Chronic disease management - Endocrinology in practice VTS Awayday 10/11/04 Dr Stephen Newell.
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Transcript of Chronic disease management - Endocrinology in practice VTS Awayday 10/11/04 Dr Stephen Newell.
Chronic disease management Chronic disease management - Endocrinology- Endocrinology in practicein practice
VTS Awayday 10/11/04VTS Awayday 10/11/04Dr Stephen NewellDr Stephen Newell
North Street Medical CareNorth Street Medical Care
At NSMC there are ~At NSMC there are ~
12700 patients12700 patients6 partners (5.5 wte)6 partners (5.5 wte)1 GP registrar1 GP registrar1 nurse-practitioner1 nurse-practitioner3 practice nurses3 practice nurses1 health care assistant1 health care assistant
Also ~Also ~
1 practice manager1 practice manager3 administrative staff 3 administrative staff
- deputy practice manager - deputy practice manager (finance)(finance)
- deputy practice manager - deputy practice manager (IM&T)(IM&T)
- practice information officer- practice information officerData entry team of 3Data entry team of 3Reception manager & her teamReception manager & her team
What types of endocrine What types of endocrine problems are there in problems are there in
general practice?general practice?
Diabetes mellitusDiabetes mellitusThyroid problemsThyroid problemsOral contraceptionOral contraceptionMenopause / HRTMenopause / HRTOther sex hormone problemsOther sex hormone problemsFertility problemsFertility problemsPCOSPCOS““Male menopause”Male menopause”CRF-related anaemiaCRF-related anaemiaAddison’s diseaseAddison’s diseasePituitary problemsPituitary problemsDiabetes insipidusDiabetes insipidusHyperparathyroidismHyperparathyroidismCushing’s diseaseCushing’s diseaseConn’s syndromeConn’s syndrome
What is the size of the What is the size of the problem?problem?
At NSMC:At NSMC:
Diabetes mellitus - 403Diabetes mellitus - 403Hypothyroidism - 248Hypothyroidism - 248Sex hormone problemsSex hormone problemsPCOSPCOSCRF-related anaemia - 2CRF-related anaemia - 2Addison’s disease - 4Addison’s disease - 4Pituitary problems - 0Pituitary problems - 0Diabetes insipidus - 1Diabetes insipidus - 1Hyperparathyroidism - 1Hyperparathyroidism - 1Cushing’s disease - 0Cushing’s disease - 0Conn’s syndrome - 0Conn’s syndrome - 0
Other conditions 1Other conditions 1Addison’s disease - 4 patientsAddison’s disease - 4 patientsF 65 – on hydrocortisone and F 65 – on hydrocortisone and fludrocortisone – attends OCH annuallyfludrocortisone – attends OCH annuallyM 37 – also hypothyroid – on HC/FC/T4 - M 37 – also hypothyroid – on HC/FC/T4 - attends Barts annuallyattends Barts annuallyF 62 – also possibly hypothyroid – on F 62 – also possibly hypothyroid – on HC and FC – attends OCHHC and FC – attends OCHF 46 – also hypothyroid – on HC/FC/T4 -F 46 – also hypothyroid – on HC/FC/T4 -attends OCHattends OCHWorry is if they have intercurrent illnessWorry is if they have intercurrent illness
Other conditions 2Other conditions 2
PCOS – number of women at any one PCOS – number of women at any one time where diagnosis is being time where diagnosis is being considered considered
Hirsutism and acneHirsutism and acne
OligomenorrhoeaOligomenorrhoea
InfertilityInfertility
Not just USS – abnormal LH/FSH ratioNot just USS – abnormal LH/FSH ratio
Underlying problem is insulin resistanceUnderlying problem is insulin resistance
Other conditions 3Other conditions 3
CRF-associated anaemiaCRF-associated anaemiaCurrently 2 at NSMCCurrently 2 at NSMCM 65 – CRF due to HT and DM - on M 65 – CRF due to HT and DM - on darbepoetin alfa (Aranesp)darbepoetin alfa (Aranesp)F 60 – CRF secondary to HT – on epoetin F 60 – CRF secondary to HT – on epoetin beta (Neocormon)beta (Neocormon)3 more last year – M 45 had transplant 3 more last year – M 45 had transplant 10/03; M 43 with diabetic nephropathy 10/03; M 43 with diabetic nephropathy died 3/04; F 60 with diabetic nephropathy died 3/04; F 60 with diabetic nephropathy died 10/03 died 10/03
Other conditions 4Other conditions 4
Diabetes insipidusDiabetes insipidusM 22M 22IdiopathicIdiopathicTreated with intranasal desmopressinTreated with intranasal desmopressin
HyperparathyroidismHyperparathyroidismF 70F 70Hypercalcaemia – presented with renal Hypercalcaemia – presented with renal stonesstonesIx shown hyperparathyroidismIx shown hyperparathyroidism
Diabetes and thyroid Diabetes and thyroid disease - what can be disease - what can be
done in practice?done in practice?
DiabetesDiabetesPrimary diabetes mellitusPrimary diabetes mellitus
Main issue is Type 2 DM – generally suitable for care Main issue is Type 2 DM – generally suitable for care
in GPin GP
At NSMC:At NSMC:
Type 2 - 357 - >50 on insulinType 2 - 357 - >50 on insulin
Type 1 - 40 or soType 1 - 40 or so
IGT – 97IGT – 97
Some with gestational diabetesSome with gestational diabetes
Few with secondary diabetes – steroid inducedFew with secondary diabetes – steroid induced
No patients with haemochromatosis at NSMCNo patients with haemochromatosis at NSMC
Epidemiology of DMEpidemiology of DM
One million diabetics in England (1 in One million diabetics in England (1 in
49)49)
1 in 20 people age > 651 in 20 people age > 65
1 in 5 people age > 851 in 5 people age > 85
2% - 3% of population have diabetes2% - 3% of population have diabetes
40-60 patients per General Practitioner40-60 patients per General Practitioner
What are the problems What are the problems in diabetes?in diabetes?
Mortality from CHD 5 times higherMortality from CHD 5 times higher
Mortality from CVA 3 times higherMortality from CVA 3 times higher
Leading cause of renal failureLeading cause of renal failure
Leading cause of blindness in working ageLeading cause of blindness in working age
Second commonest cause of lower limb Second commonest cause of lower limb
amputationamputation
Aims of diabetes NSFAims of diabetes NSF
Identify those with DM and related conditionsIdentify those with DM and related conditions
Improve quality of service for diabetic Improve quality of service for diabetic
patientspatients
Tackle variations in careTackle variations in care
Make best practice the normMake best practice the norm
Reach communities at greatest riskReach communities at greatest risk
Reduce complication ratesReduce complication rates
Eliminate discriminationEliminate discrimination
Symptoms of DMSymptoms of DMPrimary symptomsPrimary symptoms
– Weight lossWeight loss
– ThirstThirst
– PolyuriaPolyuria
Secondary symptomsSecondary symptoms
– Skin sepsisSkin sepsis
– ThrushThrush
– Visual disturbance Visual disturbance
– TirednessTiredness
– NumbnessNumbness
– EtcEtc
Who could be Who could be screenedscreened for DM? for DM?
All with CV disease – done at NSMCAll with CV disease – done at NSMC
Those with BMI > 30Those with BMI > 30
Skin sepsis especially if recurrent – at NSMCSkin sepsis especially if recurrent – at NSMC
Thrush especially if recurrent – at NSMCThrush especially if recurrent – at NSMC
Those with +ve FH of DM – now in NP interviewThose with +ve FH of DM – now in NP interview
Ethnic groups especially at certain agesEthnic groups especially at certain ages
Annual BS in those with IGT or h/o gestational Annual BS in those with IGT or h/o gestational
diabetes – done at NSMCdiabetes – done at NSMC
NSFNSF
Methods to decrease complicationsMethods to decrease complications
– Lifestyle changesLifestyle changes
– How to achieve themHow to achieve them
Clinical targetsClinical targets
– Drugs to achieve theseDrugs to achieve these
Modifiable risk factorsModifiable risk factors
WeightWeight
ExerciseExercise
Alcohol reductionAlcohol reduction
SmokingSmoking
Blood pressureBlood pressure
Glycaemic controlGlycaemic control
General practice adviceGeneral practice advice
Advise onAdvise on
– Healthy eatingHealthy eating
– No snackingNo snacking
– No high fat high energy snacks in houseNo high fat high energy snacks in house
Possibly refer to dieticianPossibly refer to dietician
Possibly weight loss clinicPossibly weight loss clinic
Role for nurse-practitioners/nursesRole for nurse-practitioners/nurses
Clinical targetsClinical targets
BMIBMI 2525
HbA1c HbA1c 7%7%
BPBP 140/80 or below140/80 or below
Total cholesterolTotal cholesterol < 5< 5
LDL cholesterolLDL cholesterol < 3< 3
TriglycerideTriglyceride < 2.3< 2.3
DrugsDrugsOral hypoglycaemic agentsOral hypoglycaemic agents
– BMI > 25 metformin up to 1g tdsBMI > 25 metformin up to 1g tds
– BMI < 25 gliclazide up to 160mg bdBMI < 25 gliclazide up to 160mg bd
Combination therapyCombination therapy
– Metformin + gliclazideMetformin + gliclazide
– Metformin + rosiglitazone up to 8mg odMetformin + rosiglitazone up to 8mg od
– Gliclazide + rosiglitazone up to 4mg odGliclazide + rosiglitazone up to 4mg od
Some will need insulin to try to achieve Some will need insulin to try to achieve
HbA1c targetHbA1c target
New developmentsNew developments
New drugsNew drugs– glitazonesglitazones– repaglinide / nategliniderepaglinide / nateglinide
New insulinsNew insulins– glargineglargine– other insulin analoguesother insulin analogues
AntihypertensivesAntihypertensives
BHS ABCD guidanceBHS ABCD guidance
Step 1 - CCB or Diuretic (older and higher Step 1 - CCB or Diuretic (older and higher
risk)risk)
2 - ACEI + CCB or Diuretic2 - ACEI + CCB or Diuretic
3 - ACEI + CCB + Diuretic3 - ACEI + CCB + Diuretic
4 - Add alpha-blocker e.g. doxazosin4 - Add alpha-blocker e.g. doxazosin
Anti-lipid therapyAnti-lipid therapy
Statins – NSF advises for all diabetics – need Statins – NSF advises for all diabetics – need
to titrate dose to optimise cholesterolto titrate dose to optimise cholesterol
FibratesFibrates
EzetimibeEzetimibe
Cholestyramine – unpleasant to takeCholestyramine – unpleasant to take
Other drugsOther drugs
Aspirin 75mg daily - for hypertensive pts aged Aspirin 75mg daily - for hypertensive pts aged
50 or more with either end-organ damage, 50 or more with either end-organ damage,
Type 2 diabetes or 10-year CHD risk 15% or Type 2 diabetes or 10-year CHD risk 15% or
moremore
Orlistat may be appropriate in some patientsOrlistat may be appropriate in some patients
Achieving good diabetes careAchieving good diabetes care
Responsible health professional - doctor or nurseResponsible health professional - doctor or nurse
Disease register - ITDisease register - IT
Adequate time, numbers of appointments – Adequate time, numbers of appointments –
“diabetic clinic”“diabetic clinic”
Clinical protocol – what management, records, ITClinical protocol – what management, records, IT
Recall system - ITRecall system - IT
Regular audit – new contract Q & O frameworkRegular audit – new contract Q & O framework
Exception coding Exception coding
What is done at the review?What is done at the review?
General health reviewGeneral health review
Diabetic understandingDiabetic understanding
Smoking and alcoholSmoking and alcohol
Glycaemic controlGlycaemic control
Symptoms of complications?Symptoms of complications?
ExaminationExamination
WeightWeight / BMI/ BMI
Blood pressureBlood pressure
Visual acuityVisual acuity
Consideration of retinopathyConsideration of retinopathy
Consideration of foot care and Consideration of foot care and neuropathyneuropathy
InvestigationsInvestigations
Urinalysis for protein – consider Urinalysis for protein – consider
screening for microalbuminuriascreening for microalbuminuria
HbA1cHbA1c
U & E’sU & E’s
Cholesterol / lipid profileCholesterol / lipid profile
Summary of managementSummary of managementGlycaemic controlGlycaemic control
Blood pressureBlood pressure
LipidsLipids
CHD risk factorsCHD risk factors
Screening for long-term complicationsScreening for long-term complications
Individualised educationIndividualised education
Targets for the futureTargets for the future
All suitable for primary care – “not rocket science”All suitable for primary care – “not rocket science”Lots of health gain for relatively straightforward Lots of health gain for relatively straightforward clinical activitiesclinical activities
Issues in diabetes careIssues in diabetes careNeeds lifelong surveillance – need a system for Needs lifelong surveillance – need a system for
registration and recall - ITregistration and recall - IT
Who should do it? At NSMC both nurses & Who should do it? At NSMC both nurses &
doctors involved, working to protocoldoctors involved, working to protocol
How frequent? At NSMC aim is at least twice p.a.How frequent? At NSMC aim is at least twice p.a.
What needs addressing?What needs addressing?
What about non-attenders?What about non-attenders?
What about the house-bound?What about the house-bound?
Thyroid diseaseThyroid disease
When should we do TFTs?When should we do TFTs?
HypothyroidismHypothyroidism
HyperthyroidismHyperthyroidism
Assessment of goitreAssessment of goitre
Much of this is possible in primary careMuch of this is possible in primary care
Thyroid function testsThyroid function testsSymptoms eg tiredness, weight lossSymptoms eg tiredness, weight loss
Type 1 DM – autoimmuneType 1 DM – autoimmune
Menstrual problemsMenstrual problems
Family historyFamily history
Biochemical dysthyroid states Biochemical dysthyroid states without clinical correlation – lab without clinical correlation – lab
TSH TSH up to 4.0 but what about up to 6.0?up to 4.0 but what about up to 6.0?
Goitre 1Goitre 1
May be hyperthyroid, euthyroid or May be hyperthyroid, euthyroid or hypothyroid hypothyroid
Nodular goitre – old distinction between Nodular goitre – old distinction between multi- or single nodules and hot and cold multi- or single nodules and hot and cold nodules less relevant nowadaysnodules less relevant nowadays
Current advice is referral to exclude Current advice is referral to exclude malignancy by FNA malignancy by FNA
Goitre 2Goitre 2
Smooth goitre with hyperthyroid state - Smooth goitre with hyperthyroid state - Grave’s diseaseGrave’s disease
Autoimmune (lab no longer doing Autoimmune (lab no longer doing microsomal antibodies – thyroxine microsomal antibodies – thyroxine peroxidase antibody)peroxidase antibody)
Imaging – USS or radioisotope scan Imaging – USS or radioisotope scan
Treatment is with carbimazole – aplastic Treatment is with carbimazole – aplastic anaemiaanaemia
Goitre 3Goitre 3
Smooth goitre with euthyroid state Smooth goitre with euthyroid state
- physiological – young women- physiological – young women
- effects of medication - hormones- effects of medication - hormones
- (iodine deficiency)- (iodine deficiency)
Smooth goitre with hypothyroid state – Smooth goitre with hypothyroid state – end of autoimmune process – not end of autoimmune process – not uncommonuncommon
HypothyroidismHypothyroidism
About 250 patients at NSMCAbout 250 patients at NSMC
Need replacement therapy with Need replacement therapy with levothyroxinelevothyroxine
Need monitoring with TSHNeed monitoring with TSH
New contract pointsNew contract points
SummarySummaryMuch “endocrinology” is at the heart of medicine and Much “endocrinology” is at the heart of medicine and primary care medicineprimary care medicine
Much of what is needed to assess and manage Much of what is needed to assess and manage endocrine problems is perfectly within the skills of the endocrine problems is perfectly within the skills of the primary health care teamprimary health care team
Many elements of the care of these conditions are Many elements of the care of these conditions are straightforwardstraightforward
Teamwork is extremely importantTeamwork is extremely important
IT is a crucial tool especially for the new GMS contract IT is a crucial tool especially for the new GMS contract of 2004of 2004