NICE Guidelines in Endocrine Care

Endocrine System

Type 1 Diabetes (T1D)

Insulin therapy: All patients require basal-bolus insulin regimen (multiple daily injections) or insulin pump therapy.
Blood glucose monitoring: Offer real-time continuous glucose monitoring (rtCGM) or intermittently scanned CGM (isCGM) to all adults and children.
HbA1c target: ≤48 mmol/mol (6.5%), individualise if risk of hypoglycaemia.
Support: Structured education programmes (e.g., DAFNE) should be offered.
Adjuncts: Metformin may be considered in overweight adults.

Type 2 Diabetes (T2D)

Lifestyle interventions: First-line for all—diet, weight loss, and physical activity.
First-line pharmacological therapy: Metformin unless contraindicated.
Further therapy: Add a second drug if HbA1c rises above target, considering SGLT2 inhibitors (especially if cardiovascular or renal disease), DPP-4 inhibitors, sulfonylureas, or GLP-1 agonists.
HbA1c targets: ≤48 mmol/mol (6.5%) for initial therapy; ≤53 mmol/mol (7.0%) for those on drugs that can cause hypoglycaemia.
Annual review: Check HbA1c, blood pressure, renal function, lipids, foot, and eye health.

Gestational Diabetes

Screening: Offer oral glucose tolerance test (OGTT) at 24–28 weeks for at-risk women.
Management:
- Start with diet and lifestyle modification.
- If blood glucose targets not met in 1–2 weeks, offer metformin; add insulin if targets still not achieved.
Targets: Fasting ≤5.3 mmol/L, 1-hour post-meal <7.8 mmol/L, 2-hour post-meal <6.4 mmol/L.
Monitor: Capillary glucose monitoring throughout pregnancy.
Postnatal: Test for persistent diabetes 6–13 weeks postpartum.

Hypothyroidism

Diagnosis: Based on elevated TSH and low free T4.
Treatment: Levothyroxine is first-line; dose titrated to achieve TSH within reference range.
Monitoring: TSH measured 6–8 weeks after dose changes, then every 6–12 months.
Special groups: Increase levothyroxine dose in pregnancy; start low and titrate slowly in elderly or cardiac disease.

Hyperthyroidism

Diagnosis: Suppressed TSH, raised free T4/T3; confirm aetiology with thyroid antibodies and imaging if needed.
First-line therapy: Antithyroid drugs (carbimazole or propylthiouracil [PTU]); PTU preferred in first trimester of pregnancy.
Alternative options: Radioiodine therapy or thyroidectomy for selected patients.
Monitoring: TFTs every 4–6 weeks during treatment, then less often once stable.
Graves’ disease: Consider definitive treatment (radioiodine or surgery) after 12–18 months if relapse.

Thyroid Cancer

Referral: Suspected thyroid cancer should be referred to a specialist multidisciplinary team.
Surgical management: Primary treatment is usually total or near-total thyroidectomy.
Radioactive iodine: Often used post-surgery for ablation.
Thyroid hormone suppression therapy: Levothyroxine to suppress TSH and reduce recurrence risk.
Monitoring: Lifelong follow-up with serum thyroglobulin, neck ultrasound, and TSH suppression.

Assessment

Risk assessment: Use FRAX or QFracture tool for adults at risk (postmenopausal women, men >50, those with previous fractures).
Bone mineral density (BMD): DEXA scan to confirm diagnosis if needed.

Treatment

First-line therapy: Oral bisphosphonates (alendronate or risedronate).
Alternatives: If intolerant/unresponsive to oral bisphosphonates—offer intravenous zoledronate, denosumab (for postmenopausal women at high fracture risk), or teriparatide for severe osteoporosis.
Calcium and vitamin D: Ensure adequate intake before starting pharmacological treatment (usually 1,000 mg calcium and 800 IU vitamin D daily).
Duration: Reassess need for ongoing treatment after 3–5 years.

Fracture Prevention

Falls assessment: Offer multifactorial risk assessment and intervention.
Secondary prevention: Start bone-protective therapy after fragility fracture.
Lifestyle advice: Encourage weight-bearing exercise, smoking cessation, and alcohol moderation.

Monitoring

Adherence: Regular review of therapy and adherence.
Side effects: Monitor for GI symptoms, hypocalcaemia (especially with denosumab), rare adverse effects (osteonecrosis of jaw, atypical femoral fractures).
Bone density: Repeat DEXA as needed (every 3–5 years) for monitoring.

NICE, “Diabetes in adults: diagnosis and management”
NICE, “Type 1 diabetes in adults: diagnosis and management”
NICE, “Diabetes in pregnancy: management from preconception to the postnatal period”
NICE, “Thyroid disease: assessment and management”
NICE, “Osteoporosis: assessing the risk of fragility fracture”
British National Formulary, “Oral antidiabetic drugs”, “Thyroid hormones and antithyroid drugs”, “Bisphosphonates”

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