Transcript NSF Diabetes 2002

Chronic disease management
- Endocrinology in practice
VTS Awayday 10/11/04
Dr Stephen Newell
North Street Medical Care
At NSMC there are ~
12700 patients
6 partners (5.5 wte)
1 GP registrar
1 nurse-practitioner
3 practice nurses
1 health care assistant
Also ~
1 practice manager
3 administrative staff
- deputy practice manager
(finance)
- deputy practice manager
(IM&T)
- practice information officer
Data entry team of 3
Reception manager & her team
What types of endocrine
problems are there in
general practice?
Diabetes mellitus
Thyroid problems
Oral contraception
Menopause / HRT
Other sex hormone problems
Fertility problems
PCOS
“Male menopause”
CRF-related anaemia
Addison’s disease
Pituitary problems
Diabetes insipidus
Hyperparathyroidism
Cushing’s disease
Conn’s syndrome
What is the size of the
problem?
At NSMC:
Diabetes mellitus - 403
Hypothyroidism - 248
Sex hormone problems
PCOS
CRF-related anaemia - 2
Addison’s disease - 4
Pituitary problems - 0
Diabetes insipidus - 1
Hyperparathyroidism - 1
Cushing’s disease - 0
Conn’s syndrome - 0
Other conditions 1
Addison’s disease - 4 patients
F 65 – on hydrocortisone and
fludrocortisone – attends OCH annually
M 37 – also hypothyroid – on HC/FC/T4 attends Barts annually
F 62 – also possibly hypothyroid – on
HC and FC – attends OCH
F 46 – also hypothyroid – on HC/FC/T4 attends OCH
Worry is if they have intercurrent illness
Other conditions 2
PCOS – number of women at any one
time where diagnosis is being
considered
Hirsutism and acne
Oligomenorrhoea
Infertility
Not just USS – abnormal LH/FSH ratio
Underlying problem is insulin resistance
Other conditions 3
CRF-associated anaemia
Currently 2 at NSMC
M 65 – CRF due to HT and DM - on
darbepoetin alfa (Aranesp)
F 60 – CRF secondary to HT – on epoetin
beta (Neocormon)
3 more last year – M 45 had transplant
10/03; M 43 with diabetic nephropathy
died 3/04; F 60 with diabetic nephropathy
died 10/03
Other conditions 4
Diabetes insipidus
M 22
Idiopathic
Treated with intranasal desmopressin
Hyperparathyroidism
F 70
Hypercalcaemia – presented with renal
stones
Ix shown hyperparathyroidism
Diabetes and thyroid
disease - what can be
done in practice?
Diabetes
Primary diabetes mellitus
Main issue is Type 2 DM – generally suitable for care
in GP
At NSMC:
Type 2 - 357 - >50 on insulin
Type 1 - 40 or so
IGT – 97
Some with gestational diabetes
Few with secondary diabetes – steroid induced
No patients with haemochromatosis at NSMC
Epidemiology of DM
One million diabetics in England (1 in
49)
1 in 20 people age > 65
1 in 5 people age > 85
2% - 3% of population have diabetes
40-60 patients per General Practitioner
What are the problems
in diabetes?
Mortality from CHD 5 times higher
Mortality from CVA 3 times higher
Leading cause of renal failure
Leading cause of blindness in working age
Second commonest cause of lower limb
amputation
Aims of diabetes NSF
Identify those with DM and related conditions
Improve quality of service for diabetic
patients
Tackle variations in care
Make best practice the norm
Reach communities at greatest risk
Reduce complication rates
Eliminate discrimination
Symptoms of DM
Primary symptoms
– Weight loss
– Thirst
– Polyuria
Secondary symptoms
– Skin sepsis
– Thrush
– Visual disturbance
– Tiredness
– Numbness
– Etc
Who could be screened for DM?
All with CV disease – done at NSMC
Those with BMI > 30
Skin sepsis especially if recurrent – at NSMC
Thrush especially if recurrent – at NSMC
Those with +ve FH of DM – now in NP interview
Ethnic groups especially at certain ages
Annual BS in those with IGT or h/o gestational
diabetes – done at NSMC
NSF
Methods to decrease complications
– Lifestyle changes
– How to achieve them
Clinical targets
– Drugs to achieve these
Modifiable risk factors
Weight
Exercise
Alcohol reduction
Smoking
Blood pressure
Glycaemic control
General practice advice
Advise on
– Healthy eating
– No snacking
– No high fat high energy snacks in house
Possibly refer to dietician
Possibly weight loss clinic
Role for nurse-practitioners/nurses
Clinical targets
BMI
25
HbA1c
7%
BP
140/80 or below
Total cholesterol
<5
LDL cholesterol
<3
Triglyceride
< 2.3
Drugs
Oral hypoglycaemic agents
– BMI > 25 metformin up to 1g tds
– BMI < 25 gliclazide up to 160mg bd
Combination therapy
– Metformin + gliclazide
– Metformin + rosiglitazone up to 8mg od
– Gliclazide + rosiglitazone up to 4mg od
Some will need insulin to try to achieve
HbA1c target
New developments
New drugs
– glitazones
– repaglinide / nateglinide
New insulins
– glargine
– other insulin analogues
Antihypertensives
BHS ABCD guidance
Step 1 - CCB or Diuretic (older and higher
risk)
2 - ACEI + CCB or Diuretic
3 - ACEI + CCB + Diuretic
4 - Add alpha-blocker e.g. doxazosin
Anti-lipid therapy
Statins – NSF advises for all diabetics – need
to titrate dose to optimise cholesterol
Fibrates
Ezetimibe
Cholestyramine – unpleasant to take
Other drugs
Aspirin 75mg daily - for hypertensive pts
aged 50 or more with either end-organ
damage, Type 2 diabetes or 10-year CHD risk
15% or more
Orlistat may be appropriate in some patients
Achieving good diabetes care
Responsible health professional - doctor or nurse
Disease register - IT
Adequate time, numbers of appointments –
“diabetic clinic”
Clinical protocol – what management, records, IT
Recall system - IT
Regular audit – new contract Q & O framework
Exception coding
What is done at the review?
General health review
Diabetic understanding
Smoking and alcohol
Glycaemic control
Symptoms of complications?
Examination
Weight / BMI
Blood pressure
Visual acuity
Consideration of retinopathy
Consideration of foot care and
neuropathy
Investigations
Urinalysis for protein – consider
screening for microalbuminuria
HbA1c
U & E’s
Cholesterol / lipid profile
Summary of management
Glycaemic control
Blood pressure
Lipids
CHD risk factors
Screening for long-term complications
Individualised education
Targets for the future
All suitable for primary care – “not rocket science”
Lots of health gain for relatively straightforward
clinical activities
Issues in diabetes care
Needs lifelong surveillance – need a system for
registration and recall - IT
Who should do it? At NSMC both nurses &
doctors involved, working to protocol
How frequent? At NSMC aim is at least twice p.a.
What needs addressing?
What about non-attenders?
What about the house-bound?
Thyroid disease
When should we do TFTs?
Hypothyroidism
Hyperthyroidism
Assessment of goitre
Much of this is possible in primary care
Thyroid function tests
Symptoms eg tiredness, weight loss
Type 1 DM – autoimmune
Menstrual problems
Family history
Biochemical dysthyroid states
without clinical correlation – lab TSH
up to 4.0 but what about up to 6.0?
Goitre 1
May be hyperthyroid, euthyroid or
hypothyroid
Nodular goitre – old distinction between
multi- or single nodules and hot and cold
nodules less relevant nowadays
Current advice is referral to exclude
malignancy by FNA
Goitre 2
Smooth goitre with hyperthyroid state Grave’s disease
Autoimmune (lab no longer doing
microsomal antibodies – thyroxine
peroxidase antibody)
Imaging – USS or radioisotope scan
Treatment is with carbimazole – aplastic
anaemia
Goitre 3
Smooth goitre with euthyroid state
- physiological – young women
- effects of medication - hormones
- (iodine deficiency)
Smooth goitre with hypothyroid state –
end of autoimmune process – not
uncommon
Hypothyroidism
About 250 patients at NSMC
Need replacement therapy with
levothyroxine
Need monitoring with TSH
New contract points
Summary
Much “endocrinology” is at the heart of medicine and
primary care medicine
Much of what is needed to assess and manage
endocrine problems is perfectly within the skills of the
primary health care team
Many elements of the care of these conditions are
straightforward
Teamwork is extremely important
IT is a crucial tool especially for the new GMS contract
of 2004