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

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?

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  patients per General Practitioner  41% NHS funding for Type 2 spent on inpatient care for management complications

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

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

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

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

Diabetics at NSMC 12,500 patients12,500 patients Register of 403 (3.2%)Register of 403 (3.2%) Type 1 = 40 (10%)Type 1 = 40 (10%) Type 2 = 357(90%)Type 2 = 357(90%) 97 with IGT97 with IGT Approx 40 Type 2 are treated with insulinApprox 40 Type 2 are treated with insulin

The team ~  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) - PIO  Data entry team of 3  Reception manager & her team

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

Modifiable risk factors  Weight  Exercise  Alcohol reduction  Smoking  Blood pressure  Glycaemic control

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

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

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

What is done at the review?  General health review  Diabetic understanding  Medication review  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

Workload Workload 344 patients attending DC344 patients attending DC Type 1 = 31(78%) seen DC in last 15 monthsType 1 = 31(78%) seen DC in last 15 months Type 2 = 317(90%)seen DC in last 15 monthsType 2 = 317(90%)seen DC in last 15 months Other 60 mixture of hosp/recidivists/houseboundOther 60 mixture of hosp/recidivists/housebound 896 dedicated diabetic or DC/CVS appts (17 appts weekly)896 dedicated diabetic or DC/CVS appts (17 appts weekly) 2/3 appts per pt annually on average2/3 appts per pt annually on average 4 clinicians4 clinicians

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?

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++

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

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

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

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

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 Symptomatic – weight loss, recent infections, thirst/polyuria, tired Not acutely unwell BMI 24 Devastated by diagnosis and implications

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

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

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

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

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

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

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