Endocrinology and Metabolic Medicine
What this domain tests
Routine diabetes care, thyroid disease, obesity and calcium/vitamin D problems - the conditions managed almost entirely in general practice.
Core rules
- Type 2 diabetes: individualise the target. An HbA1c of 53 mmol/mol (7%) suits most; relax in frailty, tighten in the young if it can be done safely. Metformin remains first-line; add an SGLT2 inhibitor or GLP-1 receptor agonist early where there is established cardiovascular disease, heart failure or chronic kidney disease, independent of HbA1c.
- The annual review is a bundle: HbA1c, blood pressure, lipids, weight, smoking, foot examination, urine albumin-to-creatinine ratio, eGFR and retinal screening. Missing the foot check and the ACR is the commonest omission.
- Hypothyroidism. Titrate levothyroxine on TSH, rechecking six to eight weeks after each change. In pregnancy, dose requirements rise - increase by roughly 25–30% and check TSH each trimester. Do not diagnose on a single borderline result; repeat in six to eight weeks.
- Hyperthyroidism. Suppressed TSH with raised free T4/T3 needs referral; a suppressed TSH with normal free hormones may be subclinical and simply observed.
- Steroid-induced hyperglycaemia is common and treatable; check capillary glucose in anyone starting high-dose prednisolone with risk factors.
- Hypercalcaemia - check corrected calcium, PTH, vitamin D; malignancy and primary hyperparathyroidism are the main causes.
Worked example
A 66-year-old with type 2 diabetes, hypertension and a previous myocardial infarction has an HbA1c of 58 mmol/mol on metformin. Because of established cardiovascular disease, you add an SGLT2 inhibitor with proven outcome benefit rather than simply escalating the metformin dose, and you ensure the annual retinal, foot and renal checks are complete.
Traps
- Chasing HbA1c in a frail older adult at the cost of hypoglycaemia.
- Forgetting the urine ACR and foot examination.
- Adjusting levothyroxine too early, before six weeks.
- Missing steroid-induced hyperglycaemia in a patient starting high-dose prednisolone.