Diabetic Challenges in Primary Care

1. Diabetic Challenges in Primary Care Susan Neal Nurse Practitioner North Street Medical Care

2. Introduction • What are the issues? • In the practice • What sort of care? • Where? • Some cases • Key management issues • How might this patient be managed in primary care? What key elements need to be in place?

3. Diabetes – the Challenge in primary Care • One million diagnosed 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 • 41% NHS funding for Type 2 spent on inpatient care for management complications

4. Finding Diabetes • 50% diabetes undiagnosed i.e. 1 million • True onset of diabetes may be 7-12 years before clinical recognition • 25% have evidence of microvascular complications at clinical diagnosis • Value of population screening has not been established • Early interventions of diet & lifestyle amongst at-risk groups is preventative and worthwhile • Focus on “at risk” populations

5. At risk populations • All with CV disease • Those with BMI > 30 • Skin sepsis especially if recurrent • Thrush especially if recurrent • Those with +ve FH of DM • Ethnic groups especially at certain ages • Annual BS in those with IGT or h/o gestational diabetes

6. 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

7. 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

8. However….. • Natural trend of disease is of deteriorating beta cell function • 50% of those on monotherapy require additions at 3 years • 50% of patients with chronic illness do not take medications as prescribed • Achieving & sustaining long term lifestyle change is difficult – over time non medication Rx becomes ineffective

9. Diabetics at NSMC • 12,500 patients • Register of 403 (3.2%) • Type 1 = 40 (10%) • Type 2 = 357(90%) • 97 with IGT • Approx 40 Type 2 are treated with insulin

10. The team ~ 6 partners (5.5 wte) 1 GP registrar 1 nurse-practitioner 3 practice nurses 1 health care assistant

11. Also ~ 1 practice manager 3 administrative staff - deputy practice manager (finance) - deputy practice manager (IM&T) - PIO Data entry team of 3 Reception manager & her team

12. What type of care? • Identification/screening • Methods to decrease complications • Lifestyle changes • How to achieve them • Clinical targets • Drugs to achieve these – achieving concordance • Supporting patients to live with chronic illness

13. Modifiable risk factors • Weight • Exercise • Alcohol reduction • Smoking • Blood pressure • Glycaemic control

14. Clinical targets • BMI 25 • HbA1c 7% • BP 140/80 or below • Total cholesterol < 5 • LDL cholesterol < 3 • Triglyceride < 2.3

15. 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

16. New developments • New drugs • glitazones • repaglinide / nateglinide • New insulins • glargine • other insulin analogues

17. 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

18. 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

19. Anti-lipid therapy • Statins – NSF advises increase dose to try to optimise cholesterol • Fibrates • Ezetimibe • Cholestyramine – unpleasant to take

20. What is done at the review? • General health review • Diabetic understanding • Medication review • Smoking and alcohol • Glycaemic control • Symptoms of complications?

21. Examination • Weight / BMI • Blood pressure • Visual acuity • Consideration of retinopathy • Consideration of foot care and neuropathy

22. Investigations • Urinalysis for protein – consider screening for microalbuminuria • HbA1c • U & E’s • Cholesterol / lipid profile

23. Workload • 344 patients attending DC • Type 1 = 31(78%) seen DC in last 15 months • Type 2 = 317(90%)seen DC in last 15 months • Other 60 mixture of hosp/recidivists/housebound • 896 dedicated diabetic or DC/CVS appts (17 appts weekly) • 2/3 appts per pt annually on average • 4 clinicians

24. Cases from Practice • Consider the clinical management of the patient • What processes and structures need to be in place to deliver good diabetic care to this patient?

25. Case 1 - Alison Age 33, married 2 children – younger one died Nov 02 at 5 yrs No FH DM PMH “borderline” gestational diabetes BMI 20, non smoker, BP 118/70, total chol 4.5, LDL 2.9 Presents June 03 – thirst, polyuria, weight loss. BS 12.7 with ketones++

26. Case 2 - Arthur Age 57, lives alone BMI 52, smoker, BP 136/78, chol 4.7 PMH dilated cardiomyopathy 1999 DM diagnosed Nov 03 on x1 random BS at 19.4 mmols Symptoms reported retrospectively – thirst/polyuria

27. Case 3 - Michael Age 56, divorced, lives alone Hypertensive, smoker, cholesterol 7.2, BMI 30 Diagnosed DM April 04 on x2 FBS – 7.7 Asymptomatic

28. Case 4 – William Age 84, lives with wife Hypertensive, IHD, BMI 22, smoker New patient screen Sept 03 Diagnosed x2 FBS Asymptomatic

29. Case 5 - David Age 54, married, DM diagnosed 1988 BMI 41, non smoker. Prev Hx ^ alcohol New patient 1999, on Metformin Diabetic or alcoholic neuropathy, retinopathy Hypertensive = Lisinopril, Atenolol + Nifedipine Statin and Aspirin added June 2000 Proteinuria 2001

30. Case 6 - Jeremy Age 46, married, HGV driver Presented August 03 with BS 20mmols plus and ketones Symptomatic – weight loss, recent infections, thirst/polyuria, tired Not acutely unwell BMI 24 Devastated by diagnosis and implications

31. Feed back 1 - Alison • Glicazide to max, Rosiglitasone (SE) - symptomatically improved but control not achieved. • Aug 03 commenced Glargine- taught in practice • Nov 03 HBA1c 6.9% • No end-organ damage indicated

32. Feed back 2 - Arthur • Treated Metformin 250mg bd and ^ • Discussions ongoing re smoking, weight, diet, etc • On furosemide & lisinopril for cardiomyopathy • HBA1c improving now at 7.9% • Now for Aspirin and statin

33. Feed back 3 - Michael • Given 3/12 trial diet/lifestyle • Trying to stop smoking • Cholesterol will need Rx • BP target not achieved if diabetic

34. Feed back 4 - William • Diet & lifestyle discussion initially • DNA to clinic 3 months later • At 6 months no dietary change, no compliance with blood tests • Asymptomatic but BS 23mmols/l (HBA1c 9.8%) • Commenced Glicazide 40 mg OD • BP controlled, chol 3.9

35. Feed back 5 - David • Diabetic control fair on 1gm Metformin bd HBA1c 7.4% • BP struggle to control now on Minoxidine • Deteriorating renal function, rising creatinine, ^ 24 hr urinary protein, under urologists

36. Feed back 6 - Jeremy • Became unwell in next few days – commenced insulin • Coped well with technicalities • Marital stress – ED • Work stress • Lifestyle changes very difficult – food etc • Control now good with Novorapid/Lantus • Marital breakdown

37. Processes and Structures • Responsible health professional - doctor or nurse • Use the team • Disease register - IT • Adequate protected time, numbers of appointments – “diabetic clinic” • Clinical protocol – what management, records, IT • Use the stepped guidelines, use the IT to guide practice • Prioritise – life long condition - KISS! • Appropriate use of experts • Support • Recall system - IT • Regular audit – new contract Q & O framework • Exception coding