Correspondence: Microalbuminuria; Paracetamol; Diabetes tests

Dr Rick Cutfield Diabetologist, responds...

I recommend annual screening of microalbumin despite use of an ACE inhibitor. Worsening microalbuminuria will trigger a response to watch blood pressure and glucose control more closely, perhaps adjusting the BP target downwards eg <120/80. It may also trigger a response to emphasise drug compliance.

It is also helpful to see stability or improvement of microalbumin levels while on treatment � to patient and doctors.

Microalbuminuria that steadily progresses to proteinuria should prompt consideration of a referral to diabetes or renal specialist.

Please note: If patients have microalbuminuria - aspirin and statins are mandatory to reduce cardiovascular risk.

Dr David Reith Paediatrician, reponds...

Paracetamol can be used for the treatment of pain and fever in infants less than 2 months of age. Although in the past paracetamol was used guardedly in this age group, there is recent data on pharmacokinetics, efficacy and safety in the neonatal age group.^1,2 Glucuronidation of paracetamol, the major pathway of elimination in older children and adults, appears to be reduced in neonates resulting in reduced clearance in this age group. This means that doses need to be given less frequently for the same effect, and also to avoid toxicity.

Paracetamol toxicity has been described in neonates following excessive dosing and it is important to communicate dosing instructions clearly to parents and caregivers.³ The BNF for children advises oral doses for term neonates of 20 mg/kg as a single dose, then 15�20 mg/kg every 6 to 8 hours as necessary, up to a maximum daily dose of 60 mg/kg.⁴ Over 3 months of age, divided doses of up to 90 mg/kg/day may be given in otherwise healthy children.

1. Anderson BJ, Pons G, Autret-Leca E, et al. Pediatric intravenous paracetamol (propacetamol) pharmacokinetics: a population analysis. Paediatr Anaesth. 2005 Apr;15(4):282�92.
2. Allegaert K, de Hoon J, Verbesselt R, et al. Intra- and interindividual variability of glucuronidation of paracetamol during repeated administration of propacetamol in neonates. Acta Paediatr. 2005 Sep;94(9):1273�9.
3. Walls L, Baker CF, Sarkar S. Acetaminophen-induced hepatic failure with encephalopathy in a newborn. J Perinatol. 2007 Feb;27(2):133�5.
4. BNF for Children 2005. BMJ Publishing Group, Royal Pharmaceutical Society of Great Britain, RCPCH Publications Ltd.

Dr Gary Sinclair (Clinical Director Primary Care and Chronic Care Management, Counties Manukau DHB) responds...

The Diabetes CCM programme was initially developed in 2001 based on an expanded version of the Chronic Care Model developed by Ed Wagner, using a Kaiser approach to delivery of service. As part of the delivery system redesign, information systems and decision support, CMDHB developed �templates� in locally used patient management systems for collection of the disease specific dataset for communication to a central �integrated care� server which collects data for decision support, exception reporting and general programme management.

At that time the national guidelines for diabetes and cardiovascular disease were in development, and so the clinical dataset (including required laboratory investigations) was derived on advice from a local programme disease specific advisory group (DSAG) which included physicians from both primary and secondary care in CMDHB.

Given that the CCM programme is targeted at high acuity patients (all patients have to satisfy entry criteria demonstrating poor control of clinical management indicators or signs of advanced end organ damage), and to facilitate ease of programme implementation, the DSAG advised on regular three monthly testing for HbA_1c, serum creatinine and albumin-creatinine ratio, lipids being tested every six months.

With the release of national guidelines for the management of diabetes and cardiovascular disease, we noted some variance between guideline based �best practice� and the CCM programme requirements for some of our enrolled patients.

We are currently engaged in the process of integrating the CCM programmes for diabetes and cardiovascular disease, based on the current national guidelines and incorporating requirements for the �Get Checked 2� dataset. At this stage we anticipate migrating to the new platform early in 2008. The new programme will have the IT capability to advise on different management for different individuals (including laboratory investigations) based on individual patient scenarios.

The DSAG has discussed the present laboratory testing protocols, and support the best practice guidelines articulated by bpac^nz. However in the interests of maintaining programme integrity, DSAG have advised that we continue collecting lab data at the afore mentioned intervals relying on the judgement of our clinicians regarding actual testing intervals until the decision support platform is deployed.