for a thyroid ultrasound scan and fine needle biopsy is not necessary unless there is an unexplained thyroid lump.

The National Institute of Health and Care Excellence lists the indications for referral in people with subclinical hypothyroidism, including cases of suspected subacute thyroiditis, people planning a pregnancy, those with cardiac disease, and amiodarone-induced hypothyroidism. Therefore, referring to an endocrinologist is not necessary in most cases of subclinical hypothyroidism.

GLP-1 mimetics can be combined with insulin in T2DM to prevent weight gain associated with insulin use, but patients still need to check their blood sugar levels before driving and throughout the journey. While SGLT2 inhibitors may help reduce blood pressure, GLP-1 mimetics do not have this effect. Additionally, while SGLT2 inhibitors have been shown to improve cardiovascular outcomes in T2DM patients, there is no evidence to suggest that GLP-1 mimetics have the same effect. It is important to note that GLP-1 mimetics can have rare but serious side effects, such as pancreatitis. Initiation of GLP-1 mimetics in T2DM should be done by a specialist team.

Diabetes mellitus is a condition that has seen the development of several drugs in recent years. One hormone that has been the focus of much research is glucagon-like peptide-1 (GLP-1), which is released by the small intestine in response to an oral glucose load. In type 2 diabetes mellitus (T2DM), insulin resistance and insufficient B-cell compensation occur, and the incretin effect, which is largely mediated by GLP-1, is decreased. GLP-1 mimetics, such as exenatide and liraglutide, increase insulin secretion and inhibit glucagon secretion, resulting in weight loss, unlike other medications. They are sometimes used in combination with insulin in T2DM to minimize weight gain. Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as vildagliptin and sitagliptin, increase levels of incretins by decreasing their peripheral breakdown, are taken orally, and do not cause weight gain. Nausea and vomiting are the major adverse effects of GLP-1 mimetics, and the Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide, reporting that it has been linked to severe pancreatitis in some patients. NICE guidelines suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated, or the person has had a poor response to a thiazolidinedione.

NICE Guidelines on Lipid Modification

According to the NICE guidelines on lipid modification (CG181), it is important to consider the possibility of familial hypercholesterolaemia in patients with a total cholesterol concentration of more than 7.5 mmol/L and a family history of premature coronary heart disease. In such cases, investigation is necessary to determine the presence of the condition.

For patients with a total cholesterol concentration of more than 9.0 mmol/L or a non-HDL cholesterol concentration of more than 7.5 mmol/L, specialist assessment is recommended even in the absence of a first-degree family history of premature coronary heart disease. This is important to ensure appropriate management and treatment of high cholesterol levels, which can significantly increase the risk of cardiovascular disease.

Overall, following these guidelines can help healthcare professionals identify and manage patients with high cholesterol levels, reducing the risk of serious health complications.

Hypercalcaemia and hypocalciuria may be caused by thiazide diuretics.

The onset of action of bendroflumethiazide is 1 to 2 hours, and its effect lasts for 12 to 24 hours. According to the BNF, the quantity of bendroflumethiazide present in breast milk is insignificant and poses no harm.

Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While thiazide diuretics are useful in treating mild heart failure, loop diuretics are more effective in reducing overload. Bendroflumethiazide was previously used to manage hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlortalidone.

Common side effects of thiazide diuretics include dehydration, postural hypotension, and electrolyte imbalances such as hyponatremia, hypokalemia, and hypercalcemia. Other potential adverse effects include gout, impaired glucose tolerance, and impotence. Rare side effects may include thrombocytopenia, agranulocytosis, photosensitivity rash, and pancreatitis.

It is worth noting that while thiazide diuretics may cause hypercalcemia, they can also reduce the incidence of renal stones by decreasing urinary calcium excretion. According to current NICE guidelines, the management of hypertension involves the use of thiazide-like diuretics, along with other medications and lifestyle changes, to achieve optimal blood pressure control and reduce the risk of cardiovascular disease.

Interpreting Diabetic Retinopathy Findings: What Requires Urgent Referral?

Diabetic retinopathy is a common complication of diabetes that can lead to vision loss if left untreated. As part of routine eye exams, healthcare professionals may identify various findings in the retina that indicate the presence and severity of diabetic retinopathy. However, not all findings require urgent referral to an ophthalmologist. Here are some examples:

– New vessels on the disc: These are a sign of proliferative retinopathy and require urgent referral as they can cause bleeding and threaten vision.
– Dot-and-blot haemorrhages: These are a feature of background retinopathy and do not require urgent referral unless they are within one-disc diameter of the fovea. Annual monitoring is recommended.
– Cataract: While cataracts are more common in people with diabetes, routine referral is sufficient if vision is significantly affected.
– Hard exudates > one-disc diameter from the fovea: These are also a feature of background retinopathy and do not require urgent referral.
– Two soft exudates in the temporal field: These cotton-wool spots are not a reason for referral, but referral for review within four weeks is indicated if other signs of pre-proliferative disease are present.

Understanding which findings require urgent referral can help healthcare professionals provide appropriate care for people with diabetic retinopathy and prevent vision loss.

Reduced bone mineral density is linked to the prolonged use of proton pump inhibitors.

Osteoporosis is a condition that is more prevalent in women and increases with age. However, there are many other risk factors and secondary causes of osteoporosis. Some of the most significant risk factors include a history of glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture history, low body mass index, and current smoking. Other risk factors include a sedentary lifestyle, premature menopause, certain ethnicities, endocrine disorders, gastrointestinal disorders, chronic kidney disease, and certain genetic disorders. Additionally, certain medications such as SSRIs, antiepileptics, and proton pump inhibitors may worsen osteoporosis.

If a patient is diagnosed with osteoporosis or has a fragility fracture, further investigations may be necessary to identify the cause of osteoporosis and assess the risk of subsequent fractures. Recommended investigations include a history and physical examination, blood tests such as a full blood count, urea and electrolytes, liver function tests, bone profile, CRP, and thyroid function tests. Other procedures may include bone densitometry, lateral radiographs, protein immunoelectrophoresis, and urinary Bence-Jones proteins. Additionally, markers of bone turnover and urinary calcium excretion may be assessed. By identifying the cause of osteoporosis and contributory factors, healthcare providers can select the most appropriate form of treatment.

Diagnosis of Primary Hypoadrenalism: A Case Study

A woman presents with a marked postural drop in blood pressure, increased pigmentation, and low cortisol levels, indicating primary hypoadrenalism as the most likely diagnosis. The high adrenocorticotropic hormone (ACTH) level causes pigmentation, and autoimmune destruction of the adrenal glands is responsible for 80% of cases. Hyponatremia and hyperkalemia are common in established cases. The National Institute for Health and Care Excellence recommends hospital admission for serum cortisol levels below 100 nmol/l and referral to an endocrinologist for levels between 100 and 500 nmol/l. Hypovolemia, HIV, hypothyroidism, and psychiatric symptoms are unlikely causes based on the case history.

Exenatide and its Metabolic Effects

Exenatide is a medication that imitates the effects of GLP-1, a hormone produced in the gut. It has been found to have beneficial effects on the metabolism of individuals with diabetes mellitus. This medication has several metabolic effects, including the suppression of appetite, inhibition of glucose production in the liver, slowing of gastric emptying, and stimulation of insulin release. However, it doesn’t increase insulin sensitivity, which is achieved by other drugs such as metformin and the glitazones. Overall, exenatide has been shown to have a positive impact on the management of diabetes by regulating various metabolic processes.

Regardless of age, ACE inhibitors/A2RBs are the first-line treatment for hypertension in diabetic patients due to their renoprotective effect, even if the patient has stage 1 hypertension according to NICE guidelines. In contrast, for patients aged over 55 years without diabetes, a calcium channel blocker is the first-line treatment.

Blood Pressure Management in Diabetes Mellitus

Patients with diabetes mellitus have traditionally been managed with lower blood pressure targets to reduce their overall cardiovascular risk. However, a 2013 Cochrane review found that tighter blood pressure control did not significantly improve outcomes for patients with diabetes, except for a slightly reduced rate of stroke. As a result, NICE recommends a blood pressure target of < 140/90 mmHg for type 2 diabetics, the same as for patients without diabetes. For patients with type 1 diabetes, NICE recommends a blood pressure target of 135/85 mmHg unless they have albuminuria or two or more features of metabolic syndrome, in which case the target should be 130/80 mmHg. ACE inhibitors or angiotensin-II receptor antagonists (A2RBs) are the first-line antihypertensive regardless of age, as they have a renoprotective effect in diabetes. A2RBs are preferred for black African or African-Caribbean diabetic patients. However, autonomic neuropathy may result in more postural symptoms in patients taking antihypertensive therapy. It is important to note that the routine use of beta-blockers in uncomplicated hypertension should be avoided, especially when given in combination with thiazides, as they may cause insulin resistance, impair insulin secretion, and alter the autonomic response to hypoglycemia.

Weight Loss Requirement for Prescription Continuation

To continue prescribing, a weight loss of at least 5% is necessary within the first three months. This means that patients must lose a certain amount of weight within the initial period of treatment to ensure that the medication is effective and safe for long-term use. It is important for patients to adhere to a healthy diet and exercise regimen to achieve this weight loss goal. Failure to meet this requirement may result in the discontinuation of the prescription.

Counselling a Diabetic on Insulin Management When Unwell

A key aspect of counselling a diabetic who has been started on insulin is to educate them on what to do if they become unwell. For type 2 diabetics, it is recommended that they check their blood glucose levels at least every 4 hours when feeling unwell.

A useful resource to refer to when advising patients in this situation is the TREND UK guideline. This guideline provides a clear algorithm for managing blood glucose levels when a patient is unwell. According to the guideline, if the patient’s blood glucose level is less than 13 mmol/L, they should take insulin as normal. However, if the level is greater than 13 mmol/L, insulin adjustment is necessary.

By following the algorithm provided in the TREND UK guideline, healthcare professionals can effectively manage the patient’s insulin dosage and blood glucose levels. For instance, if the patient requires an additional 4 units of insulin added to each dose, this can be easily determined by following the algorithm. Additionally, the patient should continue to monitor their blood glucose levels every 4 hours to ensure that their insulin management is effective.

Tumour Markers and their Clinical Applications

Monoclonal antibodies are utilized to detect serum antigens associated with specific malignancies. These tumour markers are most useful for monitoring response to therapy and detecting early relapse. However, with the exception of PSA, tumour markers do not have sufficient sensitivity or specificity for use in screening.

PSA, or prostate specific antigen, is a useful marker for screening for prostate cancer, although population screening is controversial. It can also be used to detect recurrence of the malignancy and is useful in the investigation of adenocarcinoma of unknown primary. Hypercalcaemia and bone pain may suggest metastatic carcinoma, which is common in prostate cancer.

CA 19-9, AFP, beta-HCG, and CEA are other tumour markers that are used for different types of cancer. CA 19-9 is helpful in establishing the nature of pancreatic masses, AFP is a marker for hepatocellular carcinoma, beta-HCG is used in the diagnosis and management of gestational trophoblastic disease and non-seminomatous germ-cell tumours of the testes, and CEA is used to detect relapse of colorectal cancer.

In conclusion, tumour markers have various clinical applications in the diagnosis, treatment, and monitoring of cancer. However, their sensitivity and specificity may vary, and they should be used in conjunction with other diagnostic tools for accurate diagnosis and management of cancer.

Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.

Management of Osteoporosis in Patients with T Score Criteria

Patients who fit the criteria for diagnosis of osteoporosis based on T score should be managed with a generic bisphosphonate as the first line of treatment. This is regardless of whether they have suffered an osteoporotic fracture or not. If a patient doesn’t tolerate a weekly preparation, there are monthly and intermittent IV preparations available. It is important to note that early intervention is key in preventing further bone loss and reducing the risk of fractures. Therefore, prompt management of osteoporosis is crucial in maintaining bone health and preventing complications.

Diagnosing Chest Tightness and Palpitations in Primary Care

Symptoms of chest tightness and palpitations are common in primary care, but diagnosing the underlying cause can be challenging. Episodic symptoms often require catching the symptoms during an attack to make an accurate diagnosis. Patients may describe a previous attack, but positive examination findings are often lacking when they are asymptomatic. Therefore, history is crucial, and patients should seek review when experiencing symptoms.

In this case, the patient presented with high blood pressure, tachycardia, and glycosuria during an attack. The episodic nature of the symptoms suggested panic attacks, phaeochromocytoma, or a paroxysmal tachyarrhythmia such as Wolff-Parkinson-White (WPW) syndrome. However, WPW typically causes paroxysmal supraventricular tachycardia and would not cause glycosuria. Panic attacks would not cause glycosuria, and the severity of the hypertension would go against this diagnosis. Phaeochromocytoma unifies the history and clinical features and is the underlying disorder.

Phaeochromocytoma is a rare tumour that produces catecholamines and causes episodes of hypertension, chest tightness, sweating, tremor, and flushing. Glycosuria occurs in approximately 30% of patients during an attack. Diagnosis is made by a 24-hour urine collection for metanephrines, and surgical removal is the treatment of choice.

PCOS and Hirsutism: A Common Endocrinopathy in Women

This patient is diagnosed with polycystic ovary syndrome (PCOS), which is the most common endocrinopathy in women of reproductive age. PCOS accounts for 95% of cases of hirsutism presenting to out-patient clinics. The clinical features of PCOS include hirsutism and oligomenorrhoea, which are caused by excessive androgen levels. These symptoms are often worsened by obesity.

When diagnosing hirsutism, it is important to consider other potential causes such as virilising tumours of the ovaries or adrenal gland, Cushing’s syndrome, and congenital adrenal hyperplasia. By ruling out these other conditions, healthcare providers can accurately diagnose and treat PCOS and its associated symptoms. Proper management of PCOS can improve quality of life and reduce the risk of long-term complications such as infertility and cardiovascular disease.