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