Patients with heart failure should not take pioglitazone due to its potential to cause fluid retention.

NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.

Distinguishing between type 1 and type 2 diabetes can be achieved through the measurement of C-peptide levels and diabetes-specific autoantibodies.

Diagnosis of Type 1 Diabetes Mellitus

Type 1 diabetes mellitus (T1DM) is typically diagnosed through symptoms and signs that are similar to those seen in diabetic ketoacidosis (DKA), although the diagnosis may take longer. Symptoms of DKA include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and an acetone-smelling breath. To confirm a diagnosis, urine should be dipped for glucose and ketones, and fasting glucose and random glucose levels should be measured. C-peptide levels are typically low in patients with T1DM, and diabetes-specific autoantibodies can be useful in distinguishing between type 1 and type 2 diabetes. Antibodies to glutamic acid decarboxylase (anti-GAD), islet cell antibodies (ICA), insulin autoantibodies (IAA), and insulinoma-associated-2 autoantibodies (IA-2A) are commonly used.

The diagnostic criteria for T1DM include a fasting glucose level greater than or equal to 7.0 mmol/l or a random glucose level greater than or equal to 11.1 mmol/l if the patient is symptomatic. If the patient is asymptomatic, the criteria must be demonstrated on two separate occasions. To distinguish between type 1 and type 2 diabetes, age of onset, speed of onset, weight of the patient, and symptoms should be considered. NICE recommends further investigation for adults suspected of having T1DM if the clinical presentation includes atypical features. Conversely, for patients suspected of having type 2 diabetes, if they respond well to oral hypoglycaemic agents and are over the age of 40 years, further testing for T1DM may not be necessary.

Example scenarios include a 15-year-old with weight loss and lethargy, a 38-year-old obese man with polyuria, a 52-year-old woman with polyuria and polydipsia, and a 59-year-old obese man with polyuria. The appropriate diagnostic tests should be conducted based on the patient’s symptoms and risk factors.

Understanding Prediabetes and Impaired Glucose Regulation

Prediabetes is a term used to describe impaired glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes mellitus. This includes individuals with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Diabetes UK estimates that around 1 in 7 adults in the UK have prediabetes, and many of them will eventually develop type 2 diabetes mellitus (T2DM), putting them at risk of microvascular and macrovascular complications.

To identify patients with prediabetes, NICE recommends using a validated computer-based risk assessment tool for adults aged 40 and over, people of South Asian and Chinese descent aged 25-39, and adults with conditions that increase the risk of T2DM. Patients identified as high risk should have a blood sample taken, and a fasting plasma glucose of 6.1-6.9 mmol/l or an HbA1c level of 42-47 mmol/mol (6.0-6.4%) indicates high risk.

Lifestyle modifications such as weight loss, increased exercise, and changes in diet are recommended for managing prediabetes. NICE also recommends metformin for adults at high risk who are still progressing towards T2DM despite lifestyle changes.

There are two main types of impaired glucose regulation: impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). IFG is due to hepatic insulin resistance, while IGT is due to muscle insulin resistance. Patients with IGT are more likely to develop T2DM and cardiovascular disease than those with IFG.

To rule out a diagnosis of diabetes, people with IFG should be offered an oral glucose tolerance test. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person doesn’t have diabetes but does have IGT. It is important to understand prediabetes and impaired glucose regulation to prevent the progression to T2DM and its associated complications.

On the day of surgery, it is recommended to omit the morning dose of gliclazide for patients taking sulfonylureas. However, if the patient takes BD, they can have the afternoon dose. Metformin should be taken as usual on the day before and on the day of elective surgery, except for lunchtime dose if taken three times a day.

Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

Differentiating Adrenal Gland Disorders: Phaeochromocytoma, Conn Syndrome, Cushing Syndrome, PKD, and RAS

Adrenal gland disorders can present with similar symptoms, making it challenging to differentiate between them. However, understanding the unique features of each condition can aid in accurate diagnosis and appropriate management.

Phaeochromocytoma is a tumour of the adrenal gland that causes paroxysmal secretion of catecholamines, resulting in hypertension, headache, sweating, and anxiety. It is associated with the 10% rule, where 10% of cases are extramedullary, malignant, familial, and bilateral.

Conn syndrome, or primary aldosteronism, is characterised by hypertension, hypokalaemia, and metabolic alkalosis. The most common causes are aldosterone-producing adenomas and bilateral adrenal hyperplasia.

Cushing syndrome is caused by prolonged hypercortisolism and presents with centripetal obesity, secondary hypertension, glucose intolerance, proximal myopathy, and hirsutism. Sweating, palpitations, and elevated catecholamines are not typical of hypercortisolism.

Polycystic kidney disease (PKD) is associated with hypertension due to progressive kidney enlargement. It is a significant independent risk factor for progression to end-stage renal failure, but it does not cause elevated catecholamine levels.

Renal artery stenosis (RAS) is a major cause of renovascular hypertension, but it is not associated with elevated catecholamines or the symptoms described. Patients with RAS may also have a history of atherosclerosis, dyslipidaemia, smoking, and hypertension resistant to multiple antihypertensive medications.

In summary, understanding the unique features of adrenal gland disorders can aid in accurate diagnosis and appropriate management.

Addison’s disease is a condition that requires patients to undergo both glucocorticoid and mineralocorticoid replacement therapy. This treatment usually involves taking a combination of hydrocortisone and fludrocortisone. Hydrocortisone is typically given in 2 or 3 divided doses, with patients requiring 20-30 mg per day, mostly in the first half of the day. Patient education is crucial, and it is essential to emphasize the importance of not missing glucocorticoid doses. Additionally, patients should consider wearing MedicAlert bracelets and steroid cards, and they should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis.

During an intercurrent illness, it is crucial to manage the glucocorticoid dose properly. In simple terms, the glucocorticoid dose should be doubled, while the fludrocortisone dose should remain the same. The Addison’s Clinical Advisory Panel has produced guidelines that detail specific scenarios, and patients should refer to these guidelines for more information. It is essential to discuss how to adjust the glucocorticoid dose during an intercurrent illness with a healthcare professional. Proper management of Addison’s disease is crucial to ensure that patients can lead healthy and fulfilling lives.

Hypocalcaemia: Symptoms and Signs

Hypocalcaemia is a condition characterized by low levels of calcium in the blood. Since calcium is essential for proper muscle and nerve function, many of the symptoms and signs of hypocalcaemia are related to neuromuscular excitability. The most common features of hypocalcaemia include muscle twitching, cramping, and spasms, as well as perioral paraesthesia. In chronic cases, patients may experience depression and cataracts.

An electrocardiogram (ECG) may show a prolonged QT interval, while Trousseau’s sign may be present when the brachial artery is occluded by inflating the blood pressure cuff and maintaining pressure above systolic. This causes wrist flexion and fingers to be drawn together, and is seen in around 95% of patients with hypocalcaemia and around 1% of normocalcaemic people. Chvostek’s sign, which is seen in around 70% of patients with hypocalcaemia and around 10% of normocalcaemic people, involves tapping over the parotid gland to cause facial muscles to twitch.

In summary, hypocalcaemia can cause a range of symptoms and signs related to neuromuscular excitability, including muscle twitching, cramping, and spasms, as well as perioral paraesthesia, depression, and cataracts. Trousseau’s sign and Chvostek’s sign are also commonly observed in patients with hypocalcaemia.

Understanding the Causes of Hypercalcaemia

Hypercalcaemia is a medical condition characterized by high levels of calcium in the blood. In most cases, two conditions account for 90% of hypercalcaemia cases. The first is primary hyperparathyroidism, which is the most common cause in non-hospitalized patients. The second is malignancy, which is the most common cause in hospitalized patients. Malignancy-related hypercalcaemia may be due to various processes, including PTHrP from the tumor, bone metastases, and myeloma. For this reason, measuring parathyroid hormone levels is crucial when investigating patients with hypercalcaemia.

Other causes of hypercalcaemia include sarcoidosis, tuberculosis, histoplasmosis, vitamin D intoxication, acromegaly, thyrotoxicosis, milk-alkali syndrome, drugs such as thiazides and calcium-containing antacids, dehydration, Addison’s disease, and Paget’s disease of the bone. It is important to note that hypercalcaemia may occur with prolonged immobilization in patients with Paget’s disease of the bone, although this condition is usually normal.

In summary, hypercalcaemia can be caused by various medical conditions, with primary hyperparathyroidism and malignancy being the most common. Measuring parathyroid hormone levels is essential in investigating patients with hypercalcaemia. Other causes of hypercalcaemia include sarcoidosis, tuberculosis, histoplasmosis, vitamin D intoxication, acromegaly, thyrotoxicosis, milk-alkali syndrome, drugs, dehydration, Addison’s disease, and Paget’s disease of the bone.

Subacute thyroiditis can be differentiated from Hashimoto’s thyroiditis as a cause of hypothyroidism by the presence of tenderness in the thyroid gland. The symptoms are indicative of hypothyroidism, which is confirmed by elevated TSH levels and low T4 levels in the thyroid function tests. The occurrence of a painful goitre points towards subacute thyroiditis as the most probable diagnosis. Graves’ disease, on the other hand, leads to hyperthyroidism and not hypothyroidism. Although Hashimoto’s thyroiditis can also cause hypothyroidism, it is typically painless. Riedel thyroiditis can cause hypothyroidism and may be painful, but it is less likely than subacute thyroiditis.

Understanding the Causes of Hypothyroidism

Hypothyroidism is a condition that affects a small percentage of women in the UK, with females being more susceptible than males. The most common cause of hypothyroidism is Hashimoto’s thyroiditis, an autoimmune disease that may be associated with other conditions such as IDDM, Addison’s or pernicious anaemia. Other causes of hypothyroidism include subacute thyroiditis, Riedel thyroiditis, thyroidectomy or radioiodine treatment, drug therapy, and dietary iodine deficiency. It is important to note that some of these causes may have an initial thyrotoxic phase.

In rare cases, hypothyroidism may also be caused by pituitary failure, which is known as secondary hypothyroidism. Additionally, there are certain conditions that may be associated with hypothyroidism, such as Down’s syndrome, Turner’s syndrome, and coeliac disease.

Treatment Options for Addison’s Disease

Addison’s disease is a condition in which the adrenal glands do not produce enough hormones. To manage this condition, patients are typically given replacement therapy with both glucocorticoid and mineralocorticoid medications. Fludrocortisone is a common mineralocorticoid medication used in this treatment. However, dexamethasone, aspirin, and both types of contraceptive pills have no role in the treatment of Addison’s disease. It is important for patients to work closely with their healthcare provider to determine the best treatment plan for their individual needs.