Diabetes in Primary Care

By: Juan Fernando Florido Santana
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  • Summary

  • Information for Primary Healthcare workers to understand Diabetes NICE guidance.
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Episodes
  • From AI to Reality: Navigating Multimorbidity in diabetes with NICE Guidelines

    From AI to Reality: Navigating Multimorbidity in diabetes with NICE Guidelines
    Oct 17 2023
    This episode makes reference to guidelines produced by the "National Institute for Health and Clinical Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a fictitious clinical case of a patient created by Chat GPT to see how the NICE guidelines could apply to it.  I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.   There is a YouTube version of this and other videos that you can access here: There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrkThe patient was created using the following Chat GPT prompt: A)   Provide a fictitious patient. Details that you should include are: 1)   patient's medical information including:·      name·      age·      sex·      ethnicity·      BMI·      blood pressure2)   medical history- you must include:·      either one or two of the following poorly controlled conditions: ·      type 2 diabetes·      hypertension ·      dyslipidaemia, ·      Asthma or COPD·      Any number of other medical conditions of your choice, along with whether they are well controlled or not – the medication for these conditions should appear in the next section “medications”Medications given:·      indicate whether the patient is currently taking medication for each medical condition or not.·      If medication is prescribed for a condition, indicate the specific drug(s) and their dosages. You may choose to prescribe one, two, or three drugs for each condition as appropriate.3)   State whether the patient tolerates the medication well or not, and if not, describe the side effect(s) and their severity.4)   blood test results (give a bulleted list but do not number them):·      HbA1c expressed in % and mmol/mol·      renal function tests to include creatinine (expressed first in µmol/L and then in mg/dL), eGFR, urea, sodium, and potassium (expressed in UK units first and then USA units) ·      lipid profile expressed both in mmol/L first and then in mg/dL.·      If the patient has asthma, give the peak flow reading expressed as a percentage of their best or expected reading.·      If the patient has COPD, give the FEV1 reading expressed as a percentage of the predicted reading ·      include any other relevant test results for the patient, expressing them in both UK and USA units. If the patient has hypothyroidism or takes levothyroxine medication, provide the results of their thyroid function tests, including both T4 and TSH levels, in both UK and USA units. Also, include the normal range for these investigations.B)  Provide the patient's cardiovascular risk using the QRISK2 tool, calculated as a percentage of the likelihood of experiencing a cardiovascular event over the next 10 years. C)   At the end of the patient information, ask: 'What treatment recommendations would you make?' – do not make recommendations yourselfD)  Do not include a disclaimer that the patient is fictitious. The NICE hypertension flowcharts can be found here: Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517 Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn  The full NICE Guideline on hypertension (NG136) can be found here:  Website: https://www.nice.org.uk/guidance/NG136 Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus  The full NICE Guideline on Type 2 diabetes (NG28) can be found here:  ·      https://www.nice.org.uk/guidance/ng28  The full NICE guidance on cardiovascular disease risk reduction (CG181) can be found here: ·      https://www.nice.org.uk/guidance/cg181The full NICE guidance on asthma (NG80) can be found here: ·      https://www.nice.org.uk/guidance/ng80 The full NICE guidance on depression in adults (NG222) can be found here: ·      https://www.nice.org.uk/guidance/ng222 The full guidance on obesity (CG189) can be found here:·      https://www.nice.org.uk/guidance/cg189  Thumbnail photos- From: www.freepik.com·      Image by Freepik: Image by a href="https://www.freepik.com/free-photo/excited-young-friends-running-beach_9057871.htm#page=2&query=45%20year%20old%20obese%20woman&position=10&from_view=search&track=ais"Freepik/a  Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   Music provided by Audio Library Plus   Watch: https://...
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    12 mins
  • Real life complex patient: NICE on diabetes, hypertension, hypertriglyceridemia and hypothyroidism

    Real life complex patient: NICE on diabetes, hypertension, hypertriglyceridemia and hypothyroidism
    Jul 30 2023
    My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a real-life case to demonstrate how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals and you must use your clinical judgement. The PDF version of this episode can be found here:·      Colour version: https://1drv.ms/b/s!AiVFJ_Uoigq0l3MBwm5sUpEybW8r?e=xio6pz·      Printer friendly version: https://1drv.ms/b/s!AiVFJ_Uoigq0l3RhABLRM2_pQQOz?e=jzuMxbThere is a YouTube version of this and other videos that you can access here:·      The NICE GP YouTube Channel: NICE GP - YouTubePrescribing information links:·      Website: https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/dpp-4-inhibitors/·      Download PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0liBvuQq8_0Cd-GSz?e=NnL56J·      Website: https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/glp-1-receptor-agonists/·      Download PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0liFRycIZPaVfj-lC?e=a2QTNY Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-throughTranscriptHello everyone and welcome. My name is Fernando and I am a GP in the United Kingdom. We have looked at fictitious patients in previous episodes but, in today’s episode, I am going to look at a real diabetic case to see how the guidelines could apply to it. And as you know, we are focusing only on the pharmacological treatment. If you want to download a PDF version of this episode, the link is in the episode description. Please note that I am not giving medical advice; this is only my interpretation of the guidelines and you must use your clinical judgement Remember that there is also a Youtube version of these episodes so have a look in the episode description.Right, so let’s get straight into it. The details, which have been anonymised, belong to a real patient, so we have 46-year-old man of Asian descent with T2DM who presents with the following: HbA1c is 68 mmols/mol/8.4% (therefore poorly controlled) Cholesterol 5.9 Triglycerides 5.72 HDL 0.97 ·      The path lab has not calculated LDL because triglycerides >4.5 ·      Liver and Renal function tests are normal with an eGFR of 97  Thyroid function tests show a borderline low T4 of 9 (NR 9-19.1) and a raised TSH of 9.88 (NR 0.35-4.94 ACR normal FBC and other routine blood tests were normal.  His BMI is 32, so he is obese His BP is 147/89 His PMH includes: Hypothyroidism T2DM His regular treatment is with: Levothyroxine 200mcg daily Metformin 500 mg TDS He comes to discuss his test results, feeling well in himself. His obesity is long-standing and being managed with diet and lifestyle advice. He has had hypothyroidism for 15 years and, on prompting, he says that he is feeling a little tired So, let’s have a look at the guidelines. As usual I will focus on the NICE guidelines and we will have to looks at the guidelines on type 2 diabetes, hypertension, prevention of cardiovascular disease, and hypothyroidism  Let’s look at his diabetes first. Firstly, NICE says that we need to consider if rescue therapy is necessary for symptomatic hyperglycaemia with insulin or a sulfonylurea. However, he is well and asymptomatic so we do not have to do this. We see that his current dose of metformin 500 mg 3 times a day is not enough to control his diabetes. So, given that his renal function is completely normal.  we should increase the dose to the maximum of 2000mg daily, that is, 1000mg twice a day. However, this is unlikely to be enough to bring his HbA1c of 68 or 8.4% to target. And let’s remember that according to NICE we should strive for the following targets: ·      Lifestyle management only— 48 mmol/mol (6.5%). ·      A single drug not associated with hypoglycaemia (such as metformin) — 48 mmol/mol (6.5%). ·      Drug treatment associated with hypoglycaemia (such as a sulfonylurea): 53 mmol/mol (7.0%). ·      Always adjust for people who are frail, elderly or with other co-morbidities This patient is young and otherwise well so we should aim to treat him aggressively. NICE says that for people not controlled on metformin alone, we should consider dual therapy but which?  We need to assess the person's cardiovascular status and risk to determine whether they have chronic heart failure, established atherosclerotic cardiovascular disease, or are at high risk of developing cardiovascular disease. This patient does not have heart failure or cardiovascular disease but using an online calculator, his 10-year QRISK3 score is 12%. So, being over 10%, we will consider him at high risk of developing CVD.  And NICE says that if the patient is at high...
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    13 mins
  • Chat GPT patient meets NICE: This is what happened!

    Chat GPT patient meets NICE: This is what happened!
    Apr 28 2023
    "Chat GPT Patient Meets NICE - Here's What Happened!" My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a complex random clinical case of a patient created by Chat GPT to see how the NICE guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this podcast is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  There is a YouTube version of this and other videos that you can access here: The NICE GP YouTube Channel: NICE GP - YouTube ChatGPT prompt to create a patient:  A)   Provide a fictitious patient. Details that you should include are: 1)   patient's medical information including:·      name·      age·      sex·      ethnicity·      BMI·      blood pressure2)   medical history- you must include:·      either one, two or three of the following poorly controlled conditions: ·      type 2 diabetes·      hypertension ·      dyslipidaemia, ·      Any number of other medical conditions of your choice, along with whether they are well controlled or not – the medication for these conditions should appear in the next section “medications”Medications given:·      indicate whether the patient is currently taking medication for each medical condition or not.·      If medication is prescribed for a condition, indicate the specific drug(s) and their dosages. You may choose to prescribe one, two, or three drugs for each condition as appropriate.3)   State whether the patient tolerates the medication well or not, and if not, describe the side effect(s) and their severity.4)   blood test results (give a bulleted list but do not number them):·      HbA1c expressed in % and mmol/mol·      renal function tests to include creatinine (expressed first in µmol/L and then in mg/dL), eGFR, urea, sodium, and potassium (expressed in UK units first and then USA units) ·      lipid profile expressed both in mmol/L first and then in mg/dL.·      include any other relevant test results for the patient, expressing them in both UK and USA units. If the patient has hypothyroidism or takes levothyroxine medication, provide the results of their thyroid function tests, including both T4 and TSH levels, in both UK and USA units. Also, include the normal range for these investigations.B)  Provide the patient's cardiovascular risk using the QRISK2 tool, calculated as a percentage of the likelihood of experiencing a cardiovascular event over the next 10 years. C)   At the end of the patient information, ask: 'What treatment recommendations would you make?' – do not make recommendations yourselfD)  Do not include a disclaimer that the patient is fictitious. The NICE hypertension flowcharts can be found here: Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517 Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn  The full NICE Guideline on hypertension (NG136) can be found here:  Website: https://www.nice.org.uk/guidance/NG136 Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus  The full NICE Guideline on Type 2 diabetes (NG28) can be found here:  ·      Overview | Type 2 diabetes in adults: management | Guidance | NICE The full NICE guidance on osteoarthritis (NG226) can be found here: ·      Overview | Osteoarthritis in over 16s: diagnosis and management | Guidance | NICE The full NICE guidance on cardiovascular disease risk reduction (CG181) can be found here: ·      Overview | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICEThe full NICE guidance on asthma (NG80) can be found here: ·      Overview | Asthma: diagnosis, monitoring and chronic asthma management | Guidance | NICE The full NICE guidance on depression in adults (NG222) can be found here: ·      Overview | Depression in adults: treatment and management | Guidance | NICE Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   Music provided by Audio Library Plus  Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through Transcript  Today we'll be exploring the world of NICE guidelines and how they apply to a complex patient. But this isn't just any patient - this one was randomly created by the latest buzz in town, ChatGPT. Our focus will be on the pharmacological treatment.Hello and welcome, I'm Fernando Florido, a GP in the United Kingdom.Before we dive in, I'd like to make it clear that I'm not here to provide medical advice. Rather, I'll be sharing my interpretation of the guidelines with fellow healthcare professionals. Please always use your clinical judgement when treating your patients.If you prefer a video ...
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    19 mins

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