Chronic disease management - Endocrinology in practice VTS Awayday 10/11/04 Dr Stephen Newell

North Street Medical Care

At NSMC there are ~ 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 Hypothyroidism 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 OligomenorrhoeaInfertility 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 >50 on insulin Type 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 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 WeightExercise 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% BP140/80 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 FibratesEzetimibe 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? HypothyroidismHyperthyroidism 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 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 - 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