Chapter 6: Endocrinology
Diabetes- the use of ACEI, low dose aspirin and lipid regulating drug are beneficial to reduce the
risk of CV disease.
Optimal glycaemic control- measure the fraction HbA1c, gives control over the last three months,
aim for 6.5-7.6% (normal 4-6%)
Inject insulin into upper arms, thighs, buttocks or abdomen; factors which increase insulin
requirements: infection, stress, trauma, puberty, pregnancy;
If acute onset diabetes then suitable starting doses of insulin:
Soluble insulin TDS
Medium acting at bedtime
If less severely ill then mixture 30% soluble and 70% isophane; 8 units BD
Short acting insulin: lispro and aspart
Intermediate: isophane, zinc suspension,
Long: crystalline insulin zinc suspension
Requirements for insulin decrease in renal/hepatic impairment, endocrine disorders (Addisons,
hypopituitary), celiac disease;
Monitoring: ‘normoglycaemia’ not always achieved in 24 hours without damaging hypos therefore
advise 4-10mmol/l; it may sometimes be above this for brief periods but never below.
Hypoglycaemia: need to educate patient;
An increase in the number of episodes decreases the warning symptoms to patient
therefore need to keep to minimum
Tight diabetic control will decrease the conc of glucose needed to trigger hypos
Beta-blockers mask the symptoms
If converting beef to human insulin need to decrease dose by 10% and monitor closely.
Driving:
Drivers on insulin/oral hypoglycaemics need to notify DVLA
Drivers of group II vehicles (HGV/public service vehicles) need to also inform DVLA if diet
controlled diabetes
Drivers with insulin: need to check blood glucose before driving and on long journeys at 2 hour
intervals (if on oral hypoglycaemics and at risk of hypos then also need to monitor); IDDM need to
have sugar in vehicle, and avoid driving if late for a meal; Recommendatios for hypos see pg 340
Diabetes and surgery: see sliding scale insulin guidelines pg 340-1
NICE guidelines insulin glargine: p342
Oral hypoglycaemics- prescribe only if patient fails to respond adequately to at least 3 months
restriction of energy and CHO intake and increase in physical activity; should augment diet and
exercise;
Sulphonylureas- augment insulin secretion so only effective if residual beta cell activity; long term
have extrapancreatic action; consider for patients NOT overweight; avoid in porphyria
Metformin- decrease gluconeogenesis, increase peripheral utilisation of glucose; effective only if
residual function of beta cells (acts in presence of endogenous insulin); hypoglycaemia rarely
occur with metformin; may provoke lactic acidosis (esp in renal impairment); during anaesthesia
need to stop 48 prior to surgery.
Diabetes- the use of ACEI, low dose aspirin and lipid regulating drug are beneficial to reduce the
risk of CV disease.
Optimal glycaemic control- measure the fraction HbA1c, gives control over the last three months,
aim for 6.5-7.6% (normal 4-6%)
Inject insulin into upper arms, thighs, buttocks or abdomen; factors which increase insulin
requirements: infection, stress, trauma, puberty, pregnancy;
If acute onset diabetes then suitable starting doses of insulin:
Soluble insulin TDS
Medium acting at bedtime
If less severely ill then mixture 30% soluble and 70% isophane; 8 units BD
Short acting insulin: lispro and aspart
Intermediate: isophane, zinc suspension,
Long: crystalline insulin zinc suspension
Requirements for insulin decrease in renal/hepatic impairment, endocrine disorders (Addisons,
hypopituitary), celiac disease;
Monitoring: ‘normoglycaemia’ not always achieved in 24 hours without damaging hypos therefore
advise 4-10mmol/l; it may sometimes be above this for brief periods but never below.
Hypoglycaemia: need to educate patient;
An increase in the number of episodes decreases the warning symptoms to patient
therefore need to keep to minimum
Tight diabetic control will decrease the conc of glucose needed to trigger hypos
Beta-blockers mask the symptoms
If converting beef to human insulin need to decrease dose by 10% and monitor closely.
Driving:
Drivers on insulin/oral hypoglycaemics need to notify DVLA
Drivers of group II vehicles (HGV/public service vehicles) need to also inform DVLA if diet
controlled diabetes
Drivers with insulin: need to check blood glucose before driving and on long journeys at 2 hour
intervals (if on oral hypoglycaemics and at risk of hypos then also need to monitor); IDDM need to
have sugar in vehicle, and avoid driving if late for a meal; Recommendatios for hypos see pg 340
Diabetes and surgery: see sliding scale insulin guidelines pg 340-1
NICE guidelines insulin glargine: p342
Oral hypoglycaemics- prescribe only if patient fails to respond adequately to at least 3 months
restriction of energy and CHO intake and increase in physical activity; should augment diet and
exercise;
Sulphonylureas- augment insulin secretion so only effective if residual beta cell activity; long term
have extrapancreatic action; consider for patients NOT overweight; avoid in porphyria
Metformin- decrease gluconeogenesis, increase peripheral utilisation of glucose; effective only if
residual function of beta cells (acts in presence of endogenous insulin); hypoglycaemia rarely
occur with metformin; may provoke lactic acidosis (esp in renal impairment); during anaesthesia
need to stop 48 prior to surgery.
