Dr Asjid Qureshi
MB ChB (Edin), MD (Lon), FRCP (Lon)
London Diabetes and Endocrinology
Consultant
Wellington Hospital and Clementine Churchill Hospital

 
 

London, UK

English / русский / العربية

 

   
 
Home Patients Testimonials Make a referral International Biography Contact us
 
 

 

 
 
Make a referral
Quality of care
Testimonials
Conditions treated
Hospitals
Book appointment
Insurance cover
Secretaries
Embassies
GP SECTION
 Hypercalcaemia
 Hyperthyroidism

 Hypothyroidism
 Thyroid nodule
 PCOS
 Addison`s
 Hypopituitarism
 Obesity
 Diabetes
 Hypertension
 Amenorrhoea
 Cushing`s
 Acromegaly
 Adrenal adenoma
Presentations

 Diabetes
 Endocrinology
 Obesity
 


 

G  E  N  E  R  A  L      P  R  A  C  T  I  T  I  O  N  E  R  S

To arrange a consultation, please call 07733 595 617 or
 
e-mail: nazima.sardar@hcaconsultant.co.uk

 
R  E  F  E  R  R  A  L     G  U  I  D  A  N  C  E
The comments contained below apply to adult endocrinology. When to refer a particular patient to an endocrinology specialist depends on each patient and local arrangements and protocols.
 

H Y P E R C A L C A E M I A

Overview:

  • Common cause: primary hyperparathyroidism
  • Other causes: Familial hypocalciuric hypercalcaemia
  • Be aware of other coexistent causes of hypercalcaemia, e.g. myeloma, sarcoidosis, malignancy
Investigations:
  • Simultaneous bone profile, parathyroid hormone level and vitamin D
Treatment in primary care:
  • Ensure adequate hydration is maintained
  • Stop drugs that may be contributing to hypercalcaemia, .e.g. thiazide diuretics
When to refer:
  • All cases of unexplained hypercalcaemia should be referred to an endocrinology specialist who:
What will an endocrinology specialist do:
  • Will exclude other causes
  • Assess what treatment modality is required and whether parathyroid surgery is indicated

 

 

H Y P E R T H Y R O I D I S M

Overview:

  • Graves disease - younger patients, ophthalmopathy, family history
  • Toxic multinodular goitre - older patients
  • Subacute thyroiditis - viral illness, neck discomfort, subsequent euthyroidism or hypothyroidism
  • Postpartum thyroiditis - onset within 6 months of delivery
  • Toxic nodule
  • Amiodarone - type I and II
Investigations:
  • TSH and free thyroid hormones
  • Repeat thyroid function test
  • Investigations such as TPO antibodies or thyroid isotope scans are not routinely necessary, but may be useful in some patients to determine aetiology
Treatment in primary care:
  • Treatment is usually initially with Carbimazole or propylthiouracil
  • Consider propranolol in clinically toxic patient require immediate symptom relief whilst anti-thyroid medication takes effect
  • Thyroiditis commonly requires symptomatic treatment only
  • Precise dosage of medication of medication should be discussed with an endocrinology specialist as this dependents on thyroid function and clinical state
When to refer:
  • All patients with hyperthyroidism should be referred to an endocrinology specialist
  •  
What will an endocrinology specialist do:
  • Determine the appropriate modality of treatment
  • Graves disease is usually treated with anti-thyroid medication in the first instance
  • Anti-thyroid drugs may be titrated or used in a block-and-replace regime
  • Block and replace therapy entails using anti-thyroid medication to block thyroid hormone production and levothyroxine replacement to normalise TFTs
  • The modality of treatment depends on aetiology, e.g. TMNG are usually best treated definitively with radioiodine or surgery

     

 

H Y P O T H Y R O I D I S M

Overview:

  • Commonly autoimmune aetiology
Investigations:
  • TSH and free thyroid hormones
Treatment in primary care:
  • Usually can be entirely managed in primary care
  • Cautious titration - can precipitate angina in elderly
  • Titrate levothyroxine in 25mcg steps every 3 weeks
  • Final dose depends on initial TSH and weight
  • Approx. average final daily dose in mcg =  wt (kg) x 1.7
  • Recheck TSH at 6-8 weekly intervals of stable dose
  • Aim for TSH in the lower normal range
When to refer:
  • If unhappy to manage in primary care
  • Odd results, e.g. raised TSH, but normal free thyroid hormones
  • Ongoing symptoms despite normalised results
What will an endocrinology specialist do:
  • Stabilise on therapy and discharge to primary care
  • Consider alternatives in patients with odd results

     

 

A   T H Y R O I D   NODULE

Overview:

  • Mostly benign
  • Ask about rapid nodule growth and previous irradiation
  • Mobile or fixed
Investigations:
  • Thyroid function tests
  • Ultrasound
  • Fine needle aspiration
Treatment in primary care:
  • No treatment required in primary care
When to refer:
  • All patients should be referred to an endocrinology specialist
What will an endocrinology specialist do:
  • Fine needle aspiration
  • Review histological report
  • Dependant upon report, patient may be discharged to primary care, undergo repeat FNA, or be referred for surgery

     

 

P O L Y C Y S T I C    O V A R Y    S Y N D R O M E

Overview:

  • 2 of 3 features required for diagnosis (irregular mensus, hyperandrogenism, PCO on imaging)
  • Beware of rapid onset of symptoms
  • Beware of virilising signs (male pattern boldness, cliteromegaly, deepening voice)
Investigations:
  • 9am serum testosterone
  • LH, FSH, prolactin, SHBG
  • Ovarian ultrasound (transvaginal preferred)
Treatment in primary care:
  • Life-style advice and weight control
  • Specific treatment depends on symptoms, e.g. hirsuitism or irregular menstrual cycle
When to refer:
  • All patients with newly suspected PCOS should be referred to an endocrinology specialist
What will an endocrinology specialist do:
  • Exclude other causes
  • Tailor therapy for individual patient
  • Advise on further referral if indicated

     

 

 A D D I S O N ` S    D I S E A S E

Overview:

  • Autoimmune, iatrogenic aetiologies, infiltrative lesion
Investigations:
  • Short synacthen test
  • A random cortisol is not useful
Treatment in primary care:
  • Commencing steroids may interfere with investigations
  • See when to refer
When to refer:
  • Well, but suspected - refer to outpatient clinic
  • Acutely unwell - refer for immediate admission
  • All patients should be seen by an endocrinology specialist
What will an endocrinology specialist do:
  • Short synacthen test
  • Further investigations, e.g. ACTH to confirm Addison`s Disease
  • Stabilise on replacement therapy, e.g. hydrocortisone and Fludrocortisone
  • These patients usually remain under long-term endocrine follow-up

     

 

 H Y P O P I T U I T A R I S M

Overview:

  • Usually iatrogenic (surgery, radiotherapy)
  • Pituitary tumour
Investigations:
  • TSH and free thyroid hormones
  • LH, FSH, oestradiol or testosterone (9am)
  • Prolactin
  • IGF-1
Treatment in primary care:
  • Treatment should be undertaken by an endocrinology specialist
When to refer:
  • Urgent referral to an endocrinology specialist
What will an endocrinology specialist do:
  • Review the above investigation results
  • Assessment of the glucocorticoid axis
  • Manage the glucocorticoid axis before replacing levothyroxine
  • Determine aetiology
  • Stabilise replacement therapy
  • Review detrimental effects of deficiencies
  • These patients usually remain under long-term endocrine follow-up

     

 

O b e s i t y

Overview:

  • Rising prevalence
  • Some may have eating disorders, e.g. comfort eating
  • Some may have psychological issues
  • Life-style is foundation of all treatment
  • NICE has guidance on obesity management
  • Bariatric surgery is the most successful treatment for those with BMI>40kg/m2
Investigations:
  • To exclude secondary causes where appropriate
  • e.g. thyroid function, low dose Dexamethasone suppression test
  • To evaluate co-morbidities, e.g. hypertension, diabetes, hypercholesterolaemia
Treatment in primary care:
  • Life-style advice
  • Psychologist input if indicated
  • Treat co-morbidities
  • Anti-obesity medication, e.g. Orlistat, Sibutramine.
  • Consider bariatric surgery if BMI>40 or >35  plus co-morbidity
When to refer:
  • When wanting to investigate unfamiliar secondary causes
  • For assessment before referral for bariatric surgery
What will an endocrinology specialist do:
  • Exclude secondary causes
  • Assess co-morbidities including obstructive sleep apnoea
  • Advise on best treatment program
  • Assess suitability for bariatric surgery
  • Review impact of surgery post-operatively

     

 

D i a b e t e s

Overview:

  • Type 1 and 2
  • Gestational
  • Genetic - MODY 1, 2, 3, 4, 5, 6 (very strong family history)
  • Pancreatitis
  • Latent Autoimmune Diabetes of Adulthood (LADA) - phenotypically type 1, age of type 2 and usually GAD or islet cell anti-bodies
Investigations:
  • In asymptomatic patients, fasting glucose>7mmol/l on 2 occasions
  • In symptomatic patients, random glucose>11mmol//l
  • Oral glucose test if unhelpful results: Diabetes if 2hr glucose >11.1mmol/l and impaired glucose tolerance if fasting glucose <7 mmol/l and 2hr glucose ≥ 7.8 mmol/l and < 11.1 mmol/l
  • Criteria for OGTT diagnosis for gestational diabetes are different
Treatment in primary care:
  • Education and life-style advice
  • Referral to diabetes specialist nurse, dietician, podiatrist, etc.
  • Type 1 diabetes - 24hrs insulin requirement can be estimated at 40-50% of patients weight in kg
  • Metformin is first line in type 2 diabetes
  • MODY patients (many respond better to life-style + oral agents than insulin)
  • LADA - may develop insulin dependence some years after diagnosis
When to refer:
  • To clarify type of diabetes
  • To advise on management of complications
  • To optimise control if unsuccessful in primary care
  • Type 1 diabetes
  • Gestational diabetes (in conjunction with obstetric team)
  • Suspected LADA or MODY
What will an endocrinology specialist do:
  • Investigate to clarify type of diabetes
  • Advise on managing complications
  • Optimise control
  • Follow up patients with type 1, gestational and genetic diabetes

     

 

h y p e r t e n s i o n

Overview:

  • 5-10% of hypertension is secondary hypertension
  • Conn`s syndrome
  • Phaeochromocytoma
  • Cushing`s syndrome
  • Renal artery stenosis
  • Polycystic kidneys
Investigations:
  • If suspected this is best investigated by an endocrinology specialist
  • Renal artery stenosis is best investigated by nephrologists
Treatment in primary care:
  • Gradual BP control using anti-hypertensive medication
  • Avoid beta blockers before alpha blockade in patients with suspected phaeochromocytoma
  • ACE inhibitors and angiotensin 2 receptor blockers may cause renal impairment in patients with renal artery stenosis
When to refer:
  • If secondary hypertension is suspected
  • If there is hypertension and hypokalaemia
  • Combination of features, e.g. diabetes, hypertension and osteoporosis
  • Young patient with hypertension
  • Poorly controlled hypertension on a number of anti-hypertensive drugs
What will an endocrinology specialist do:
  • Investigate as appropriate, e.g. Aldosterone: renin ratio, low dose Dexamethasone suppression test, MRA
  • Manage endocrine disease accordingly
  • Advise on drugs to avoid
  • Advise regarding onward referral to surgery or nephrology

     

 

A M E N O R R H O E A

Overview:

  • Many causes
  • Polycystic Ovary Syndrome
  • Hyperprolactinaemia
  • Thyroid dysfunction
  • Androgen secreting tumour
  • Hypopituitarism
  • Turner`s Syndrome
  • Anorexia
  • Exercise related
Investigations:
  • 9am serum testosterone, oestradiol, LH and FSH
  • Prolactin
  • Thyroid function
  • Further investigation depends on results of above tests
Treatment in primary care:
  • It is advisable to avoid treatment until endocrinology opinion has been sort, e.g. dopamine agonists can reduce size of pituitary lesions dramatically such they become undetectable on MRI
When to refer:
  • All such patients should be referred to an endocrinology specialist after above investigations
What will an endocrinology specialist do:
  • Determine differential diagnosis
  • Investigate accordingly, e.g. macroprolactin screen, pituitary function tests, karyotype,
  • Advise treatment
  • Dopamine agonists are generally very successful in micro- and macroprolactinomas
  • Advise on hormone replacement
  • Advise on referral to surgery where indicated, e.g. large macroprolactinoma (>1cm) causing rapid visual disturbance
  • Advise on referral to specialist clinics, e.g. Turner`s clinics, infertility

     

 

C u S h i n g ’ s    s y n d r o m e

Overview:

  • Cushing`s disease (pituitary)
  • Other causes of Cushing`s syndrome - iatrogenic (steriod inhalers and creams), adrenal adenoma, ectopic ACTH secretion
Investigations:
  • 24hr urine cortisol
  • A random cortisol is not useful
Treatment in primary care:
  • Discontinue steroid inhalers, creams were possible
  • Reassess
  • Referral to an endocrinology specialist
When to refer:
  • All patients suspected to have Cushing`s disease should be referred to an endocrinology specialist
What will an endocrinology specialist do:
  • Low dose Dexamethasone suppression
  • Possibly high dose Dexamethasone suppression test
  • Possibly a midnight serum cortisol
  • MRI or CT or pituitary or adrenal glands
  • Treat medically with Ketokonazole +/- Metyrapone
  • Refer for surgery as indicated

     

  

a c r o m e g a l y

Overview:

  • Usually pituitary GH secreting tumour
  • Rarely ectopic GH or GHRH secreting tumour
Investigations:
  • IGF-1 (raised in acromegaly)
  • A random GH is not useful
Treatment in primary care:
  • No treatment in primary care is required
When to refer:
  • Patients with suspected acromegaly should all be referred to an endocrinology specialist
What will an endocrinology specialist do:
  • Oral glucose tolerance test with glucose and GH measurements
  • Possibly a TRH test
  • Pituitary MRI scan
  • Advise on referral for neurosurgery

     

 

a D R E N A L    A D E N O M A    ( I N C I D E N T A L O M A )

Overview:

  • 4% prevalence
  • Mostly non-secretory
  • Mostly benign
Investigations:
  • UEs
Treatment in primary care:
  • No treatment in primary care is required
When to refer:
  • All adrenal incidentalomas should all be referred to an endocrinology specialist
What will an endocrinology specialist do:
  • 24hr urine cortisol or low dose Dexamethasone suppression test
  • Aldosterone to renin ration
  • Serum testosterone
  • If non-secretory and <5cm diameter, usually observed
  • If non-secretory and >5cm diameter, usually surgery advised
  • If secretory then surgery is usually advised

     

p r e s e n t a t i o n    H A N D O U T s    f o r    d o w n l o a d

Please click on the links below to download handouts for presentations that Dr Qureshi has given.

E N D O C R I N O L O G Y

Presentation

Year
   
Thyroid function in primary care 2010
   
Calcium, vitamin D and hyperparathyroidism 2010
   
Hirsutism 2009
   
PCOS 2005
   
Thyroid function in the elderly 2002
   
 


 

D I A B E T E S

Presentation

Year
   
New Perspectives in Type 2 Diabetes 2009
   
DPPIV inhibtors; NICE and type 2 diabetes 2009
   
Diabetes; seamless management of patients and achieving targets 2009
   
New therapies in diabetes 2009
   
QoF targets, NICE and Diabetes 2009
   
Diabetes and 2009 QOF targets 2009
 
Radical Diabetes and Working to the New QOF 2009
 
DPPIV inhibitors 2008
   
Glycaemic control update 2008
 
Acute Complications in Diabetes 2008
   
Designer insulins 2005
   
 


 

O B E S I T Y

Presentation

Year
   
Obesity_2 2006
   
Obesity_1 2005
   
 

 

   

 
     
 

 
www.000webhost.com