Metabolic Problems and Endocrinology

Metabolic and endocrine conditions are heavily tested in the AKT, with diabetes and thyroid disease being the most common topics. You need to know current NICE guidelines and be able to interpret blood results.

Type 2 diabetes management follows the NICE NG28 pathway. First-line is metformin (standard release initially, modified release if GI side effects). If HbA1c remains above target (usually 48 mmol/mol for most patients), add a second agent. SGLT2 inhibitors (dapagliflozin, empagliflozin) are recommended early, especially if the patient has CVD, heart failure, or CKD, because of their cardiovascular and renal benefits. GLP-1 receptor agonists (semaglutide, liraglutide) are options if BMI is above 35 or other oral agents have failed. Insulin is introduced when oral and injectable agents cannot achieve target HbA1c.

Diabetic complications screening: annual review including HbA1c, renal function (eGFR and urine ACR), blood pressure, cholesterol, foot examination (monofilament and pulse check), and retinal screening. Diabetic kidney disease is indicated by persistently raised ACR (above 3 mg/mmol on two occasions). Treatment includes ACE inhibitor or ARB and SGLT2 inhibitor.

Thyroid disease: hypothyroidism is diagnosed by raised TSH with low free T4. Subclinical hypothyroidism (raised TSH, normal T4) may warrant treatment if TSH is above 10, symptoms are present, or the patient is trying to conceive. Levothyroxine is the treatment, with TSH monitoring 6-8 weeks after dose changes and annually once stable. Hyperthyroidism presents with weight loss, tremor, palpitations, heat intolerance, and lid lag. Graves' disease (autoimmune, positive TSH receptor antibodies) is the most common cause. Treatment options include carbimazole (block and replace or titration regimen), radioiodine, and surgery.

Adrenal conditions: Addison's disease (primary adrenal insufficiency) presents with fatigue, weight loss, hyperpigmentation, and postural hypotension. Short Synacthen test is the diagnostic investigation. Treatment is lifelong hydrocortisone and fludrocortisone. Sick day rules are critical: double the hydrocortisone dose during illness.

Calcium metabolism: hypercalcaemia is most commonly caused by primary hyperparathyroidism (raised PTH with raised calcium) and malignancy (suppressed PTH). Symptoms include fatigue, thirst, constipation, confusion, and renal stones ("bones, stones, groans, and moans").