In this section : Diabetes and Endocrinology
Paediatric Diabetic Ketoacidosis (DKA) Guideline
Paediatric Ketone Correction Guideline
Insulin Correction Factor Table (Paediatrics)
Management of Hypoglycaemia in Children with Type 1 Diabetes
Newly diagnosed diabetic – not in DKA (Walking wounded)
Prescribing Advice on Admission – Insulin
Diabetic Retinopathy
Adrenal Insufficiency
Hyperglycaemia & Steroids
Variable Rate Insulin Infusion
In-patient Hyperglycaemia Management
Hyperthyroidism
Newer Antidiabetic Drugs
Hypoglycaemia
Diabetic Ketoacidosis
Switching from VRII
Insulin Pumps
Diabetes Mellitus
The Diabetic Foot
Subcutaneous Insulin
Diabetes and Acute Coronary Syndrome
Hyperosmolar Hyperglycaemic State
Adrenal Insufficiency
Last updated 27th September 2024
When to Suspect
- Insidious onset dizziness, lethargy, weight loss, postural hypotension and a tan and increased pigmentation palmar creases together are highly suggestive of Addison’s
- Addisonian crisis may be first presentation of undiagnosed hypoadrenalism – abdominal pain, nausea, vomiting, muscle weakness in addition to above
- U&E typically show hyponatraemia (lack of cortisol) with hyperkalaemia (lack of aldosterone). There may also be mild anaemia, hypoglycaemia
Causes
- Addison’s disease – an autoimmune disease that tends to run in families and be associated with type 1 diabetes, thyroid disease, pernicious anaemia, coeliac, alopecia, vitiligo
- Other causes are bronchial carcinoma causing adrenal mets, TB, long term steroids and pituitary failure
Investigations
- 9am or random cortisol (3mls serum gel) >500nmol/l excludes.
- Patients with cortisol <500nmol/l require Synacthen test
- 9am cortisol <100nmol/l is sufficiently suggestive to recommend starting treatment immediately unless a synacthen test can be performed at same time
- Also check ACTH, TFTs – may indicate pituitary failure
Short Synacthen Test
- Aim to do this at 9am (because cortisol levels fall in afternoon) and in hospital (because can cause anaphylactic reaction)
- Check baseline cortisol, Rx Synacthen 250micrograms IV then repeat cortisol at 30 and 60 mins
- Normal baseline >250nmol/l, increment >170nmol/l and 30 and 60 minute cortisol >550nmol/l
- 30 minute cortisol sometimes <550 because baseline low which is why 60 minute sample important
- NB Combined OCP and HRT should be stopped 6 weeks before, Prednisolone 24 hours before and Hydrocortisone omitted on morning of test
Emergency Treatment
- Rx Hydrocortisone 100mg IV stat then every 6 hours together with 0.9% Saline IV until patient responds.
- Once patient stable Rx Hydrocortisone 20mg orally on waking, then 20mg 5 and 10 hours later switching to maintenance therapy as condition responds
Typical Maintenance Therapy
- Glucocorticoid – Hydrocortisone 10mg on waking, 5mg at lunch and 5mg with evening meal
- Mineralocorticoid – Fludrocortisone 100 micrograms od though not necessary to start this immediately as the higher doses of hydrocortisone have a mineralocorticoid effect
Follow Up
- All patients with newly diagnosed Addison’s should have endocrine clinic review at 6 weeks
- Consider hydrocortisone day curve at least once with renin assessment pre and 120 min post dose – renin should suppress if dose of fludrocortisone adequate
- Thereafter review annually checking postural fall BP, U&E and TFTs
- Ensure patient has steroid card and emergency instructions – see below
Patients on Long Term Steroids
- Patients on long term steroid therapy or known adrenocortical failure should be instructed to double the steroid dose during acute illness or elective surgery.
- Minor procedures eg cystoscopy, give IV hydrocortisone 100mg before the procedure.
- If nil by mouth, not eating, malabsorbing or very unwell, give hydrocortisone 100mg IV immediately followed by 200mg pver 24 hours by continuous infusion.
Patients Undergoing Surgery
- Recommended doses for intra and postoperative steroid cover can be found by clicking this link – Surgical Guidelines for Addison’s Disease and Other Forms of Adrenal Insufficiency[pdf]
Corticosteroid Dose Equivalences
- Prednisolone 5mg is approximately equivalent to
- Hydrocortisone 20mg
- Dexamethasone 0.75mg
- Methylprednisolone 4mg