What are the best practices for managing hypertension, diabetes, and skin cancer in Australian general practice?

Best Practices for Managing Hypertension, Diabetes, and Skin Cancer in Australian General Practice

Patient-centered care with multidisciplinary approaches and home blood pressure monitoring are essential for effective management of hypertension, diabetes, and skin cancer in Australian general practice.

Hypertension Management

Blood Pressure Classification and Targets

• Blood pressure should be categorized as non-elevated BP, elevated BP, and hypertension to aid treatment decisions 1
• Target BP for most patients: <130/80 mmHg 2
• For patients with diabetes and hypertension: <140/90 mmHg 1

Assessment Approach

• Use validated automated devices for BP measurement with appropriate cuff size
• Ensure patient is sitting quietly for 5 minutes before measurement
• Avoid caffeine, exercise, and smoking for at least 30 minutes prior to measurement 2
• Home BP monitoring is strongly recommended for better BP control and patient empowerment 1

Treatment Algorithm

1. Lifestyle Modifications (for all patients with BP >120/80 mmHg):

   • DASH-style eating pattern with reduced sodium (<2,300 mg/day)
   • Increased potassium, fruits (8-10 servings/day), vegetables
   • Low-fat dairy products (2-3 servings/day)
   • Weight loss if overweight/obese (5-20 mmHg reduction per 10kg lost)
   • Physical activity (at least 150 minutes/week)
   • Moderate alcohol consumption 1, 2

2. Pharmacotherapy:

   • For BP ≥140/90 mmHg: Initiate single agent + lifestyle therapy
   • For BP ≥160/100 mmHg: Prompt initiation of two drugs or single-pill combination + lifestyle therapy 1

   First-line options:

   • ACE inhibitors or ARBs (preferred for patients with diabetes, CKD, or albuminuria)
   • Thiazide-like diuretics (chlorthalidone, indapamide preferred)
   • Dihydropyridine calcium channel blockers
   • For Black patients: Start with calcium channel blocker or thiazide-like diuretic 1, 2

3. Resistant Hypertension Management:

   • Add mineralocorticoid receptor antagonist when BP remains ≥140/90 mmHg despite three agents
   • Monitor serum creatinine/eGFR and potassium levels at least annually for patients on ACE inhibitors, ARBs, or diuretics 1

Patient Education and Follow-up

• Schedule follow-up within 1 month for BP 130-139/80-89 mmHg
• Schedule follow-up within 2-4 weeks for BP 140-159/90-99 mmHg
• Schedule follow-up within 1-2 weeks for BP ≥160/100 mmHg 2
• Use motivational interviewing to enhance treatment adherence 1
• Implement physician-patient web communications for reporting home BP readings 1

Diabetes Management

Assessment and Targets

• Comprehensive cardiovascular risk assessment using SCORE2 for patients aged 40-69 years
• SCORE2-OP for patients aged ≥70 years 1
• HbA1c target: <7.0% for most patients (individualize based on risk of hypoglycemia)

Treatment Algorithm

1. Lifestyle Modifications:

   • Structured weight loss programs (≥16 sessions over 6 months)
   • Focus on diet, physical activity, and behavioral strategies
   • Target 500-750 kcal/day energy deficit 2

2. Pharmacotherapy:

   • Metformin as first-line therapy (promotes modest weight loss)
   • Consider SGLT2 inhibitors or GLP-1 receptor agonists (cardiovascular benefits)
   • For hypertensive diabetic patients: ACE inhibitors or ARBs preferred 1, 2
   • Avoid combinations of ACE inhibitors and ARBs 1

3. Special Considerations for Pregnant Women:

   • Control BP to 110-135/85 mmHg
   • Avoid ACE inhibitors, ARBs, and spironolactone
   • Safe options: methyldopa, labetalol, and long-acting nifedipine
   • Monitor postpartum patients with gestational hypertension for 72 hours in hospital and 7-10 days after discharge 1

4. Metabolic Surgery:

   • Strongly recommended for patients with BMI ≥40 kg/m² regardless of glycemic control
   • Consider for patients with BMI 35.0-39.9 kg/m² if hyperglycemia is inadequately controlled 2

Skin Cancer Management

Prevention and Early Detection

• Regular skin checks for all patients, especially high-risk groups:
  • Fair skin, blonde/red hair, blue/green eyes
  • History of excessive sun exposure or sunburn
  • Multiple moles or atypical moles
  • Family history of skin cancer
  • Immunosuppression

Screening Recommendations

• Annual total body skin examination for high-risk patients
• Every 2 years for moderate-risk patients
• Teach patients self-examination techniques

Management Approach

• Biopsy suspicious lesions
• Refer to dermatologist or skin cancer clinic for complex cases
• Follow up treated patients according to risk stratification

Implementation in Australian General Practice

Australian GPs report higher usage of evidence-based guidelines compared to other countries 3, with approximately two-thirds routinely using guidelines for managing conditions including diabetes, hypertension, and chronic respiratory diseases.

Effective Implementation Strategies:

• Utilize non-medical staff to educate patients about self-management
• Implement GP reminder systems for test results and guideline-based interventions 3
• Incorporate behavior change concepts beyond the traditional 5As framework (Ask, Assess, Advise, Assist, Arrange) 4
• Focus on patient-centered approaches, as community surveys show patients accept and appreciate preventive care from GPs 5

Common Pitfalls to Avoid

• Relying solely on clinical experience rather than evidence-based guidelines (more common in older GPs) 3
• Using paternalistic approaches rather than collaborative care models 4
• Neglecting psychological factors that influence preventive health behaviors 6
• Failing to target health promotion activities specifically for older patients 7

By implementing these best practices, Australian GPs can effectively manage hypertension, diabetes, and skin cancer while improving patient outcomes and quality of life.