Clinical Pharmacy · Short notes

Diabetes and Endocrine Therapeutics: Short Notes & Cheat Sheet

Diagnosing and treating diabetes, hypoglycaemia, DKA, sick-day and Ramadan advice, and managing thyroid and adrenal disorders.

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Short notes

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Choosing the next drug after metformin

Pick the second drug by the patient's main problem, not by HbA1c alone.

Diagnosis and targets

Diabetes is diagnosed by fasting glucose ≥ 126 mg/dL (7.0 mmol/L), 2-hour OGTT ≥ 200 mg/dL (11.1 mmol/L), HbA1c ≥ 6.5%, or a random glucose ≥ 200 mg/dL with symptoms.
Prediabetes: fasting glucose 100–125 mg/dL, OGTT 140–199 mg/dL or HbA1c 5.7–6.4%.
The usual HbA1c target is below 7%, relaxed (e.g. below 8%) for frail elderly patients or those at high risk of hypoglycaemia.
Screen yearly for complications: eyes, feet, urine albumin-to-creatinine ratio, eGFR and lipids.

Type 2 diabetes treatment

Start with lifestyle change plus metformin, unless it is contraindicated.
With established cardiovascular disease, heart failure or CKD, add an SGLT2 inhibitor or GLP-1 agonist with proven benefit, whatever the HbA1c.
When weight loss is a priority, GLP-1 agonists (or tirzepatide) are most effective. When cost is the priority, a sulfonylurea (gliclazide) or pioglitazone is used.
Start insulin when HbA1c is very high (above about 10%), glucose is ≥ 300 mg/dL, or the patient is losing weight with symptoms.
Basal insulin is usually started at 10 units (or 0.1–0.2 units/kg) at night and adjusted every few days according to fasting glucose.

Emergencies, sick days and Ramadan

Hypoglycaemia is glucose below 70 mg/dL. Rule of 15: give 15 g fast-acting carbohydrate, recheck after 15 minutes and repeat if needed. If unconscious, give IM glucagon or IV dextrose.
Sulfonylurea-induced hypoglycaemia can recur for many hours, so the patient needs observation.
DKA: IV 0.9% saline, fixed-rate IV insulin (0.1 units/kg/hour), potassium replacement, and dextrose once glucose falls below about 250 mg/dL.
Sick-day rules: never stop insulin. Temporarily hold metformin, SGLT2 inhibitors, ACE inhibitors/ARBs, diuretics and NSAIDs when dehydrated.
Ramadan: move metformin doses to iftar and sehri, prefer gliclazide over glibenclamide, reduce basal insulin, and break the fast if glucose is below 70 or above 300 mg/dL.

Thyroid and adrenal

Hypothyroidism: levothyroxine about 1.6 µg/kg/day (start at 25–50 µg in the elderly or those with heart disease). Check TSH after 6–8 weeks. The dose usually needs to rise by about 25–30% in pregnancy.
Hyperthyroidism: carbimazole or methimazole (PTU in the first trimester), with a β-blocker for symptoms. Radioactive iodine or surgery for definitive treatment.
Thyroid storm: PTU, then iodine an hour later, plus propranolol and hydrocortisone.
Addison's disease: hydrocortisone in divided doses plus fludrocortisone; double the dose when ill. Adrenal crisis: IV hydrocortisone 100 mg and fluids.

Cheat sheet

High-yield facts in one place. Cover the right-hand column and test yourself.

Diagnostic thresholds

Test	Diabetes · prediabetes
Fasting glucose	≥ 126 · 100–125 mg/dL
2-h OGTT	≥ 200 · 140–199 mg/dL
HbA1c	≥ 6.5% · 5.7–6.4%
Random glucose + symptoms	≥ 200 mg/dL

Sick-day drugs to pause (SADMANS)

Drug	Why pause when dehydrated
Sulfonylureas	Hypoglycaemia if not eating
ACE inhibitors	Acute kidney injury
Diuretics	Dehydration, acute kidney injury
Metformin	Lactic acidosis
ARBs	Acute kidney injury
NSAIDs	Acute kidney injury
SGLT2 inhibitors	Euglycaemic DKA, dehydration

Memory aids

Rule of 15: 15 g fast sugar, wait 15 minutes, recheck, repeat.
SADMANS: Sick-day pause list: Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors. Insulin is never stopped.

Exam traps

Insulin should never simply be stopped during illness, even if the patient is not eating; the dose is adjusted instead.
Glibenclamide carries more hypoglycaemia risk than gliclazide, especially in the elderly and during Ramadan.
In thyroid storm, iodine is given after the thionamide, so it does not feed new hormone synthesis.
SGLT2 inhibitors can cause euglycaemic DKA, so ketones must be checked even if glucose looks normal.

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