Medico-Legal Implications of Diabetes, Thyroid Disorders, and Glucocorticoid Therapy

Diabetes Mellitus is an extremely common disorder. The incidence of Type 2 Diabetes Mellitus (DM2) has exploded in parallel with the rising incidence of obesity: so much so that the colloquial name Diabesity has come to designate the combination of the two conditions. Diabetes has many complications— some sudden onset, and others occurring after years of living with the disease.

Sudden onset complications may include diabetic coma due to excessively high blood glucoses, or polar opposite hypoglycemia due to insulin excess. Complications occurring after years of Diabetes include small vessel disease of the eye (diabetic retinopathy), kidney (diabetic nephropathy) and/or nerve (diabetic neuropathy); and larger vessel disease of the brain, heart and lower limbs, which can lead to stroke, heart attack, and/or claudication of the lower limb with or without limb loss.

Sudden Onset Complications

Acute (sudden onset) complications of Diabetes are due to insulin excess— too much injected insulin or not enough food to counteract insulin, or the body’s own insulin production due to sulfonylurea drugs. Caution must be exercised in the presence of kidney dysfunction or kidney failure in a diabetic using insulin or sulfonylureas. Insulin is excreted by the kidneys; therefore, kidney failure means that the same amount of insulin tends to go farther, thereby enhancing potential for hypoglycemia. Other issues related to kidney failure include side effects from the use of multiple of diabetic medications. These medications should either not be used, or doses should be modified (typically downward) in individuals with kidney failure.

Long Term Complications

Chronic (long term) complications of Diabetes typically happen after 20 years’ duration, and are typically multi-factorial. Risk factors include length of diabetes, obesity, smoking, high lipids, high blood pressure and blood glucoses higher than goal range HbA1c of 7. All risk factors need to be addressed early on in the DM’s diagnosis to minimize complications.

Diabetic foot ulcers and gangrene with resultant loss of limb typically occur with pre-existing foot deformities (Charcot joint) in the presence of diabetic peripheral neuropathy. The result can be altered sensation and/or cuts on feet without the patient knowing, and then super-infection. Smoking is major risk factor in diabetic foot ulcers and sequelae. All Diabetics should conduct daily self-foot examinations, alongside regular foot care by podiatry.

Diabetic Medications

All diabetic medications, both oral and by injection, have a host of side effects specific to the medication’s group. Potential side effects are easily referenced and will not be enumerated here.

Thyroid

Thyroid nodules and cancer are being recognized with increasing frequency, due to an uptick of neck imaging for reasons unrelated to Diabetes. It is believed that the rapid increase in incidence of thyroid nodules and cancer does not signal a rise in disease, but rather the uncovering of a pre-existing reservoir of thyroid nodules and cancer. Despite the increased incidence of thyroid cancer, the death rate has remained constant and low over the years.

Because these thyroid nodules are recognized with increasing frequency, and as only 5-10% of them are cancer, each patient must consider watchful wait versus surgical intervention. Moreover, most nodules and cancer of the thyroid are considered a “low risk disease” (i.e low risk for recurrence after surgical removal and low risk for mortality). Therefore it is prudent to make a therapeutic decision between surgical extent, with attendant potential complications, and risk of watchful wait.

One poorly recognized complication of thyroid surgery< is the patient’s inability to replicate “metabolism” despite currently accepted thyroid hormone replacement goals. The result can be profound fatigue and weight gain, with the potential for future development of hypercholesterolemia, hypertension, hyperglycemia and ultimately cardio-vascular disease. Hence it is important to carefully select those who would benefit from thyroid surgery— and carefully select the extent of the surgery!

The well recognized complications of thyroid surgery are injury to the nerve to the larynx (voice box) with resultant hoarseness and loss of specific voice tones important to singers. If both nerves are damaged with resultant paralysis of both vocal cords, a permanent tracheostomy may be needed. Laryngeal nerve injury occurs whether intra-operative nerve monitoring is used or not. Also, if the parathyroid glands in close proximity to the thyroid are damaged, temporary or permanent low calcium may result, with attendant cramping and pins and needles which necessitates treatment with calcium and vitamin D. One complication of vitamin D treatment is the potential for kidney stone development.

Research suggests that thyroid surgery should only be performed by specialized surgeons proficient in thyroid surgery, and not by a surgeon who performs thyroid surgery infrequently. A surgeon who performs a single thyroidectomy annually has an 87% increased complication rate, compared to a surgeon who does over 26 annually.[1]

Disorders of thyroid function are common— particularly an underactive thyroid (hypothyroidism). If not adequately treated with thyroid hormones, the patient in an extreme scenario is in danger of suffering from myxedema coma, a medical emergency with a high fatality rate. Complications of long-term over-treatment with thyroid hormones are atrial fibrillation and its sequelae, which include stroke and bone thinning, which can result in osteoporotic fractures.

A less common abnormality of thyroid function is an overactive thyroid gland. If not adequately treated, this condition may also be associated with atrial fibrillation and thinning of bone and its sequelae. If treated medically with anti-thyroid drugs (ATD), potential side effects of these agents are low white cell count (agranulocytosis) which can result in severe if not fatal infection, as well as liver dysfunction and liver failure.

Glucocorticoids

Glucocorticoids (Prednisone, Decadron, Hydrocortisone) are amazingly effective medications and very powerful anti-inflammatory drugs. However, they are fraught with a host of side effects, including peptic ulcer disease, avascular necrosis of bone and osteoporosis with fractures, as well as psychotic reactions – one of world’s first successful transplant candidates in the early 1970s succumbed to suicide thought to be related to “steroid psychosis.”

[1] Sosa JA et al., Annals of Surgery 1998;228:320-330