SHOW / EPISODE

Chat GPT patient meets NICE: This is what happened!

18m | 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: 


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”

  1. 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: 

The full NICE Guideline on hypertension (NG136) can be found here:  

 

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 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]   


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 format, we've also got a YouTube version of these episodes. The link is in the episode description.

Alright, let's generate our patient using ChatGPT. It was created using a specific prompt, which is available in the episode description. Let's get started!

Right, so our fictitious patient is Sarah Johnson, a 52-year-old African American woman. Sarah is currently obese with a BMI of 31, and her Blood Pressure is above the target at 142/88 mmHg. 

She has a Medical History of 

  • Type 2 diabetes and Hypertension, which are both poorly controlled as well as
  • Osteoarthritis (which is well-controlled with ibuprofen)
  • Asthma (which is well-controlled with salbutamol inhaler) and
  • Depression (which is well-controlled with fluoxetine)

Her regular Medications are:

  • Metformin 1000 mg twice a day for diabetes
  • Lisinopril 20 mg once a day for hypertension
  • Atorvastatin 40 mg once a day for dyslipidaemia
  • Ibuprofen 400 mg twice a day for osteoarthritis
  • Salbutamol inhaler 2 puffs as needed for asthma
  • Fluoxetine 20 mg once a day for depression

 

Fortunately, she tolerates all medications well without any side effects.

We also have her blood test results, which show the following:

  • An HbA1c: 8.5% (69 mmol/mol) 
  • A Creatinine: 94 µmol/L (1.06 mg/dL)

·      An eGFR: 72 mL/min/1.73m2

(Urea: 5.2 mmol/L (14.67 mg/dL)

Sodium: 139 mmol/L (139 mEq/L)

Potassium: 4.2 mmol/L (4.2 mEq/L))

·      A Total Cholesterol: 6.1 mmol/L (236.39 mg/dL)

(HDL Cholesterol: 1.3 mmol/L (50.1 mg/dL))

·      And an LDL Cholesterol: 4.1 mmol/L (158.57 mg/dL)

(Triglycerides: 1.8 mmol/L (159.27 mg/dL)

TSH: 2.5 mIU/L , 2.5 µIU/mL

Free T4: 15 pmol/L, 1.2 ng/dL

Normal TSH range: 0.4-4.0 mIU/L , 0.4-4.0 µIU/mL

Normal Free T4 range: 9-25 pmol/L , 0.8-2.0 ng/dL ) 

Finally, Sarah's QRISK2 score is 20%, indicating a high risk of developing cardiovascular disease over the next 10 years.

Based on Sarah's medical history, blood test results, and QRISK2 score, I would recommend the following treatment options.

Upon initial examination, this 52-year-old woman presents with a significant amount of multimorbidity, including diabetes, hypertension, dyslipidaemia, osteoarthritis, asthma, and depression. Her obesity is likely exacerbating her conditions, particularly her diabetes, hypertension, and osteoarthritis, and may also be contributing to her depression. Given this, tackling her obesity could potentially have a positive impact on her overall health. However, for the purpose of this case, we will focus on the pharmacological treatment rather than lifestyle interventions.

It is worth noting that the patient's eGFR of 72 indicates stage 2 CKD, which will factor into our treatment decisions. We will assume that there is no significant microalbuminuria since ACR results are not available. Additionally, the patient has a high risk of CVD, so managing her conditions aggressively will also help mitigate this risk.

Moving on to her poorly controlled diabetes, which is currently being treated with metformin 1gr BD and has an HbA1c of 8.5% or 69 mmol/mol, NICE guidelines recommend an SGLT2 inhibitor as step 2 treatment after metformin for patients at high risk of CVD. SGLT2 inhibitors are also beneficial for those with CKD and can promote weight loss, so a good option for this patient. In this case, starting the patient on dapagliflozin 5mg OD initially, and potentially increasing to 10mg daily within four weeks if well-tolerated, would be a suitable option.

It is important to note that SGLT2 inhibitors have been associated with an increased risk of DKA, toe and lower limb amputations, and Fournier's gangrene.

Fournier’s gangrene is a rare but life-threatening type of necrotizing fasciitis, which specifically affects the genital and perineal area. The condition develops rapidly, and symptoms may include fever, severe pain, redness, swelling, and foul-smelling discharge in the affected area. The infection can spread quickly and cause significant tissue damage, leading to sepsis, shock, and organ failure if not treated promptly.

Therefore, it is crucial to educate the patient on DKA symptoms, advise against starting a ketogenic diet while taking an SGLT2 inhibitor, as this increases the risk of DKA, and promote excellent foot care. Additionally, we should advise the patient to seek urgent medical advice if they experience severe pain, erythema, or swelling in the genital or perineal area, especially if there is fever or malaise, as urogenital infection or perineal abscess may precede necrotising fasciitis.

While GLP-1 receptor agonists would be recommended for patients with high CVD risk following the European and American guidelines, the NICE guidelines are more restrictive in this respect. However, an SGLT2 inhibitor is still an effective and straightforward option for this patient.

Now that we have addressed her diabetes, let's move on to her hypertension.

We'll be treating our patient's clinic BP as accurate, in accordance with NICE guidelines. If a patient has hypertension, we don't need to use ABPM or HBPM unless there are concerns, but for patients with diabetes, both sitting and standing BP should be checked due to the risk of postural hypotension, especially if affected by autonomic neuropathy.

Our patient is being treated with an ACEI, lisinopril 20 mg OD, which aligns with NICE guidance. For people with diabetes of any age and ethnicity background, an ACEI or ARB is recommended as first-line treatment, given their protective effect on the kidneys. This is especially important for patients with early stages of CKD like our patient.

I'd like to mention that our patient takes ibuprofen regularly for osteoarthritis. However, this is concerning for two reasons: it can increase blood pressure, and it's a nephrotoxic drug that can worsen CKD. We'll discuss this more when reviewing her osteoarthritis treatment.

Our patient’s BP is 142/88. NICE says that the target BP for people under the age of 80 is below 140/90, making her reading borderline. OK, what would I do?

Our patient's BP is 142/88, with a target BP below 140/90 for people under 80, making her borderline. We are starting her on dapagliflozin for her diabetes so we could see what happens to her BP. SGLT2 inhibitors, due to their diuretic effect, can sometimes have a BP lowering effect, especially when given in combination with antihypertensive agents such as ACEIs. We are probably going to advise this patient to stop or drastically reduce the use of ibuprofen, so that may also have a positive effect on her BP. Because her current BP is not desperately high, we could afford to wait for a few weeks to see if her BP drops spontaneously.

What would I do if the BP remained above target? We know that the dose of lisinopril can be increased to 40 mg and up to a maximum to 80 mg daily. However, we also know that ACEIs and ARBs are generally less effective as monotherapy in patients of African or African-Caribbean family background because these patients have a tendency towards a low renin state and a lower cardiac output, together with increased peripheral resistance.     

So, should we increase her dose of lisinopril or should we start her on a combination with, for example, a CCB? We know that CCBs are the preferred choice for patients of African and African-Caribbean family background if they do not have diabetes.

You can obviously assess her individual circumstances but, in general terms, it would be better to optimise the dose of lisinopril to the maximum tolerated dose and increase it further if possible. ACEIs and ARBs are important in the treatment of chronic kidney disease, and, avoiding these drugs in African-Caribbean patients may inadvertently contribute to worse outcomes for chronic kidney disease in these patients. 

Moving on to her osteoarthritis, we don't know which joints are affected, but we do know her symptoms are well controlled on regular ibuprofen 400mg BD. 

It's important to keep in mind that NICE recommends the following:

A non-pharmacological approach should be attempted first. This involves ensuring that the patient has engaged with physiotherapy and weight loss strategies. If the patient has not received support for this, they should be referred accordingly.

If non-pharmacological management has not been effective, a topical non-steroidal anti-inflammatory drug should be offered for knee osteoarthritis, and it should be considered for other osteoarthritis-affected joints as well. If this treatment has not been tried before, we should recommend it.

If topical treatment is not effective, NICE suggests using oral NSAIDs only at the lowest effective dose and for the shortest possible time. We should review whether to continue treatment regularly. For instance, if the patient is taking ibuprofen regularly, we should assess whether they could cope with intermittent use or a lower dose of, say, 200mg twice daily.

Finally, if the patient requires regular NSAIDs, it should be given with gastroprotection to minimise the risk of upper gastrointestinal bleeding. Therefore, we should be prescribing a proton pump inhibitor, such as omeprazole 20 mg daily, as long as they are taking ibuprofen.

Additionally, NICE advises against the use of paracetamol or weak opioids in osteoarthritis unless they are used infrequently for short-term pain relief and all other treatments have been ineffective or unsuitable.

Now, let’s look at her hyperlipidaemia and her QRISK2 score of 20%. We know that she has no history of cardiovascular disease so we are assessing her for primary prevention. 

We should normally assess patients’ QRISK2 score before starting a statin. After starting a statin, we should focus on the decrease of non-HDL cholesterol with statin therapy instead of the actual QRISK2 score since, by starting a statin, we already know that the patient is at high risk.

Let's take a closer look at the NICE guidelines on this subject:

NICE recommends using the QRISK2 tool to assess cardiovascular risk for primary prevention in individuals up to age 84, including those with type 2 diabetes. However, it's not suitable for people already at high risk due to other medical conditions such as pre-existing CVD, type 1 diabetes, CKD with an eGFR less than 60 and / or  albuminuria, familial hypercholesterolemia, or other genetic causes.

For patients like this one with a QRISK2 score of 10% or higher, NICE recommends offering atorvastatin 20 mg for primary prevention of CVD in addition to lifestyle advice.

After starting atorvastatin 20 mg, we'll recheck the patient's lipids after three months and assess non-HDL cholesterol reduction. If non-HDL cholesterol hasn't decreased by more than 40%, we'll reinforce lifestyle advice and adherence and consider increasing the atorvastatin dose to 40 mg, and later on up to 80 mg, if the patient is at higher risk due to comorbidities.

Regarding this particular patient, we assume that the score is pre-treatment, and even though she is taking 40 mg of atorvastatin, her lipids are still high. We'll need to check her pre-treatment non-HDL cholesterol to see if the 40% drop has been achieved. If not, we may consider increasing the dose to 80 mg daily.

Before we move on, let's quickly summarize what NICE recommends for patients already on statins:

We'll measure liver transaminase enzymes before starting a statin, within three months of starting or increasing the dose, and again at 12 months, unless clinically indicated.

Consider annual non-fasting blood tests for non-HDL cholesterol to inform discussions or annual reviews with the patient.

Do not offer a statin in combination with fibrate, nicotinic acid, or a bile acid sequestrant. However, combining with ezetimibe may be appropriate for patients with primary hypercholesterolemia.

Now, let's turn our attention to the patient's asthma. The history says that her asthma is well controlled with on-demand reliever therapy as needed, in this case, Salbutamol inhaler 2 puffs when required. 

According to NICE guidelines, patients with infrequent, short-lived wheezing and normal lung function can be treated with SABA reliever therapy alone. However, if symptoms indicate the need for maintenance therapy, for example, asthma-related symptoms occurring three or more times a week or symptoms causing waking at night, a low dose of an ICS such as standard beclomethasone 100mcg, one or two inhalations twice daily should be offered.

Moving on to depression, NICE recommends SSRIs such as fluoxetine as the first choice for most people, due to their good safety profile and tolerability. Tricyclic antidepressants, on the other hand, have a higher risk of danger in overdose. Lofepramine is indicated as the TCA with the best safety profile. Antidepressants are usually taken for at least 6 months, and for some time after symptoms remit.

We would need to investigate whether the patient is ready to reduce or stop the medication. NICE advises that withdrawal symptoms can occur with a wide range of antidepressant medication, including tricyclics, SSRIs, and SNRIs. It's also important to note that some commonly used antidepressants, such as paroxetine and venlafaxine, are more likely to be associated with withdrawal symptoms, so particular care is needed with them. However, fluoxetine's prolonged duration of action means that it can sometimes be safely stopped by taking 20mg alternate days for a period of time. For people taking higher doses, such as 40mg to 60mg fluoxetine a day, a more gradual withdrawal schedule should be used.

If a person experiences withdrawal symptoms when they stop taking antidepressant medication or reduce their dose, NICE recommends reassuring them that they are not having a relapse of their depression. It's important to explain that these symptoms are common, and that relapse does not usually happen as soon as medication is stopped or the dose is lowered. Additionally, it's important to note that even if the medication is restarted or the dose is increased, withdrawal symptoms may take a few days to disappear. 

In summary, here are the steps we will be taking:

We will start with dapagliflozin at 5mg and increase to 10mg daily if the patient tolerates it.

We will monitor the patient's blood pressure while on dapagliflozin and consider increasing the dose of lisinopril to 40mg once daily if necessary.

We will encourage the patient to attend physiotherapy and weight management support sessions, while also starting topical NSAIDs and reducing oral ibuprofen as much as possible. Any future doses of ibuprofen will come with gastroprotection, such as omeprazole, and the patient will be warned about the nephrotoxic effects of ibuprofen.

We will check the patient's non-HDL cholesterol levels and consider increasing atorvastatin to 80mg once daily if the current statin therapy has not resulted in a 40% reduction in non-HDL cholesterol.

We will evaluate the patient's asthma control and, if needed, offer low-dose inhaled corticosteroids, such as beclomethasone 100mcg, one or two inhalations twice daily, if the patient experiences asthma-related symptoms three or more times a week or wakes up at night due to asthma symptoms.

Finally, we will discuss the patient's depression and assess whether she is ready to gradually discontinue fluoxetine.

It is important to note that these steps will likely require multiple appointments to complete.

Please keep in mind that this is only my interpretation of the patient's case, and there may be alternative treatment options available.

 We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye  

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