Diabetes in Primary Care Juan Fernando Florido Santana

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=ecJGF5QCuMLQ6hrk
The 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 pressure
2)   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 yourself
D)  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  

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=jzuMxb
There is a YouTube version of this and other videos that you can access here:
·      The NICE GP YouTube Channel: NICE GP - YouTube
Prescribing 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
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Transcript
Hello 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: 
·      Li

"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 pressure
2)   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 yourself
D)  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 | NICE
The full NICE guidance on asthma (NG80) can be found here: 
·      Overview | Asthma: diagnosis, monitoring and chronic asthma man

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a new random case to see 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 remember that guidelines are there to be interpreted and applied using your clinical judgement. What I am doing here is sharing with you what my interpretation would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient.
There is a YouTube version of this and other videos that you can access here:
·      The NICE GP YouTube Channel: NICE GP - YouTube
This podcast also appears in:
 Primary Care guidelines podcast:
·      Redcircle: https://redcircle.com/shows/primary-care-guidelines
·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK
·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148
Prescribing information links:
 
·      Website: DPP-4 inhibitors | Prescribing information | Diabetes - type 2 | CKS | NICE or
·      Download PDF: DPP-4 inhibitors- Prescribing information- Diabetes- type 2- NICE.pdf
·      Website: GLP-1 receptor agonists | Prescribing information | Diabetes - type 2 | CKS | NICE or
·      Download PDF: GLP-1 receptor agonists- Prescribing information- Diabetes- type 2- NICE.pdf
 
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
Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.
In today’s episode I look at a new random diabetic case to see how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; see the description for full information about this:
·     NOT medical advice
·     Intended for health care professionals
·     Only my interpretation of the guideline
·     Use your clinical judgement
 
And as you know, we are focusing only on the pharmacological treatment.
Remember that there is also a podcast version of these videos so have a look in the description below.
Remember that there is also a Youtube version of these episodes so have a look in the episode description.
Right, so let’s generate our random patient. So, we have 45-year-old woman with poorly controlled T2DM with an HbA1c of 60 mmols/mol/7.6%, who has CKD stage 3a with an eGFR of 45 and who is also at high risk of CVD. She is also on triple therapy with Metformin 500 mg BD, Dapagliflozin 10 mg OD and Saxagliptin 2.5mg OD. And finally, she is severely obese with a BMI of 43
So, let’s have a look at the guidelines. As usual I will focus on the NICE guidelines but at the end I will tell you what my interpretation would have been following the EASD / ADA consensus guideline.
Firstly NICE says that we need to consider if rescue therapy is necessary for symptomatic hyperglycaemia with insulin or a sulfonylurea.
And for the clinical presentation we will say that she has no symptoms of diabetes, her obesity is long-standing and being managed with diet, lifestyle advice and bariatric referral. We have excluded other causes of Obesity e.g. hypothyroidism or Cushing’s disease and, because of her age, other causes of CKD such as glomerulonephritis or obstructive nephropathy have also been excluded and she has the diagnosis of diabetic nephropathy.
Right, so what are my thoughts? Firstly, that she is relatively young and she already has a degree of diabetic nephropathy. So we should manage her fairly aggressively to try and improve her diabetic control and improve long term outcomes.
Secondly, it seems quite clear that her main problem is her weight. She is severely obese and already being managed for that. I am v

My name is Fernando Florido and I am a GP in the United Kingdom. With this episode I am starting a new series on Diabetes Guidelines in Practice, looking at how the guidelines could apply to randomly selected clinical cases. By way of disclaimer, remember that guidelines are there to be interpreted and applied using your clinical judgement. What I am doing here is sharing with you what my interpretation would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient. 
This episode also appears in the Primary Care guidelines podcast: 
·      Redcircle: https://redcircle.com/shows/primary-care-guidelines
·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK
·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148
 There is a YouTube version of this and other videos that you can access here: 
·      The NICE GP YouTube Channel: NICE GP - YouTube 
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
Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.
With today’s episode I am starting a new series on Diabetes Guidelines in Practice, looking at how the guidelines could apply to randomly selected clinical cases. By way of disclaimer, remember that guidelines are there to be interpreted and applied using your clinical judgement. I am not giving medical advice here and what I am only doing is sharing with you what my interpretation of the guideline would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient. So, you must always apply your clinical judgement at all times.
 I will also say that I will only focus on the pharmacological treatment of type 2 diabetes. By all means, we will need to advise about diet, exercise, lifestyle etc, but this will not be addressed in these episodes.
Remember that there is also a podcast version of these videos so have a look in the description below.
Remember that there is also a Youtube version of these episodes so have a look in the episode description.
Right, so let’s get started and let’s generate our random patient. For that we are going to spin a random wheel: 
Right, so we have an 85-year-old man, newly diagnosed with type 2 diabetes who is poorly controlled with an HbA1c of 65 mmols or 8.1%, who also has heart failure and CKD stage 3b with an eGFR of 32. In addition, he is underweight, even possibly malnourished to some degree. 
Right, we are going to look at the guidelines and how to apply them. Although I will focus on the NICE guideline, in this case my interpretation and the outcome would be exactly the same if you follow the EASD recommendations or the ADA guideline.
So, what does NICE say that we should do? Firstly, we need to consider if rescue therapy is necessary because, for symptomatic hyperglycaemia, we will need to consider insulin or a sulfonylurea and review when blood glucose control has been achieved. 
So, we are going to assume that he is well and that he has no symptoms of diabetes. He is underweight, but this has been like this for a few years. There hasn’t been rapid weight loss indicating an urgent need for insulin and his urinary ketones are negative. Other causes of unintentional weight loss such as cancer have also been excluded.
So, we are just focusing on the diabetes. His HbA1c is high and has not improved with diet and lifestyle advice, so we should do something. However, given his age, we are not going to manage him too aggressively because, at 85, we are probably more concerned about harmful hypoglycaemia. But he does need treatment and certain diabetic agents could also help his co-morbidities. 
So, next, we must look at his

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I I give my summary of the online course by the EASD learning website “Cardiovascular health and diabetes”.
This podcast will be saved on a website. 
There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:
https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw 
The online course can be found on the EASD learning website:
https://easd-elearning.org/courses/cardiovascular-health-and-diabetes/
 
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
Hello everyone and welcome to the channel. My name is Fernando Florido and I am a GP in the United Kingdom. Today we are going to talk about the link between cardiovascular health and diabetes. The information that I am going to give is based on an online course that is available on the EASD learning website. I highly recommend it and I will put the link to access this course in the episode description. It has seven modules and it is likely to take you between 5 and 7 hours to complete it, depending on how quickly you can process the information. Today’s episode is a summary of the course, which I hope that you will find useful.
 As ever, remember that there is a YouTube version of this episode and the link to the YouTube channel is also in the episode description.
People with type 2 diabetes have twice as many coronary heart disease and strokes as those without it. At first glance, you could think it was too much, but in reality, this is a significant improvement. Previous data indicated that the risk of cardiovascular disease increased by around four to six times. Thus, doubling the risk indicates a significant improvement. Blood pressure control and strict cholesterol treatment are now standard management. And as a result, there are far fewer atherosclerotic events that affect persons with type 2 diabetes. However, as a result, heart failure is now becoming more common.
According to research, people with type 1 diabetes have steadily experienced a decline in CVD, CV mortality, and CV hospitalisation. However, there is still a significant gap between those who have type 1 diabetes and those who do not.
The same research, however, revealed that those with type 2 diabetes had experienced a far bigger improvement, resulting in, at worst, a doubling of the risk of cardiovascular disease (CVD), hospitalisation for CVD, and cardiovascular mortality. And once more, this has been associated with intensive blood pressure and cholesterol management; perhaps this is something that might be applied to patients with type 1 diabetes, where the focus is still often on glycaemia-related issues.
According to other studies, people with type 2 diabetes have an increased chance of developing heart failure. This increased risk is most noticeable in the middle-aged group, perhaps those up to the age of 55, and it appears to be less of an issue as people get older. Therefore, heart failure is now one of the most significant CVD symptoms in persons with type 2 diabetes.
Atherosclerotic disease, coronary heart disease, or strokes are still the earliest signs of vascular illness in the non-diabetic population. However, peripheral vascular disease or heart failure are the most typical early presentations of vascular disease in persons with type 2 diabetes.
Heart failure in diabetics is caused by a number of different ways. First, excess atherosclerotic disease. Also, the heart's ability to operate can then be impacted by hypertension itself. Additionally, a lot of our patients are now recovering from myocardial infarctions, and as time passes, the ventricle develops scarring that exacerbates heart failure. Furthermore, apart from atherosclerosis and hypertension, there is a heart condition known