Chronic Disease Management when Resources are Limited

Transcription

1 Chronic Disease Management when Resources are Limited Paul R. Larson MD, MS, DIM&PH Director, Global Health Education UPMC St. Margaret Family Medicine Residency Pittsburgh, PA Disclosures I have no financial interest or relationship with any pharmaceutical company or manufacturer of any commercial product or service discussed in this presentation You will be able to Diagnose and treat three common chronic diseases in the content of limited resources Reference resources to aide in the diagnosis and treatment of these diseases Hospital formulary Disease management protocols 1

2 Instructions Please divide into groups of 4-5. Read the assigned cases and discuss the associated questions. Discussion Questions What testing is available? What treatment options are available? What are the clinical guidelines? What are the goals of care? Baptist Medical Center (BMC) Nalerigu, Ghana 2

3 A busy clinic day Case 1: 18 February, 2017 Abibatu is a 65-year-old man with a past medical history of hypertension (HTN), chronic back pain and gastroesophageal reflux (GERD) presenting for review. He reports no new complaints. A quick review of his chart reveals regular visits approximately every March, June, and October at which time he has received 2 month supplies of BDFZ/Bendro 2.5-5mg daily, Nifedipine 20mg daily and a variety of anti-inflammatory pain medications. Documented blood pressure readings include 120/80; 115/80; 140/80; 150/90; 124/80; 130/80. Today the triage reading is 140/80 and he ran out of meds several months ago. Hypertension - Protocol First line is bendroflumethazide (thiazide diuretic we have), 2.5 or 5 mg (no evidence that 5 mg lowers better than 2.5). Beta-blocker is atenolol or propanolol ACE inhibitor is lisinopril Calcium channel blocker is Nifedipine 20 mg BID. Lasix, aldactone, and aldomet are also available. 3

4 Hypertension - Guidelines South African Hypertension Guidelines 2011, Revised 2014 Target <140/90 Lower targets no longer recommended Lifestyle Modification and education Control other CV risk factors Medication: Thiazide, CCB, ACE/ARB Hypertension Goals Risk Reduction: Stroke Heart failure Chronic kidney disease Coronary heart disease PQRS Quality Measure %>18-85; Dx HTN & BP<140/90 %>18; Screened for HTN with documented f/u Case 2: 19 February, 2017 Zaharah is a 41-year-old female with past medical history of diabetes mellitus. Zaharah lives some distance from the hospital but comes twice daily at approximately 8am and 6pm for random blood sugar readings. Between November 24 th and January 24 th, she received 30 units of 70/30 premix in the morning and 10 units in the evening. But, for the past month her blood sugar before breakfast has ranged from mmol/l. Due to this instability she has received her morning insulin based on a sliding scale. Zaharah does not eat on a regular schedule and frequently misses meals. Her blood sugar is currently 2.6 mmol/l but last night you remember it was 30 something. 4

5 Diabetes Mellitus - Protocol Glibenclamide is the sulfonylurea of choice, up to 10 mg BID. Metformin is available. Insulin availability is variable. Regular insulin or NPH are usually what is available, and patients may be sent home with insulin to be kept in a shaded place. Monitoring is with RBS (random blood sugar) or FBS (fasting). Diabetes - Guidelines No Specific Africa Guidelines Education: healthy diet, physical activity, normal weight and no tobacco use Medication: Metformin preferred Add: Oral agents, GLP-1 agonist or insulin Diabetes - Goals Risk Reduction Stroke Heart failure Chronic kidney disease Coronary heart disease / Heart attacks Blindness Limb amputation PQRS Quality Measure Poor Control: %>18; Dx DM & HbA1C >9% 5

6 Case 3: 20 February, 2017 Adisah Imow is a 55-year-old female with a past medical history of asthma. She has been admitted frequently for acute asthma exacerbations and pneumonia. On outpatient routine review she is generally prescribed salbutamol tablets, an oral antibiotic, prednisone, or a fluticasone-salmeterol inhaler. Last night Adisah was admitted to female ward for the second time in 3 weeks due to a cough, chest pain, and difficulty breathing. She is currently wheezing but has no fever. She has been ordered IV aminophylline and salbutamol tablets. Asthma - Protocol Nebulization with albuterol is available. For severe cases, aminophylline 250 mg IV Q6 may be given. In less severe cases, Aminophylline 200 mg PO QID is available. In young children, the dose is 50 mg IV/PO QID; older children, 100 mg IV/PO QID. For exacerbations, prednisone 1 mg/kg/day PO x 5 days is available. Dexamethasone IV is available but has never been shown more effective than oral steroids. Asthma - Guidelines South African Thoracic Society 2007, Revised 2013 Acute Monitor lung function (peak flow) & oxygen saturation 1st Oxygen, Beta-2 Agonist, glucocorticosteroids 2nd Magnesium sulphate or Aminophylline Chronic SA Fam Pract 2007:49(5) Inh SABA / +ICS / +LABA / +Montelukast or Theophylline 6

7 Asthma - Goals Reduce: Frequency of Acute asthma exacerbation Emergency room treatment or admission to hospital Requirement for glucocorticosteroid Hypoxemia and airflow obstruction, Restore lung function and plan to avoid relapse PQRS Quality Measure %>5: Dx Persistent Asthma on long-term control medication References Cardiovasc J Afr Mar-Apr;26(2):90. S Afr Med J Feb;102(2):94. S Afr Med J May;103(5):334. SA Fam Pract 2007:49(5) 7