Endocrine conditions Flashcards
What is endocrinology?
a branch of biology and medicine dealing with the endocrine system, its diseases, and its specific secretions called hormones
What is the function of the endocrine system?
to maintain homeostasis by responding to both internal and external stimuli
List six endocrine conditions.
diabetes (type 1 and type 2) osteoporosis Addison's disease hypothyroidism and hyperthyroidism Cushing's syndrome Graves' disease
How many endocrine conditions can affect any given population?
200
What is the prevalence of type 1 diabetes in the UK?
> 370,000
10% of all diabetes cases
Who is most affected by type 1 diabetes in the UK?
usually appears before the age of 40 years
men are more affected than women
What is the prevalence of type 2 diabetes in the UK?
over 3.2 million people with a prevalence rate of 6%
90% of all diabetes cases
Who is most affected by type 2 diabetes in the UK?
usually appears after the age of 40 years
appears after the age of 25 years in people of South Asian and Afro-Caribbean origin
men are more affected than women
What is the prevalence of osteoporosis in the UK?
> 3 million
Who is most affected by osteoporosis in the UK?
women are more affected than men
What is the prevalence of Addison’s disease in the UK?
> 8400
1 in 20,000
Who is most affected by Addison’s disease in the UK?
all age groups and genders are equally affected
most affected age group is 30-50 years
What is the prevalence of hyperthyroidism in the UK?
> 700,000
0.2-2%
Who is most affected by hyperthyroidism in the UK?
prevalence rate in women of 2% (673,000)
0.2% in men (65,580)
What is the prevalence of hypothyroidism in the UK?
132,000
2%
Who is most affected by hypothyroidism in the UK?
women are 5-10 times more likely to be affected than men
What is the prevalence of Cushing’s disease in the UK?
1-2 per million of the population each year
Who is most affected by Cushing’s disease in the UK?
women are more affected than men
usually diagnosed between 30-40 years
What is the prevalence of Graves’ disease in the UK?
accounts for 60-80% of thyrotoxicosis diagnoses
this equates to 420,000-560,000 cases
Who is most affected by Graves’ disease in the UK?
occurs mostly in women 30-60 years
What is type 1 diabetes?
an autoimmune disease that destroys the beta cells in the islets of Langerhans in the pancreas that produce insulin
this prevents the body from being able to produce enough insulin to adequately regulate blood glucose levels
What is the function of insulin?
to bind to insulin receptors on the plasma membrane of liver and muscle cells
insulin enables the conversion of glucose into glycogen for storage (glycogenesis)
What happens if insulin is not produced?
excess amount of glucose present in the blood circulation
this causes hyperglycaemia (blood glucose >11 mmol/L, compared to 4-7 mmol/L in non-diabetics)
What are some of the long-term complications of type 1 diabetes?
blindness (retinopathy)
kidney failure (nephropathy)
foot ulceration leading to amputation (neuropathy)
premature heart disease, stroke and death
What interventions can greatly reduce the risk of complications caused by type 1 diabetes?
medication to maintain blood glucose levels within normal limits and reduce tissue damage
early detection and active management
What is type 2 diabetes?
a chronic metabolic condition characterised by insulin resistance (the body’s inability to effectively use insulin) and insufficient pancreatic insulin production
this causes hyperglycaemia
What are some of the risk factors for type 2 diabetes?
obesity physical inactivity raised blood pressure raised blood lipid levels certain ethnicities
Whar ethnicities are more at risk of type 2 diabetes (PHE, 2018)?
South Asian population - 6 times more likely than the white population
African and African-Caribbean population - 3 times more likely than the white population
What are some of the long-term complications of type 2 diabetes?
microvascular and macrovascular complications
a tendency to develop thrombosis
increased cardiovascular risk
retinopathy, nephropathy, neuropathy
reduced quality of life and life expectancy
What interventions can greatly reduce the risk of complications caused by type 2 diabetes?
patient education and self-management to make lifestyle changes and reduce complexities and possible side effects of therapy
What percentage of UK healthcare expenditure is related to diabetes care (PHE, 2018)?
UK healthcare - 5%
NHS - 9% (£8.8 billion per year)
What proportion of all people in hospital have diabetes (PHE, 2018)?
1 in 6
due to complications (e.g. amputation, blindness, kidney failure, stroke)
List some of the signs of hyperglycaemia.
polyuria
unintentional weight loss
infections (thrush, skin, bladder)
vomiting (ketone breath)
List some of the symptoms of hyperglycaemia.
polydipsia (excessive thirst)
fatigue
blurred vision
nausea
Apart from the signs and symptoms, what blood glucose measurements indicate hyperglycaemia?
blood glucose levels >7.0 mmol/L when fasting (pre-breakfast)
blood glucose levels >11.0 mmol/L 2 hours after meals
What is diabetic ketoacidosis (DKA)?
serious complication of type 1 diabetes (less common in type 2 diabetes)
occurs when blood glucose level is very high and acidic substances (ketones) build up to dangerous levels in the body
What is the incidence of DKA?
4.6-8 episodes per 1,000 diabetic patients
What is hypoglycaemia?
a condition in which blood glucose levels are lower than expected for normal bodily functions
What causes hypoglycaemia?
insufficient food intake to balance cell demands
can relate to the dosage of medication and whether it remains therapeutic to patient needs (e.g. weight loss, illness that affects the ability to eat or drink, other medication, e.g. antibiotics)
List some of the signs of hypoglycaemia.
sweating shaking or trembling fatigue palpitations appearance (pale) slurred speech
List some of the symptoms of hypoglycaemia.
polyphagia (excessive appetite) altered sensation (tingling lips) vertigo (dizziness) mood alterations (irritable) difficulty concentrating weakness
Apart from the signs and symptoms, what blood glucose measurements indicate hypoglycaemia?
blood glucose levels <4 mmol/L
some guidance states <3 mmol/L
What is considered ‘mild’ hypoglycaemia (JBDS, 2018)?
adults who are conscious, orientated and able to swallow
How should you treat ‘mild’ hypoglycaemia (JBDS, 2018)?
give 15-20g of quick acting carbohydrate, such as 5-7 Dextrosol tablets or 4-5 Glucotabs OR 150-200ml pure fruit juice
test blood glucose level after 15 mins and if still <4 mmol/L repeat up to 3 times
if still hypoglycaemic, call doctor and consider IV 10% glucose at 100 ml/hr or 1mg glucagon IM (may take up to 15 mins to work)
What is considered ‘moderate’ hypoglycaemia (JBDS, 2018)?
patient conscious and able to swallow, but confused, disorientated or aggressive
How should you treat ‘moderate’ hypoglycaemia (JBDS, 2018)?
if capable and cooperative, treat as for mild hypoglycaemia
if not capable and cooperative but can swallow give 1.5-2 tubes of 40% glucose gel
if ineffective, use 1mg glucagon IM
test blood glucose level after 10-15 mins and if still <4 mmol/L repeat up to 3 times
if still hypoglycaemia, call doctor and consider IV 10% glucose at 100 ml/hr
What should happen after treatment for ‘mild’ and ‘moderate’ hypoglycaemia (JBDS, 2018)?
blood glucose level should now be 4 mmol/L or above
give 20g of long-acting carbohydrate, e.g. two biscuits/slice of bread/200-300ml milk/next meal containing carbohydrate (give 40mg if IM glucagon has been used)
How should you treat patients with an enteral feeding tube (JBDS, 2018)?
give 20g quick-acting carbohydrate via enteral tube, e.g. 50-70ml Ensure Plus Juice or Fortijuice
check glucose after 10-15 mins
repeat up to 3 times until glucose >4 mmol/L
What is considered ‘severe’ hypoglycaemia (JBDS, 2018)?
patient unconscious/fitting or very aggressive or nil by mouth (NBM)
How should you treat ‘severe’ hypoglycaemia (JBDS, 2018)?
check ABC, stop IV insulin, contact doctor uregently
give IV glucose over 15 mins as 75ml 20% glucose OR 150ml 10% glucose OR 1mg Glucagon IM
recheck glucose after 10 mins and if still <4 mmol/L repeat treatment
What should happen after treatment for ‘severe’ hypoglycaemia (JBDS, 2018)?
if glucose now 4 mmol/L or above, follow up treatment as described for mild and moderate hypoglycaemia
if NBM, once glucose >4 mmol/L give 10% glucose infusion at 100 ml/hr until no longer NBM or reviewed by doctor
What should you remember following treatment for ‘mild’, ‘moderate’, and ‘severe’ hypoglycaemia (JBDS, 2018)?
do not omit subsequent doses of insulin
continue regular capillary blood glucose monitoring for 24-48 hours
review insulin/oral hypoglycaemic doses
give hypoglycaemia education and refer to diabetes team
Glucagon may be ineffective in which patients (JBDS, 2018)?
undernourished patients
severe liver disease
repeated hypoglycaemia
caution in oral hypoglycaemic agent-induced hypoglycaemia
What should you remember about treating hypoglycaemia in patients with renal/cardiac disease (JBDS, 2018)?
use IV fluids with caution
avoid fruit juice in renal failure
List five long-term complications of diabetes.
nephropathy (kidney damage) retinopathy chronic painful neuropathy autonomic neuropathy CVD
Diabetes complications are divided into which two categories?
microvascular - due to damage to small blood vessels
macrovascular - due to damage to larger blood vessels; increased risk of CVA and MI
What are the statistics associated with nephropathy?
the largest cause of renal failure in people of working age in the UK
about 3 in 4 people with diabetes will develop some stage of CKD in their lifetime
kidney disease accounts for 21% of deaths in people with type 1 diabetes
What are the statistics associated with retinopathy?
diabetes is the leading cause of preventable blindness in people of working age in the UK
diabetic retinopathy accounts for 7% of people who are registered blind in England and Wales
What are the statistics associated with chronic painful neuropathy?
this is estimated to affect up to 26% of people with diabetes
people with diabetes are estimated to be up to 30 times more likely to have an amputation compared with the general population
Autonomic neuropathy affects which organs?
skin (sweating) blood vessels (postural hypotension) GI tract (gastroparesis and diarrhoea) heart bladder function sexual function (35–90% of men with diabetes have erectile dysfunction) it may also blunt the symptoms
What are the statistics associated with CVD?
accounts for 44% of deaths in people with type 1 diabetes
What checks may be undertaken, alongside regular blood test reviews, for patients with diabetes?
blood glucose test (HbA1c), BP, cholesterol, eye screening, foot and leg check, kidney tests, dietary advice, emotional and psychological support or referral, diabetes education course, or expert patient program referral, care from diabetes specialists if needed, free flu jab due to long-term impact of condition and immune response, support with sexual problems, help to quit smoking, specialist care if planning to have a baby
What is the HbA1c test?
a blood test that establishes the average blood glucose level over a 3-6 month period
the blood is taken every 3-6 months, or more often if there are concerns about glucose control, especially for patients with type 1 diabetes
What is the target HbA1c level for adults with type 1 or type 2 diabetes?
48 mmol/mol (6.5%) or lower, to minimise the risk of long‑term vascular complications
this may be adjusted by considering other factors (e.g. daily activities, aspirations, comorbidities, occupation, history of hypoglycaemia)
What is the target fasting plasma glucose level on waking for patients with type 1 diabetes?
5-7 mmol/L
What is the target plasma glucose level before meals at other times of the day for patients with type 1 diabetes?
4-7 mmol/L
What is the target plasma glucose level at least 90 mins after eating for patients with type 1 diabetes?
5-9 mmol/L
Why is it important for patients with diabetes to receive advice on diet, weight, and exercise?
to ensure they minimise complications (e.g. CVD) caused by lifestyle choices
some patients with type 1 diabetes may be offered training and education in carbohydrate counting
What insulin regimen is recommended by NICE (2015) for patients with newly diagnosed type 1 diabetes?
multiple daily basal-bolus insulin injection regimens that may encompass long- and short-acting analogues rather than twice‑daily mixed insulin regimens
What is the recommended long-acting insulin for adults with type 1 diabetes?
patients are offered glargine OD or twice-daily insulin detemir as basal insulin therapy
alternatives are sort if the above is not achieving the desired results (blood glucose targets), or is not tolerated
What is the recommended rapid-acting insulin for adults with type 1 diabetes?
patients are offered rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement
the use of rapid‑acting insulin analogues after meals is not recommended
What is the recommended mixed insulin for adults with type 1 diabetes?
patients are offered twice-daily human mixed insulin regimen if a multiple daily injection basal-bolus insulin regimen is not possible and a twice-daily mixed insulin regimen is chosen
What factors should be considered to optimise insulin therapy in adults with erratic and unpredictable blood glucose control?
injection technique
injection sites (rotated)
self-monitoring skills
knowledge and self‑management skills
lifestyle
psychological and psychosocial difficulties
possible organic causes (e.g. gastroparesis)
Metformin may be prescribed alongside insulin therapy to improve blood glucose control in which patients?
BMI of 25 kg/m2 (23 kg/m2 for people from South Asia and related minority ethnic groups)
What is continuous subcutaneous insulin therapy (CSII or insulin pump) therapy?
a mode of delivering intensive insulin therapy which usually leads to improved glucose control and reduced hypoglycaemia
What is islet transplantation?
islets are taken from the pancreas of a deceased organ donor
the islets are purified, processed, and transferred into another person
once implanted, the beta cells in these islets start to produce and release insulin
Which patients with type 1 diabetes should be considered for islet transplantation?
adults with recurrent severe hypoglycaemia that has not responded to other treatments
adults with suboptimal diabetes control who have had a renal transplant and are currently on immunosuppressive therapy
Who are the key stakeholders involved in management, offering guidance, or even education of how to manage diabetes?
Public Health England Health Education England NICE Diabetes UK consultant diabetologists and endocrinologists, diabetes specialist nurses specialist diabetes dieticians diabetes educators
What support is available in Birmingham for people with diabetes?
Diabetes UK local support group - Kings Heath, in the Robin Centre adjacent to All Saints Church on Alcester Road, B14 7RA at 19:30
Diabetes UK - type 1 support group meets every two months in central Birmingham
What expert patient programs are available in Birmingham for people with diabetes?
UHB - diabetes centre (Nuffield House); structured education programs; dietetics, podiatry, retinal screening; multidisciplinary diabetes clinics; inpatient diabetes support (QE)
BCH - comprehensive diabetes care; diabetes home care plan; GP/practice nurse support
BWC - support groups and activities
What did Malik et al. (2019) conclude about adolescent perspectives on the use of social media to support type 1 diabetes management?
adolescents with type 1 diabetes expressed interest in the use of social media as a tool to support diabetes management and increase engagement with their diabetes care team
specific implementation measures around privacy and professionalism should be considered when developing a social media intervention to facilitate communication between adolescents and care teams
What did O’Donnell et al. (2015) conclude about the impact of sharing personalised clinical information with people with type 2 diabetes prior to their consulation?
although participants found it useful to receive their clinical results, no differences were found in patient involvement during the consulation, diabetes management self-efficacy, or glycaemic control
further pilot work on the timing of the intervention, who it is targeted at and what outcomes are measured is warranted before proceeding to a full-scale RCT
What did Bunn et al. (2017) conclude about what works for whom in the management of diabetes in people living with dementia?
there is a need for personalised care continuity and family-centred approaches (limited evidence that this happens routinely)
there is a need for a flexible service model that prioritises quality of life, independence and patient and carer priorities
future research must look at how organisational structures and workforce development can be better aligned to their needs
