Explore every episode of the podcast Primary Care Guidelines
| Title | Pub. Date | Duration | |
|---|---|---|---|
| Podcast - NICE News - August 2026 | 13 Sep 2026 | 00:07:51 | |
The video version of this podcast can be found here: · https://youtu.be/HJBi-1DAS60 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in August 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
Tracks:
00:00 – Introduction and welcome 00:25 – Allergic rhinitis 03:22 – Acne vulgaris 07:21 – Thank you and good-bye
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for August 2026 can be found here:
· https://www.nice.org.uk/guidance/published?from=2026-08-01&to=2026-08-31
The updated NICE technology appraisal on 12 SQ-HDM SLIT for treating allergic rhinitis and allergic asthma caused by house dust mites [TA1045] can be found here: · https://www.nice.org.uk/guidance/ta1045/ The updated NICE technology appraisal on 12 SQ-Bet SLIT for treating moderate to severe allergic rhinitis or conjunctivitis caused by tree pollen in people 5 years and over [TA1087] can be found here: · https://www.nice.org.uk/guidance/ta1087
The updated NICE guideline on Acne vulgaris: management [NG198] can be found here: · https://www.nice.org.uk/guidance/ng198
The new updated NICE guideline on Heavy menstrual bleeding: assessment and management [NG88] can be found here: · https://www.nice.org.uk/guidance/ng88 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in August 2026, focusing on what is relevant in Primary Care only. This month, we have only two areas to cover: updated guidance allergic rhinitis and conjunctivitis, and an update on acne vulgaris. Right, let’s jump into it. There are two updates on allergic rhinitis that are very similar, so let’s take them together.They both involve sublingual immunotherapy for allergic rhinitis, and both updates expand the eligible population to include younger children. The first one is Acarizax, for house dust mite allergic rhinitis. It was recommended for people aged 12 to 65 and it now also includes children aged 5 to 11 years. The second is Itulazax, for allergic rhinitis or conjunctivitis caused by tree pollen from the birch group.It was recommended for adults and it now includes people aged 5 years and over. In both cases, the symptoms need to be moderate to severe, the diagnosis needs to be supported by a positive sensitisation test, such as skin prick testing or specific IgE, and symptoms must persist despite symptom-relieving treatment. So, what are these treatments? As we said Acarizax is for house dust mite allergic rhinitis, while Itulazax is for birch-related tree pollen allergic rhinitis or conjunctivitis. Both are sublingual immunotherapy tablets. Acarizax contains house dust mite allergen extract and Itulazax contains birch pollen allergen extract. Both are placed under the tongue and work by gradually desensitising the immune system to the relevant allergen. So these are not just another antihistamine or nasal spray. They are allergen immunotherapy treatments, aiming to modify the immune response itself rather than simply providing temporary symptom relief. In usual care, allergic rhinitis, with or without conjunctivitis, is treated first with standard medicines, such as antihistamines and intranasal corticosteroids. These immunotherapy treatments come later, when symptoms remain moderate to severe and persistent despite standard treatment. It is worth saying that Acarizax is not recommended for allergic asthma, even when house dust mite allergy may be triggering it. Having asthma does not necessarily prevent someone from receiving Acarizax for rhinitis, but the NICE recommendation is not for asthma treatment itself. Itulazax is for tree pollen allergy from the birch group, and it can be given for allergic rhinitis, conjunctivitis, or both. Although these may not be treatments that GPs routinely prescribe, they are useful to know about because we will see children and adults with persistent allergic rhinitis despite antihistamines and nasal steroids, and , in those cases, these options may be relevant for specialist referral or discussion. Let’s now look at the updated NICE guideline on acne vulgaris. This update is quite focused and NICE has amended references to polycystic ovarian syndrome, because this condition is now called polyendocrine metabolic ovarian syndrome, or PMOS. This name change was agreed by global consensus and reflects that this is a whole-body metabolic and hormonal condition, not a disease defined by ovarian cysts. Additionally the recommendation on triamcinolone injections has been withdrawn, but this is relevant to specialist care. For us in primary care, the main acne management is otherwise unchanged so let’s give it a very quick overview. For drug treatment, NICE recommends a 12-week course of one first-line treatment option, depending on severity and patient preference. For many patients, we can use a fixed-combination topical treatment, such as adapalene with benzoyl peroxide, or tretinoin with clindamycin. Adapalene with benzoyl peroxide has the advantage that it does not contain an antibiotic, but for mild to moderate acne, we can also consider benzoyl peroxide with clindamycin. For moderate to severe acne, we should usually use a topical treatment together with an oral antibiotic, either lymecycline or doxycycline. If the person cannot use lymecycline or doxycycline, we can consider trimethoprim or an oral macrolide, such as erythromycin. Topical benzoyl peroxide alone can also be considered if the other options are contraindicated, or if the person wants to avoid topical retinoids or antibiotics. We should not use topical antibiotic monotherapy, oral antibiotic monotherapy, or a combination of topical and oral antibiotics, because of the risk of antimicrobial resistance. We should also explain that treatment can take 6 to 8 weeks before improvement become noticeable. Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning pregnancy, so effective contraception or an alternative treatment is needed for people of childbearing age. If hormonal contraception is wanted, we should consider the combined oral contraceptive pill in preference to the progestogen-only pill. We should then review first-line treatment at 12 weeks. If the treatment includes an oral antibiotic and the acne has cleared, we should consider stopping the antibiotic but continuing the topical treatment. If the acne has improved but has not completely cleared, we should consider continuing the oral antibiotic with the topical treatment for up to 12 more weeks. We should only continue antibiotic-containing treatment for more than 6 months in exceptional circumstances, with review every 3 months, and we should stop the antibiotic as soon as possible. We should refer if there is diagnostic uncertainty, acne conglobata, or nodulo-cystic acne. We should also consider referral if acne is not responding to treatment, or if acne is causing scarring, persistent pigmentary change, or significant psychological distress. For PMOS and acne, we should use a first-line acne treatment option first. If that is not effective, we should consider adding co-cyprindiol or an alternative combined oral contraceptive pill. For people using co-cyprindiol, we should review at 6 months and discuss continuation or alternative options. We should consider specialist referral if acne and PMOS are associated with hyperandrogenism, or if there is severe acne resistant to standard treatment. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice, but only my summary and interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - 2026 Menopause Part 5 HRT Made Practical | 30 Aug 2026 | 00:09:04 | |
The video version of this podcast can be found here: · https://youtu.be/eQwGStVNHe4 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Menopause: identification and management [NG23] can be found here:
· https://www.nice.org.uk/guidance/NG23
The link to the visual aid on HRT and the likelihood of some medical conditions can be found here:
The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:
The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:
GP notebook on contracpetion and HRT:
· https://gpnotebook.com/pages/gynaecology/hormone-replacement-therapy-hrt-and-contraception Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we’re doing a practical review of menopause, focusing on what is relevant in primary care only. We’ve recently covered the NICE guideline, so today we’ll keep things practical. We’ll look at key definitions, common prescribing pitfalls, HRT regimens, contraception while using HRT, and how to advise someone who wants to delay a period for a holiday. Right, let’s jump into it. Let’s start with some definitions first. Systemic HRT means HRT that is absorbed into the bloodstream and has effects throughout the body. The oestrogen can be oral, or transdermal. The progestogen can be oral, transdermal, or provided through a levonorgestrel intrauterine system. This is different from vaginal oestrogen, which is used locally for genitourinary symptoms. It is absorbed locally, with only a minimal amount absorbed into the bloodstream, so it is unlikely to have a significant systemic effect. Vaginal oestrogen can be used alone or with systemic HRT. Let’s look at the types of HRT, starting with combined HRT. Combined HRT means HRT with both oestrogen and progestogen. We use this in people with a uterus because unopposed systemic oestrogen increases the risk of endometrial hyperplasia and endometrial cancer. Combined HRT can be continuous or sequential. Continuous combined HRT means oestrogen and progestogen are taken together every day. The aim is no regular withdrawal bleed and it can be used when the person is postmenopausal, meaning at least 12 months since their last period or from around age 54 if the bleeding pattern is unclear.. Continuous combined HRT is not usually suitable during perimenopause or within 12 months of the last menstrual period, because it can cause irregular bleeding. In these cases, we would use sequential combined HRT, also called cyclical HRT. This means oestrogen is taken every day, and progestogen is usually taken for part of the month, usually giving a predictable monthly bleed. Another option for combined HRT is to prescribe an oestrogen-only preparation with a separate progestogen, for example, micronised progesterone which is usually given as Utrogestan in the UK. Common regimens are Utrogestan 200 mg at night for 12 days per 28-day cycle, usually days 15 to 26, for sequential combined HRT or, for a continuous combined HRT, 100 mg at night from days 1 to 25 of each 28-day cycle. Another progestogen option for endometrial protection is a 52 mg levonorgestrel intrauterine system, such as Mirena, which should be changed every 5 years when used for this purpose. Let’s now look at oestrogen-only HRT. This means oestrogen is given without progestogen and it is usually used in people who have had a total hysterectomy. But we should mindful of possible pitfalls. For example, after subtotal hysterectomy, some endometrial tissue may remain in the cervical stump. In that situation, progestogen may be still needed. Another important pitfall is a history of previous widespread endometriosis. This is because even after hysterectomy, residual endometriosis deposits can remain, so combined HRT may be advised here too. In these two cases, we should consider specialist advice before prescribing unopposed oestrogen. Oestrogen-only HRT can be oral or transdermal. Transdermal is often the first choice because it has a more favourable venous thromboembolism and stroke risk profile than oral oestrogen. The general principle is to use the lowest effective dose that controls symptoms. If symptoms are not controlled after a reasonable trial, or side effects occur, we can adjust the dose, change the route, or change the progestogen. In practice, we should allow around 3 months after starting or changing HRT before judging the full effect, unless there are significant issues. When starting HRT, we should explain the expected bleeding pattern. With sequential combined HRT, a regular withdrawal bleed is expected. With continuous combined HRT, the aim is no bleeding, but irregular bleeding can occur initially. Now let’s talk about contraception. The main message is simple: HRT is not contraception. If pregnancy is possible and not wanted, contraception still needs to be discussed. Non-hormonal contraception can obviously be used alongside HRT. A 52 mg levonorgestrel intrauterine system or Mirena, can be particularly useful because it can provide both contraception and endometrial protection when used with systemic oestrogen. Although Mirena is licensed for up to 8 years for contraception, for endometrial protection as part of HRT it is only effective for up to 5 years. If a Mirena intrauterine device is not possible, we need to remember that not all progestogen-only contraceptives can be used for endometrial protection with oestrogen-only HRT. For example, the progestogen-only pill, progestogen-only implant, and depot medroxyprogesterone acetate cannot be used for this. However, they can normally be used as contraception alongside HRT. On the other hand, combined hormonal contraception should not be used in combination with HRT. In eligible women under 50, combined hormonal contraception can be used as an alternative to HRT for symptom relief and bone protection, but not together with HRT. If a woman reaches 50 while using combined hormonal contraception, they are usually switched to a progestogen-only method, and then we should reconsider HRT options. And let’s finish with a practical question that often comes up: how to delay a predictable HRT withdrawal bleed for a holiday. In UK practice, we could treat this as a short-term HRT schedule adjustment, rather than routine period delay tablets. Here we would usually extend the progestogen-containing phase until after the holiday. That is because the bleed usually happens when the progestogen phase stops. So, for someone using transdermal or oral sequential combined HRT, if the holiday falls when they are due to bleed, the practical option is usually to continue the progestogen containing patches or tablets through the holiday. After the holiday, they switch back to the oestrogen-only patches or tablets and should expect a withdrawal bleed. We should not extend the oestrogen-only phase to delay bleeding, because that increases time on unopposed oestrogen. And we should not casually add high dose oral norethisterone on top of sequential combined HRT, because the patient may already be receiving progestogen in the combined phase, and extra norethisterone may add side effects and risk. If the patient uses separate daily oestrogen with cyclical progestogen, they simply continue the progestogen until after the holiday. Then they stop the progestogen, expect a withdrawal bleed, and return to the usual monthly schedule. This is an off-licence schedule adjustment, and we should explain that spotting can still happen, and they should seek review for heavy, persistent, or unusual bleeding. So that is it, a practical review of menopause. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE News - July 2026 | 16 Aug 2026 | 00:10:28 | |
The video version of this podcast can be found here: · https://youtu.be/n-tqArOvxcI This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in July 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for July 2026 can be found here:
· https://www.nice.org.uk/guidance/published?from=2026-07-01&to=2026-07-30
The updated NICE guideline on low back pain and sciatica in over 16s: assessment and management [NG59] can be found here: · https://www.nice.org.uk/guidance/ng59
The updated NICE guideline on Osteoporosis: risk assessment [NG259] can be found here: · https://www.nice.org.uk/guidance/ng259
The new updated NICE guideline on Heavy menstrual bleeding: assessment and management [NG88] can be found here: · https://www.nice.org.uk/guidance/ng88 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in July 2026, focusing on what is relevant in Primary Care only. This month, we have three areas to cover: updated guidance on low back pain and sciatica, updated guidance on heavy menstrual bleeding, and a brand-new guideline on osteoporosis risk assessment. Right, let’s jump into it. Let’s start with osteoporosis risk assessment. NICE says to assess fragility fracture risk in all people aged 50 and over, and in women who have experienced menopause, if they have had a previous fragility fracture or currently use, or frequently use, systemic glucocorticoids. It also says to consider assessment in all men aged 75 and over, all women aged 65 and over, and younger people with risk factors. These include 2 or more falls in the last year, hip fracture in a first-degree relative, BMI below 18.5, smoking, alcohol intake over 14 units per week, or other risk factors such as, for example, endocrine or gastrointestinal conditions, multiple myeloma, Parkinson’s disease, immobility, COPD, autoimmune disease, and CKD stage 4 or 5. For people under 50, the threshold is higher: we should assess risk after a previous hip or vertebral fragility fracture, 2 or more major osteoporotic fractures, or another major risk factor. For people aged 40 to 90, we should use FRAX or QFracture to estimate 10-year major osteoporotic fracture risk. For people aged 30 to 39, we should use QFracture. For people over 90, we should remember that FRAX assumes age 90, while QFracture calculates risk up to age 100. We should seek specialist advice for people under 30 or with rare bone diseases. We should offer DXA to people aged 30 and over with a previous hip or vertebral fragility fracture, a single major osteoporotic fragility fracture in the last 2 years, or 2 or more fragility fractures. We should also consider DXA when the 10-year major osteoporotic fracture risk is 10% or more. When starting treatment, we should usually do a baseline DXA unless it is not tolerated or feasible. If DXA is delayed, we should consider fast-tracking within 6 weeks if anabolic treatment is likely, or starting antiresorptive treatment if anabolic treatment is unlikely. NICE also discusses DXA-based vertebral fracture assessment, or VFA. What is VFA exactly? VFA is an extra spine image done using the DXA scanner to look for vertebral fragility fractures. We should consider VFA in men aged 70 and over and women aged 60 and over. In younger people, we should consider VFA during DXA if there has been a previous major osteoporotic fracture, signs or symptoms of vertebral fracture, systemic glucocorticoid use, or exceptionally low bone mineral density for age. For treatment decisions, we should consider FRAX or QFracture risk scores, DXA results if available, previous fragility fractures, and risk factors. For people aged 50 and over, and women who have experienced menopause, we should consider treatment after a previous hip or vertebral fragility fracture, or high-dose systemic glucocorticoids. We should also consider treatment with a T-score of minus 2.5 or less, or minus 1.5 or less if there is previous fragility fracture, systemic glucocorticoid use, or other risk factors. Treatment can also be considered without DXA if the person meets assessment criteria but DXA is not tolerated or feasible, for example in frail older people. If someone declines treatment, we should advise when and how to re-access the service if they change their mind or circumstances change. If 10-year risk is below 10%, we should reassess if circumstances change, or at 5 years. If 10-year risk is 10% or more, or DXA was done but treatment criteria were not met, we should do the same, but consider repeat DXA within 2 to 3 years if they were close to treatment criteria. Now let’s move to low back pain and sciatica. In this update NICE has withdrawn the recommendations on psychological therapy and combined physical and psychological programmes for low back pain or sciatica. The rest of the primary care approach is largely unchanged. We should think about alternative diagnoses, including red flags, cancer, infection, trauma, and inflammatory disease. Management may involve exercise programmes, with or without manual therapy. We should not routinely offer imaging. If referring, we should explain that imaging may still not be needed and that imaging should only be considered by a specialist if it is likely to change management. For self-management, we should encourage normal activities and consider group exercise programmes for suitable patients. Manual therapy, including manipulation, mobilisation, or massage, can be considered only as part of a package that includes exercise. For medicines, NICE says not to offer gabapentinoids, other antiepileptics, oral corticosteroids, benzodiazepines, or opioids for low back pain and sciatica. If prescribing NSAIDs, we should consider gastrointestinal, liver and cardio-renal toxicity, age, and other risk factors and use the lowest effective dose for the shortest possible time. Weak opioids, with or without paracetamol, can be considered for acute low back pain only if NSAIDs are contraindicated, not tolerated, or ineffective. But NICE says not to offer paracetamol alone for low back pain. It also says not to routinely offer opioids for acute low back pain, and not to offer opioids for chronic low back pain. Finally, let’s look at heavy menstrual bleeding. The update is about serum ferritin testing. Previously, NICE advised not to routinely test serum ferritin in women with heavy menstrual bleeding. That recommendation has now been removed because of the risk of iron deficiency. Heavy menstrual bleeding can have a major impact on quality of life, and management should focus on this rather than blood loss alone. If there are no related symptoms, NICE says we can consider pharmacological treatment without physical examination. However, we should offer examination if there is intermenstrual bleeding, pelvic pain, pressure symptoms, or if considering a levonorgestrel-releasing intrauterine system. We should a full blood count and use clinical judgement on ferritin. We should consider coagulation testing if heavy bleeding has been present since periods started and there is a personal or family history suggesting a coagulation disorder. We should not do female hormone or thyroid testing unless clinically indicated. We can start pharmacological treatment without investigating if history or examination suggests low risk of uterine or histological abnormality. If cancer is suspected, we should follow the NICE suspected cancer pathway. If investigations are needed, we should use history and examination to decide between hysteroscopy and ultrasound as the first line investigation. We should offer outpatient hysteroscopy if the history suggests submucosal or endometrial pathology, for example if there is persistent intermenstrual bleeding or risk factors for endometrial pathology. However we should offer pelvic ultrasound if the uterus is palpable abdominally, a pelvic mass is suspected, or examination is inconclusive or difficult. For suspected adenomyosis, with significant period pain or a bulky, tender uterus, we should offer transvaginal ultrasound in preference to transabdominal ultrasound or MRI. For no identified pathology, fibroids under 3 cm without cavity distortion, or suspected adenomyosis, we should consider a levonorgestrel-releasing intrauterine system first. If this is declined or unsuitable, we should consider tranexamic acid, NSAIDs, combined hormonal contraception, or cyclical oral progestogens. Progestogen-only contraception may suppress menstruation, which may also help. We should refer if treatment is unsuccessful, pharmacological treatment is declined, symptoms are severe, there are submucosal fibroids, or fibroids are 3 cm or more. While investigations or definitive treatment are being organised, tranexamic acid and NSAIDs can still be offered. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice, but only my summary and interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
| |||
| Podcast - NICE 2026 Menopause Part 4 Premature menopause and HRT review | 02 Aug 2026 | 00:07:37 | |
The video version of this podcast can be found here: · https://youtu.be/2sD5P3AfRq0 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Menopause: identification and management [NG23] can be found here:
· https://www.nice.org.uk/guidance/NG23
The link to the visual aid on HRT and the likelihood of some medical conditions can be found here:
The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:
The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only. Today we will focus on early menopause, and premature ovarian insufficiency. In the previous three episodes, we covered diagnosis, symptom management and HRT risks and benefits in people aged 45 and over. Right, let’s jump into it. In terms of disease prevention, NICE says we should not offer combined or oestrogen-only HRT for the primary or secondary prevention of cardiovascular disease or for the purpose of dementia prevention. For cardiovascular risk reduction, and dementia prevention we should follow the relevant NICE guidelines on those subjects. Now let’s look at premature ovarian insufficiency, which applies to people under 40. Premature ovarian insufficiency is diagnosed in people under 40 based on symptoms, including no or infrequent periods and elevated FSH levels on 2 blood samples taken 4 to 6 weeks apart. We should not diagnose premature ovarian insufficiency based on a single blood test. If there is doubt about the diagnosis, we should seek specialist advice. For premature ovarian insufficiency, NICE says we should offer sex steroid replacement, unless it is contraindicated. This can be either HRT or a combined hormonal contraceptive. We should explain the importance of hormonal treatment until at least the age of natural menopause, unless there is a contraindication. We should advise that both HRT and combined oral contraceptives offer bone protection and that HRT may have a beneficial effect on blood pressure compared with a combined oral contraceptive. On the other hand,HRT is not contraception, so contraception still needs to be discussed if pregnancy is possible and not wanted. We should also explain that the baseline population risk of diseases such as breast cancer and cardiovascular disease increases with age, and is very low in people under 40. If hormonal treatment cannot be taken, we should still give advice on bone health, cardiovascular health, and symptom management and consider specialist referral if necessary. Let’s now look at early menopause, which is defined as menopause between the ages of 40 and 44. Here the benefits and risks of taking or not taking HRT are likely to sit between those for premature ovarian insufficiency and those for people aged 45 or over. In premature ovarian insufficiency, that is, before 40, the potential benefit of HRT is usually greater, because we are not only thinking about the risks of HRT but also the risks of not taking it, particularly in respect of bone health. As we know, HRT helps reduce fragility fracture risk. In early menopause, between 40 and 44, the same issue still applies, but to a lesser extent, so the balance of risks and benefits sits between premature ovarian insufficiency and menopause at 45 or over. In simple terms, the younger the person is at menopause, the more important it is to consider the health effects of not taking HRT. As always, the discussion should be tailored to the person’s age, circumstances, and individual risk factors. Now let’s look at starting and stopping HRT. Firstly, if the person has a medical condition that may be affected by HRT, we should consider seeking specialist advice before starting it. For symptoms control, we should offer combined HRT to people with a uterus and oestrogen-only HRT to people who have had a total hysterectomy and use the lowest effective dose. For people with a uterus, we should explain that vaginal bleeding is a common side effect during the first 6 months of taking systemic HRT, or within 3 months of changing the dose or preparation. They should also be advised to seek medical help promptly if unscheduled vaginal bleeding happens beyond these timeframes. There is limited evidence for unscheduled bleeding while on HRT, and NICE signposts the British Menopause Society guidance on unscheduled bleeding on HRT. Let’s have a look at what they say: The British Menopause Society guidance say that we should first assess the patient fully, including, amongst other things, the bleeding pattern, adherence, examination, BMI, and individual risk factors for endometrial cancer. Major risk factors include a BMI of 40 or more and some hereditary conditions. Minor risk factors include a BMI between 30 and 39, diabetes, and polycystic ovarian syndrome. In people at low risk, if bleeding occurs within 6 months of starting HRT, or within 3 months of changing it, we will adjust the progestogen or HRT preparation, for 6 months in total, before arranging further investigations. If unscheduled bleeding continues in low-risk women, after six months of adjustments, we could request an urgent transvaginal ultrasound. We should also do this if bleeding first occurs more than 6 months after starting HRT, or more than 3 months after changing treatment, and also if bleeding is heavy, prolonged, or if there are 2 minor risk factors. An urgent suspected cancer referral is recommended if there is 1 major risk factor or 3 minor risk factors for endometrial cancer, regardless of bleeding pattern or timing. Now let’s go back to the NICE guideline and look at stopping HRT. NICE says we should offer a choice between gradually reducing treatment or stopping it immediately. Gradually reducing it may decrease recurrence of symptoms in the short term but it makes no difference in the long term. Finally, systemic HRT should be stopped in people diagnosed with breast cancer. What should we cover during an HRT review? We should encourage nationally recommended health screening and, at 3 months, we should review the effect of HRT on menopausal symptoms. After that, treatment should be reviewed annually, unless there is a clinical reason to review sooner, such as poor response or side effects. If HRT is not effective or tolerated, we should seek specialist advice. So that is it, a review of a section of the NICE guideline on the menopause. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE News - June 2026 | 19 Jul 2026 | 00:06:41 | |
The video version of this podcast can be found here: · https://youtu.be/i9b7QqtmcAs This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in May 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for June 2026 can be found here:
· https://www.nice.org.uk/guidance/published?from=2026-06-01&to=2026-06-30 The new Technology appraisal guidance [TA694] Bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia can be found here: · https://www.nice.org.uk/guidance/ta694 The updated NICE guideline on Ectopic pregnancy and miscarriage: diagnosis and initial management [NG126] can be found here: · https://www.nice.org.uk/guidance/ng126
The updated NICE guideline on Postnatal care [NG194] can be found here: · https://www.nice.org.uk/guidance/ng194
The new updated NICE guideline on Multiple sclerosis in adults: management [NG220] can be found here: · https://www.nice.org.uk/guidance/ng220
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in June 2026, focusing on what is relevant in Primary Care only. This month, the main update is the guidance on bempedoic acid with ezetimibe, although we will also briefly touch on ectopic pregnancy and miscarriage, postnatal care, and multiple sclerosis. Right, let’s jump into it. And let’s start with the new guidance on bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia. But first, what is bempedoic acid? Bempedoic acid is a relatively new oral, non-statin lipid-lowering drug used to reduce LDL cholesterol. It works in the liver by inhibiting cholesterol production earlier in the pathway than statins. Because it is activated mainly in the liver rather than skeletal muscle, it can be useful when statins are not tolerated, particularly because of muscle symptoms. The result is reduced cholesterol synthesis in the liver and increased clearance of LDL cholesterol from the blood. Bempedoic acid is usually given with ezetimibe because the two drugs work in complementary ways. Bempedoic acid reduces cholesterol production in the liver, while ezetimibe reduces cholesterol absorption from the intestine. Together, they lower LDL cholesterol more than either drug alone, and they provide an all-oral option for people who cannot tolerate statins. Now let’s look at the NICE guidance. In the NICE guideline, bempedoic acid with ezetimibe is an option for adults with primary hypercholesterolaemia or mixed dyslipidaemia only when statins are contraindicated or not tolerated, and ezetimibe alone has not controlled LDL cholesterol well enough. The evidence shows LDL cholesterol reduction, with cardiovascular outcome evidence. In practical terms, this is not a replacement for statins as first-line lipid-lowering treatment. NICE describes the usual pathway as statins first, with ezetimibe added if LDL cholesterol is not lowered enough. NICE also notes that there was no direct comparison with PCSK9 inhibitors such as alirocumab or evolocumab, and indirect comparison suggested bempedoic acid may be less effective than these options. However, a useful practical point is that bempedoic acid is an oral treatment, whereas alirocumab and evolocumab are given by subcutaneous injection. Despite those uncertainties, NICE concluded that bempedoic acid with ezetimibe is a cost-effective option for people with primary hypercholesterolaemia or mixed dyslipidaemia, where statins are contraindicated or not tolerated, and ezetimibe alone does not control LDL cholesterol well enough. Let’s now move to the updated guideline on ectopic pregnancy and miscarriage. The main change affects secondary care, but it is useful for us to know that anti-D immunoglobulin prophylaxis is no longer offered for ectopic pregnancy, miscarriage, or threatened miscarriage up to and including eleven weeks and six days’ gestation. However, from twelve weeks and zero days to twelve weeks and six days, anti-D remains relevant for RhD-negative pregnant people. And while we are here, we should remember that in any woman of reproductive age with non-specific symptoms, we should consider pregnancy and think about offering a pregnancy test. We should also refer to early pregnancy assessment services if there is bleeding or pain, and the pregnancy is of 6 weeks or more, or the pregnancy is of uncertain gestation. The urgency will depend on the clinical situation. If the pregnancy is under 6 weeks, there is bleeding but no pain, and there are no risk factors such as previous ectopic pregnancy, NICE recommends expectant management. We should advise them to return if bleeding continues or pain develops, to repeat a urine pregnancy test after 7 to 10 days, and to return if it is positive. A negative test will mean the pregnancy has miscarried. Let’s now touch on the updated guideline on postnatal care. For GP practice, the June 2026 update itself probably changes very little. NICE has added a recommendation to offer vitamin K prophylaxis for babies, linking to the intrapartum care guideline. For primary care, the main practical message is unchanged: the 6-to-8-week postnatal check remains an opportunity to assess maternal physical and mental health, contraception, pelvic floor and perineal problems, bleeding, safeguarding, feeding, and the baby’s wellbeing and development. And finally, the updated guideline on multiple sclerosis. The main change is diagnostic: the guideline now refers to specialist criteria known as the McDonald criteria, and NICE has removed the old statement that MS should not be diagnosed solely on MRI findings. But this does not affect us in primary care. For us, the practical message is that we should think of MS when there are focal neurological symptoms evolving over more than 24 hours, lasting days or weeks, often improving afterwards, and not explained by other common diagnoses. However, we should not routinely suspect MS from fatigue, dizziness, or vague sensory symptoms alone. We should then refer suspected MS cases to neurology, and secondary care will make the diagnosis following specific criteria. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Menopause Part 3 HRT risks explained | 05 Jul 2026 | 00:07:15 | |
The video version of this podcast can be found here: · https://youtu.be/lgHKxBVz6kE This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Menopause: identification and management [NG23] can be found here:
· https://www.nice.org.uk/guidance/NG23
The link to the visual aid on HRT and the likelihood of some medical conditions can be found here:
The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:
The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only. Today we will focus on HRT risks and benefits in people aged 45 and over. In the next episode, we’ll cover early menopause, meaning people aged 40 to 44, and premature ovarian insufficiency, which refers to those aged under 40. In the previous two episodes, we covered diagnosis, treatment choices, and symptom management. Right, let’s jump into it. So let’s start by looking at the effects of HRT on specific health outcomes. When discussing the risk of individual medical conditions, NICE recommends using its HRT discussion aid to explain risks and benefits more clearly. The link to this aid is in the episode description. It presents the information as the number of cases per 1,000 people over a 5- or 10-year period. So, in practice, the message is more nuanced than simply saying that HRT is safe or unsafe. Let’s first look at the effects that are similar with combined and oestrogen-only HRT. For people aged 45 or over, we will explain that neither combined HRT or oestrogen-only HRT is likely to affect life expectancy. Equally, for people without coronary heart disease, the risk of developing it or mortality from it does not increase with either combined HRT or oestrogen-only HRT. For osteoporosis, fragility fracture risk is reduced while on either combined HRT or oestrogen-only HRT and the benefit is maintained during treatment, but decreases once HRT stops. It may continue for longer in people who take HRT for longer. There is also limited evidence that HRT improves muscle mass and strength. Neither combined HRT or oestrogen-only HRT increases the risk of developing type 2 diabetes and it has no adverse effect on blood glucose. And finally, for venous thromboembolism, route matters. The risk is not increased with transdermal HRT, but it is increased with oral HRT, both combined and oestrogen-only. And now let’s review the specific effects of combined HRT, which is given to people with a uterus. And we will start looking at the Breast cancer risk first, which varies depending on the person’s risk factors. With combined HRT, breast cancer risk increases, and this increase rises with duration of use. In addition, the risk is higher while taking HRT compared to having taken it in the past and, after stopping HRT, the risk goes down, but it can persist for at least 10 years. NICE says there is a very small increase in the risk of death from breast cancer too. The type of combined HRT also matters. Breast cancer risk is lower with sequential combined HRT than with continuous combined HRT, but it is still higher than without HRT. There is not enough evidence that any specific progestogen carries a higher risk of breast cancer. Contrary to what happens with breast cancer, for endometrial cancer, continuous combined HRT reduces risk whereas sequential combined HRT may slightly increase it, and this increases with the duration of use, fewer days of progestogen per cycle, or a higher dose of oestrogen. For ovarian cancer there is a very slight increase in risk with combined HRT, but we should explain that the baseline population risk in women under 60 is very low. For dementia, the risk might increase if it is started at the age of 65 or over. For stroke, we should explain that the baseline population risk in women under 60 is very low. Stroke risk is unlikely to increase with combined HRT that includes transdermal oestrogen, but it increases with combined HRT containing oral oestrogen. This increase rises with higher oestrogen dose and longer duration of treatment, for example if used for more than 5 years. The risk is also higher when HRT is started at a later age, and may be higher in Black people. So, in summary, combined HRT is used in people with a uterus, breast cancer risk is increased and rises with duration of use, continuous combined HRT reduces endometrial cancer risk, and transdermal treatment has a more favourable profile for stroke and VTE risk than oral treatment. Let’s now move to oestrogen only HRT, remembering that this is the option recommended for people who have had a total hysterectomy. Starting with breast cancer, the discussion is different from combined HRT. Oestrogen-only HRT causes very little or no increase in breast cancer risk or breast cancer mortality. For endometrial cancer, the key point is that oestrogen-only HRT should not be used in people with a uterus precisely because it increases the risk of endometrial malignancy. Ovarian cancer risk increases very slightly after 5 years of oestrogen-only HRT, and rises with longer use, regardless of the route. However, the baseline risk in women under 60 is very low. For dementia, NICE says that the risk is unlikely to increase. For stroke, the route of oestrogen matters. Stroke risk increases with oral oestrogen-only HRT, and this increase rises with the dose of oestrogen and if started after the age of 60. However, stroke risk is unlikely to increase with transdermal oestrogen-only HRT. So, in summary, oestrogen-only HRT is generally used after total hysterectomy, breast cancer risk is very little or not increased, and transdermal treatment has a more favourable profile for stroke and VTE risk than oral treatment. So that is it, a review of a section of the NICE guideline on the menopause. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Menopause Part 2 Symptoms and treatments | 21 Jun 2026 | 00:07:16 | |
The video version of this podcast can be found here: · https://youtu.be/2zTvO-QuDNE This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Menopause: identification and management [NG23] can be found here:
· https://www.nice.org.uk/guidance/NG23
The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:
The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only. Today we will focus on symptom management and treatment risks. In the last episode we covered diagnosis, and treatment choices and in future episodes we will cover the other sections of the guideline. Right, let’s jump into it. We will start by covering the management of menopausal symptoms in people aged 40 or over. This is because, for people under 40, we should follow the separate NICE guideline on premature ovarian insufficiency. Let’s look at the various possible symptoms one by one. For vasomotor symptoms, such as hot flushes and sweats, NICE says we should offer HRT. Menopause-specific CBT can also be considered and used in addition to or instead of HRT. Fezolinetant is also recommended as an option when HRT is unsuitable. Fezolinetant is not HRT. It works through receptor pathways involved in temperature regulation. Although recommended as an option, in practice, it may well be specialist initiated only, depending on local prescribing guidance. NICE says we should not routinely offer SSRIs, SNRIs, or clonidine as first-line treatment for vasomotor symptoms alone. Now let’s look at genitourinary symptoms. For people with no history of breast cancer, we should offer vaginal oestrogen, including in people who are already using systemic HRT. We should explain that serious adverse effects are very rare and that symptoms often return when vaginal oestrogen is stopped, but treatment can be restarted if necessary. Vaginal oestrogen is absorbed locally and a minimal amount is absorbed systemically, which is unlikely to have a significant effect throughout the body. Types of vaginal oestrogen include creams, gels, vaginal tablets, pessaries, or rings. They can be used alone, or with non-hormonal moisturisers or lubricants. If vaginal oestrogen is contraindicated, or the person prefers not to use it, we should then just consider non-hormonal vaginal moisturisers or lubricants. If vaginal oestrogen, moisturisers, or lubricants have not worked, NICE says we should consider vaginal prasterone or oral ospemifene. These medicines are not started routinely in primary care, and their use will depend on local formulary and prescribing guidance. For people with genitourinary symptoms and overactive bladder, or recurrent urinary tract infections, NICE signposts their specific guidance in those areas. For people with a personal history of breast cancer and genitourinary symptoms, we should initially only offer non-hormonal moisturisers or lubricants. If symptoms continue despite this, vaginal oestrogen can be considered and used with a non-hormonal moisturiser or lubricant. However, this is an off-label use so we should seek specialist advice before initiating them, particularly if the patient is taking aromatase inhibitors as adjuvant treatment for breast cancer. Patients should be made aware that it is unknown whether vaginal oestrogen affects the risk of breast cancer recurrence, given that only a minimal amount is absorbed systemically. For people with oestrogen receptor-negative breast cancer, vaginal oestrogen is unlikely to increase the risk recurrence. On the other hand, for people with oestrogen receptor-positive breast cancer, NICE says the risk of recurrence could potentially increase. However, adjuvant treatments, such as tamoxifen, would reduce any such potential impact. For depressive symptoms associated with menopause, NICE says we can consider HRT if the symptoms do not meet the criteria for depression, and started around the same time as other menopause-associated symptoms. CBT can also be considered for depressive symptoms which are associated with vasomotor symptoms. However, if someone has depression, we should also follow the NICE guideline on depression. For sleep problems, such as night-time awakening associated with vasomotor symptoms, menopause-specific CBT can be considered, either alone of alongside other options, including HRT. For low sexual desire associated with menopause, NICE says we can consider testosterone supplementation if HRT alone is not effective. However, in the UK, testosterone use for this indication is off-label, and prescribing depends on local formulary guidance. So, as GPs, we should consider specialist advice, although ongoing prescribing may sometimes continue in primary care. Before offering treatment for the menopause, we should consider referral if there are contraindications to HRT, or if there is uncertainty about the most suitable option. For people with type 2 diabetes, we can consider HRT after taking comorbidities into account and specialist advice can be sought if needed. For people at increased risk of venous thromboembolism, we should consider transdermal rather than oral HRT, and this includes people with a BMI over 30. For people at high risk of venous thromboembolism, for example those with a strong family history or thrombophilia, we should also refer to a haematologist before starting HRT. For people with a personal history of coronary heart disease or stroke, HRT should only be offered by a menopause specialist. For people with a personal history of breast cancer, or a high risk of breast cancer, NICE says we should also refer to a menopause specialist. There is separate specific guidance for people at high familial risk of ovarian cancer, so we will not cover it here. For people who are likely to experience menopause because of medical or surgical treatment, NICE says they should be able to discuss fertility with a fertility specialist. Trans men and those who have taken gender-affirming hormone therapy in the past, should also be referred to a menopause specialist. So that is it, a review of a section of the NICE guideline on the menopause. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE News – May 2026 | 10 Jun 2026 | 00:04:40 | |
The video version of this podcast can be found here: · https://youtu.be/hx1KVBpBbB4 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in May 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for May 2026 can be found here:
The new Technology appraisal guidance [TA1152] Semaglutide for reducing the risk of major adverse cardiovascular events in people with cardiovascular disease and overweight or obesity can be found here: · https://www.nice.org.uk/guidance/ta1152
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in May 2026, focusing on what is relevant in Primary Care only. This month, we only have one technology appraisal that is relevant to primary care, which is semaglutide for reducing the risk of major adverse cardiovascular events in people with cardiovascular disease and overweight or obesity. Right, let’s jump into it. This particular technology appraisal recommends semaglutide for reducing the risk of major adverse cardiovascular events in adults with established cardiovascular disease and overweight or obesity. The difference is that this is not a general obesity recommendation. This is about secondary prevention in people who already have established cardiovascular disease and a BMI of at least 27. NICE defines established cardiovascular disease in this guidance as having at least one of the following: a previous MI, previous ischaemic or haemorrhagic stroke, or symptomatic peripheral arterial disease. For peripheral arterial disease, NICE specifies intermittent claudication with an ankle brachial index below 0.85 at rest, or previous peripheral arterial revascularisation, or amputation because of atherosclerotic disease. The recommendation is that semaglutide, up to a maintenance dose of 2.4 mg once weekly, can be used alongside standard routine management in order to reduce the risk of a major adverse cardiovascular event. In this guidance, a major adverse cardiovascular event means cardiovascular death, non-fatal MI, or non-fatal stroke. The guidance does not specify which setting semaglutide should be used in and it does not say that it needs to be provided in Primary Care but it does say that, once recommended by NICE, it must be funded in the NHS in England within 90 days of final publication. NHS England has said semaglutide is expected to become available to eligible people over the next few years, but there is not yet a single national primary care prescribing pathway. Some local formularies still restrict semaglutide in primary care, although many of these restrictions relate to weight management services rather than this new cardiovascular indication, so we will have to watch the space. In the rationale, NICE states that lifestyle changes and standard medicines are used to reduce cardiovascular risk. These measures include diet, exercise, reducing alcohol, stopping smoking, and managing weight. Medicines may include antihypertensives, lipid lowering drugs, antiplatelets, and anticoagulants. Semaglutide is positioned as another option alongside standard care for secondary prevention given that trial evidence shows that it reduces the risk of a first major adverse cardiovascular event compared with placebo. We know that people from South Asian, Chinese, other Asian, Middle Eastern, Black African, or African Caribbean ethnic backgrounds may have a higher cardiovascular risk at lower BMI thresholds. However, NICE did not recommend semaglutide below a BMI of 27 because of licensing reasons and because evidence in that lower BMI group is not available. In summary, for us primary care, the main message is that semaglutide is a cardiovascular secondary prevention option for people with established cardiovascular disease and a BMI of at least 27. And semaglutide should be used alongside standard cardiovascular prevention, not instead of it. So, we should still give lifestyle advice and optimise blood pressure and lipids and prescribe antiplatelet or anticoagulant treatment where appropriate. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Menopause Part 1 Diagnosis and choices | 03 Jun 2026 | 00:07:42 | |
The video version of this podcast can be found here: · https://youtu.be/JktVjws4xQ4 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Menopause: identification and management [NG23] can be found here:
· https://www.nice.org.uk/guidance/NG23
The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only. Today we will focus on patient information, diagnosis, and treatment choices. In future episodes we will cover the other sections of the guideline. Right, let’s jump into it. Let’s start by saying that the NICE menopause guideline applies to women, trans men, and non-binary people registered female at birth who have menopause-associated symptoms now, or who may experience them in the future. It does not apply to people having gender-affirming hormone therapy. Let’s now look at what information should be given to patients. When we assess and manage menopause, we should use shared decision making when discussing symptom management, including the benefits and risks of different options. We should explain that menopause usually happens in mid-life, but that it can also happen earlier because of surgery, medical treatment, an inherited condition, or an unknown cause. Menopause symptoms may be mild or severe, and they may last for a short time or a long time. Symptoms may include changes in the menstrual cycle, hot flushes, vaginal dryness, mood symptoms, joint or muscle pain, and sexual difficulties, such as low sexual desire. NICE says we should discuss contraception with people who have menopause-associated symptoms because menopause symptoms do not necessarily mean that ovulation has stopped. Although fertility declines with age, contraception may still be needed if pregnancy is not wanted. For people using non-hormonal contraception, the Faculty of Sexual and Reproductive Healthcare advises that contraception can usually be stopped after 2 years of amenorrhoea between the ages of 40 and 50, or after 1 year of amenorrhoea after the age of 50. However, most women using hormonal contraception during the perimenopause will have altered bleeding patterns or amenorrhoea. As a result, it can be difficult to give accurate advice, so we should check the specific recommendations for each type of hormonal contraceptive in the Faculty of Sexual and Reproductive Healthcare guidance. In general, it advises that contraception can be stopped at age 55, because spontaneous pregnancy after this age is exceptionally rare. Bone health should be discussed too, explaining the importance of maintaining muscle mass and strength through physical activity. For people experiencing early menopause, between the ages of 40 and 44, we should offer psychological support if they are distressed by it. Let’s now look at the diagnosis. In otherwise healthy people aged 45 or over, with menopause-associated symptoms, NICE says we can usually identify perimenopause and menopause without laboratory tests. Perimenopause can be identified if vasomotor symptoms have recently started, and there are changes in the menstrual cycle. Menopause can be identified if the person has not had a period for at least 12 months, and they are not using hormonal contraception. In people who have had a hysterectomy, menopause is identified based on the type and combination of symptoms, for example vasomotor symptoms. NICE also says that menopause can be harder to identify in people taking hormonal treatments, because, as we mentioned earlier, hormonal contraception can alter bleeding patterns, making it difficult to know the underlying menopausal status. NICE says we should not use FSH to identify menopause in people using combined oestrogen and progestogen contraception, or high-dose progestogen and The Faculty of Sexual and Reproductive Healthcare explains why: combined hormonal contraception suppresses oestradiol, FSH, and LH, and depot medroxyprogesterone acetate can suppress FSH to some extent, meaning someone could be menopausal but not show the expected rise in FSH. NICE also says that people from some ethnic minority backgrounds, and people with some lifelong conditions, may experience menopause at a younger age. NICE does not give a list of specific ethnicities, but in its rationale, it gives Down’s syndrome as an example of a lifelong condition. So, the practical point is to think about menopause earlier in these groups. NICE says that FSH should only be considered in specific situations. This includes people aged 40 to 45 with menopause-associated symptoms, including a change in their menstrual cycle. It also includes people under 40 in whom menopause is suspected, where we also need to think about premature ovarian insufficiency. When discussing management options with people aged 40 or over, we should discuss the benefits and risks of the various treatment options. Additionally, when discussing HRT, we should discuss combined HRT compared with oestrogen-only HRT, and explain which type the person would be offered and why. We should also discuss transdermal HRT compared with oral HRT, the different types of oestrogen and progestogen, and when to give sequential versus continuous combined HRT, and why. If the person chooses to take HRT, we should discuss the possible duration of treatment from the start and revisit, at every review, the benefits and risks of continuing it. We should also explain that symptoms may return when HRT is stopped, and discuss the option of restarting treatment if needed. Cognitive behavioural therapy can also be discussed as a possible management option, including menopause-specific CBT, which may include face-to-face or remote sessions, individual or group sessions, and self-help options, depending on the person’s preferences. For complementary therapies, we should explain that the safety, quality, and purity of unregulated preparations may be unknown. There is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms, but NICE says we should also explain that their safety is uncertain, preparations may vary, and interactions with other medicines have been reported. For people with a personal history of breast cancer, or at high risk of breast cancer, we should explain that, although St John’s wort may help relieve vasomotor symptoms, there is uncertainty about the correct dose, how long the effect lasts, and the variation in strength and content between preparations. We should also warn about potential serious interactions with other medicines, including tamoxifen, anticoagulants, and anticonvulsants. So that is it, a review of a section of the NICE guideline on the menopause. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
| |||
| Podcast - NICE 2026 Hypertension Part 4 Stepwise Treatment | 27 May 2026 | 00:07:28 | |
The video version of this podcast can be found here: · https://youtu.be/9vJt7FMA0to This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Hypertension in adults: diagnosis and management [NG136] can be found here:
· https://www.nice.org.uk/guidance/NG136
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only. In previous episodes we covered the diagnosis, criteria for urgent referral, when to start drug treatment and blood pressure targets. Today we will focus on antihypertensive drug treatment. Right, let’s jump into it. Let’s start with what antihypertensive treatment to choose. The recommendations in this guideline apply to people with hypertension, with or without type 2 diabetes, but for people with type 1 diabetes or CKD, we should refer to the relevant NICE guideline. We should also remember that ACE inhibitors and angiotensin receptor blockers should not be used in pregnancy, breastfeeding, or when planning pregnancy, unless absolutely necessary. If used, we must discuss risks and benefits and follow safety guidance. In general, and if possible, we should choose once daily treatments. For isolated systolic hypertension, defined as a systolic blood pressure of 160 or higher, we should treat in the same way as people with both raised systolic and diastolic blood pressure. We should offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension, in line with the general guideline on hypertension. For women planning pregnancy, who are pregnant, or breastfeeding, we should manage hypertension in line with the specific NICE guideline on hypertension in pregnancy, including guidance during breastfeeding. When choosing antihypertensive treatment for adults of Black African or African Caribbean family origin, we should consider an angiotensin receptor blocker in preference to an ACE inhibitor. This is because ACE inhibitors may be less effective in this group, partly because low renin hypertension is more common, and they also carry a higher risk of angioedema. For people with cardiovascular disease, we should first follow the disease specific recommendations in the relevant NICE guideline for their condition. These include: · acute coronary syndromes, · acute and chronic heart failure, · stable angina, and · type 1 diabetes. If blood pressure remains uncontrolled despite following these disease specific recommendations, we should then offer the general stepwise approach outlined in the hypertension guideline. Let’s have a look at it. As step 1 treatment, we should offer an ACE inhibitor or an ARB as step 1 treatment if they have type 2 diabetes, regardless of age or family origin. We should also offer an ACE inhibitor or an ARB to adults under the age of 55, provided they are not of Black African or African Caribbean family origin. If an ACE inhibitor is not tolerated, for example because of cough, we should offer an ARB instead. We should not combine an ACE inhibitor with an ARB. We should offer a calcium channel blocker as step 1 treatment if they are aged 55 or over and do not have type 2 diabetes. We should also offer a calcium channel blocker to adults of Black African or African Caribbean family origin who do not have type 2 diabetes, regardless of age. If a calcium channel blocker is not tolerated, for example because of oedema, we should offer a thiazide like diuretic. Equally, if there is evidence of heart failure, we should offer a thiazide like diuretic and follow the NICE guideline on chronic heart failure. If starting or changing diuretic treatment, we should prefer a thiazide like diuretic, such as indapamide, over conventional thiazides such as bendroflumethiazide or hydrochlorothiazide. If blood pressure is stable and well controlled on bendroflumethiazide or hydrochlorothiazide, we should continue the current treatment. Now let’s move on to step 2 treatment. Before considering the next step, we should discuss with the person whether they are taking their medication as prescribed. If blood pressure is not controlled on step 1 treatment with an ACE inhibitor or an ARB, we should offer one of the following in addition: a calcium channel blocker, or a thiazide like diuretic. If blood pressure is not controlled in adults taking step 1 treatment with a calcium channel blocker, we should offer one of the following in addition: an ACE inhibitor, an ARB, or a thiazide like diuretic. For adults of Black African or African Caribbean family origin without type 2 diabetes, not controlled on step 1 treatment, we should consider an ARB in preference to an ACE inhibitor as the add on treatment. Now let’s move on to step 3 treatment. Before considering the next step, we should make sure that optimal tolerated doses are being taken, and we should discuss adherence. If blood pressure is not controlled on step 2 treatment, we should offer a combination of three drugs, that is: an ACE inhibitor or an ARB, plus a calcium channel blocker, plus a thiazide like diuretic. And finally, let’s now move on to step 4 treatment. If blood pressure is not controlled despite optimal tolerated doses of an ACE inhibitor or an angiotensin receptor blocker, plus a calcium channel blocker, plus a thiazide like diuretic, we should regard this as resistant hypertension. Before considering further treatment, we should confirm the elevated clinic readings using ambulatory or home blood pressure monitoring. We should assess for postural hypotension. And we should discuss adherence. If resistant hypertension is confirmed, we should consider a fourth antihypertensive drug or seek specialist advice. If considering a fourth drug. we should consider adding low dose spironolactone if the blood potassium is 4.5 millimoles per litre or less, using caution if kidney function is reduced, because of hyperkalaemia. When starting further diuretic therapy, we should monitor sodium, potassium, and renal function within one month, and repeat as needed. If potassium is above 4.5, we should consider an alpha blocker or a beta blocker instead. If blood pressure remains uncontrolled despite four drugs at optimal tolerated doses, we should seek specialist advice. So that is it, a review of a section of the NICE guideline on hypertension. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Hypertension Part 3 Starting Treatment and Targets | 20 May 2026 | 00:08:05 | |
The video version of this podcast can be found here: · https://youtu.be/ab9q6W0B1OU This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Hypertension in adults: diagnosis and management [NG136] can be found here:
· https://www.nice.org.uk/guidance/NG136
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only. In the last two episodes we covered the diagnosis and the criteria for urgent referral. Today we will focus on initial management, when to start drug treatment and how to monitor hypertension. Right, let’s jump into it. And let’s remember that the recommendations in the hypertension guideline apply to all adults, including those with type 2 diabetes. However, in some situations, management differs, and NICE recommends referring to other relevant guidelines, including those on chronic kidney disease, type 1 diabetes, and hypertension in pregnancy. Now let’s look at lifestyle interventions. We should offer lifestyle advice and continue to reinforce this periodically. We should ask about diet and exercise patterns, because a healthy diet and regular exercise can help reduce blood pressure. We should ask about alcohol consumption, and encourage a reduced intake if the person drinks excessively, as this can lower blood pressure and has broader health benefits. We should discourage excessive consumption of coffee and other caffeine rich products. We should encourage people to keep their dietary sodium intake low, either by reducing salt or using substitutes, as this can also reduce blood pressure. However, salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease, or those taking certain antihypertensive drugs, such as ACE inhibitors or angiotensin receptor blockers. In these groups, we should focus on reducing salt intake rather than using substitutes. Finally, we should offer advice and support to help people stop smoking. Now let’s look at when we should start antihypertensive drug treatment. We should offer antihypertensive drug treatment to adults of any age with persistent stage 2 hypertension. That is, a clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent daytime average on ambulatory monitoring, or average on home monitoring of 150/95 mmHg or higher. We should use clinical judgement for people with frailty or multimorbidity in order to minimise overtreatment and the risk of side effects. What about those with stage 1 hypertension, that is, a clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent daytime average on ambulatory monitoring, or average on home monitoring ranging from 135/85 mmHg to 149/94 mmHg? Well, treatment here will depend on risk factors. For adults under 80 with persistent stage 1 hypertension, we should definitely start treatment if they have signs of target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk of 10 percent or more, again, we should use clinical judgement in people with frailty or multimorbidity. In other situations, NICE is less prescriptive and advises us to “consider” treatment, which means using our clinical judgement more flexibly. For example, in adults under 60 with stage 1 hypertension and a 10-year cardiovascular risk below 10 percent, we should still consider treatment, bearing in mind that a 10-year risk score may underestimate lifetime cardiovascular risk. Similarly, in adults over 80 with stage 1 hypertension, we should consider treatment if clinic blood pressure is above 150 over 90. And this distinction between “offer” and “consider” is important. It reflects the level of certainty in the evidence and reminds us that clinical judgement is crucial. Finally, for adults under 40, we should consider specialist referral for secondary causes and assessment of long-term risks and benefits of treatment. Now let’s go through clinic blood pressure targets. For adults under 80, the general target is a clinic blood pressure below 140 over 90. This applies to people with hypertension, with or without type 2 diabetes, and also to those with type 1 diabetes or CKD if the albumin to creatinine ratio is below 70. However, if the albumin to creatinine ratio is 70 or higher, the target is lower, below 130 over 80. For adults aged 80 and over, the general clinic blood pressure target is below 150 over 90. And although this may feel counterintuitive, this target also applies to people with type 1 or type 2 diabetes, regardless of albumin to creatinine ratio. In this age group, albumin to creatinine ratio only changes the target for people with CKD. NICE does not set lower blood pressure targets in people over 80 just because they have diabetes, as the evidence for lower blood pressure in this age group is limited. So, if they have CKD with an albumin to creatinine ratio below 70, the target is below 140 over 90, and if it is 70 or higher, the target is below 130 over 80. Now let’s look at monitoring in practice. We should use clinic blood pressure measurements to monitor response to treatment. We should check for postural hypotension in people with type 2 diabetes, symptoms of postural hypotension, or who are aged 80 and over. If there is a significant postural drop, or symptoms, we should base treatment targets on standing blood pressure. We should also consider ambulatory or home monitoring in addition to clinic readings if there is a white coat effect or masked hypertension. For people who self-monitor, we should use home blood pressure monitoring and we should remember that out of clinic readings are about 5 mm of mercury lower. So, in adults without relevant comorbidities, under 80, the target is below 140 over 90 in clinic, or below 135 over 85 at home. Over 80, the target is below 150 over 90 in clinic, or below 145 over 85 at home. We should use the same blood pressure targets regardless of whether the person has established cardiovascular disease. When type 2 diabetes is diagnosed, we should review blood pressure control and the medications used and make changes if the current treatment is not appropriate because of microvascular complications or metabolic problems. Finally, we should provide an annual review for all adults with hypertension. So that is it, a review of a section of the NICE guideline on hypertension. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE News - April 2026 | 13 May 2026 | 00:08:47 | |
The video version of this podcast can be found here: · https://youtu.be/35Yog27dOoA This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in April 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for April 2026 can be found here:
· https://www.nice.org.uk/guidance/published?from=2026-04-01&to=2026-04-30&ndt=Guidance&ndt=Quality+standard The updated guideline on acne vulgaris: management [NG198] can be found here: · https://www.nice.org.uk/guidance/ng198 The updated guideline on suspected cancer: recognition and referral can be found here: · https://www.nice.org.uk/guidance/ng12/ The updated guideline on Menopause: identification and management [NG23] can be found here: · https://www.nice.org.uk/guidance/ng23
The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:
The updated quality standard on ovarian cancer [QS18] can be found here: · https://www.nice.org.uk/guidance/qs18 The updated guideline on Ovarian cancer: recognition and initial management [CG122] can be found here: · https://www.nice.org.uk/guidance/cg122
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in April 2026, focusing on what is relevant in Primary Care only. This month, we have a lot to cover and the areas are wide ranging: acne, the menopause and cancer, in particular endometrial and ovarian cancer and weight loss as a symptom of concern. Right, let’s jump into it. And let’s start with acne. The update does not change how we manage it. It’s still structured, stepwise, and based on severity. We should explain that there is no strong evidence for specific diets for acne. For mild to moderate acne, we should give a 12 week course of a first line option, which for most patients includes a fixed combination topical such as adapalene with benzoyl peroxide, or alternatives such as tretinoin with clindamycin, or benzoyl peroxide with clindamycin. For moderate to severe acne, we should combine the first line topical treatment with an oral antibiotic such as lymecycline or doxycycline. Topical or oral antibiotics should not be used as monotherapy, and courses for more than 6 months should be in exceptional circumstances. We should review at 3‑monthly intervals and stop the antibiotic as soon as possible. Additionally, we should not use a combination of a topical antibiotic and an oral antibiotic. If there is a poor response, we should consider switching options, and referral. Hormonal treatment like combined oral contraception, can be considered in women if first-line treatment is not effective. For people with polycystic ovary syndrome we can consider adding co-cyprindiol also known as dianette, or an alternative combined oral contraceptive pill. Now, the update itself relates to isotretinoin safety. Although it is initiated in secondary care, we should still be aware of the issues. There is no longer a requirement for two independent prescribers to approve its use in people under 18. Instead, updated MHRA safety measures must be followed. There is strengthened emphasis on mental health, requiring assessment and monitoring of mental health problems. Patients should be advised about the potential for psychiatric adverse effects of isotretinoin, including low mood, depression, and suicidal thoughts, and told to seek medical advice if these occur. In addition, as isotretinoin is teratogenic, patients must follow the MHRA pregnancy prevention programme, which includes effective contraception and formal acknowledgement of risk before treatment begins. Let’s now move to the update on menopause management. The main change here is about unscheduled vaginal bleeding in people taking systemic HRT. NICE now says that people should be told that vaginal bleeding is a common side effect during the first 6 months of taking systemic HRT, or within 3 months of changing the dose or preparation. They should also be told to seek medical help promptly if they have unscheduled vaginal bleeding beyond those timeframes. NICE has added that there is limited evidence for unscheduled bleeding while on HRT, and signposts the British Menopause Society guidance. The link is in the episode description. Let’s see what they recommend. We should first assess the patient fully, including, amongst other things, assessing the bleeding pattern, adherence, examination, BMI, and individual risk factors for endometrial cancer. Major risk factors include a BMI of 40 or more and some hereditary conditions. Minor risk factors include a BMI between 30 and 39, diabetes, and polycystic ovarian syndrome. In people at low risk, if bleeding occurs within 6 months of starting HRT, or persists within 3 months of changing it, we will adjust the progestogen or HRT preparation, for 6 months in total, before arranging further investigations. If unscheduled bleeding continues in low-risk women, after six months of adjustments, we could request an urgent transvaginal ultrasound. We should also do this if bleeding first occurs more than 6 months after starting HRT, or more than 3 months after changing treatment, and also if bleeding is heavy, prolonged, or if there are 2 minor risk factors. An urgent suspected cancer referral is recommended if there is 1 major risk factor or 3 minor risk factors for endometrial cancer, regardless of the bleeding pattern or timing. In terms of reducing bleeding, we should check adherence, prescribe adequate progestogen and consider a levonorgestrel intrauterine system. We should also consider vaginal oestrogens if the examination suggests atrophic changes. And now let’s move on to the area of cancer. The first updated area is endometrial cancer. Previously, NICE recommended suspected cancer referral with unexplained postmenopausal bleeding, particularly if they were aged 55 or over. The updated wording is more specific. NICE now recommends a cancer referral if they have unexplained postmenopausal bleeding that cannot be attributed to HRT, again, particularly if they are aged 55 or over, although we should consider it for younger patients too. So this update links the suspected cancer guideline with the menopause guidance and makes it clearer that bleeding on HRT needs context, rather than automatically leading to a cancer referral. Next is ovarian cancer. Examples of ovarian cancer symptoms are, for example, abdominal distension or pain, loss of appetite, and unexplained urinary symptoms, amongst many others. Previously, NICE used a single CA125 threshold of 35 IU per ml or greater to trigger ultrasound. Now, the updated guidance is more age specific. For people aged 39 or under with symptoms, we should not use CA125 in isolation and consider an urgent direct access ultrasound scan. This is because CA125 is not an accurate indicator of ovarian cancer risk in this age group. For people aged 40 or over, we should still check CA125, but there are now age specific thresholds for urgent ultrasound. These are 35 IU per ml or greater from 40 to 49, 31 from 50 to 59, 24 from 60 to 69, 25 from 70 to 79, and 31 from 80 onwards. The third updated area is unexplained weight loss. Previously, NICE recommended urgent investigation or suspected cancer pathway referral for people with unexplained weight loss without an age threshold. The new recommendation is narrower and now applies to people aged 60 and over. Unexplained weight loss is defined as more than 5 percent weight loss within 6 months, which can be a symptom of several cancers. In this situation we will assess further to clarify which cancer is most likely, and then offer urgent investigations, a suspected cancer pathway referral, or a non specific symptoms pathway referral. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE Hypertension Guideline Part 2: Investigations & Emergencies | 06 May 2026 | 00:07:51 | |
The video version of this podcast can be found here: · https://youtu.be/Ybf2fuw880Y This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Hypertension in adults: diagnosis and management [NG136] can be found here:
· https://www.nice.org.uk/guidance/NG136
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only. In the last episode we covered the diagnosis and initial assessment and then, we said that we would cover the investigations for target organ damage and the criteria for urgent referral in this episode. So let’s go through that now. Right, let’s jump into it. For all people with hypertension, we should offer the following investigations for target organ damage. We should test for protein in the urine by sending a urine sample for albumin to creatinine ratio, and test for haematuria using a reagent strip. We should take a blood sample to measure glycated haemoglobin, electrolytes, creatinine, eGFR, total cholesterol, and HDL cholesterol. We should examine the fundi for hypertensive retinopathy. And we should arrange a 12-lead ECG. Examples of target organ damage include left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy, or an increased urine albumin to creatinine ratio. Now let’s move on to identifying who to refer for same day specialist review. We should consider this when a person has severe hypertension, defined as a clinic blood pressure of 180 over 120 or higher. However, referral depends on more than just the blood pressure reading. So, we should refer people for same day specialist assessment if they have a clinic blood pressure of 180 over 120 or higher together with specific high-risk features. These include signs of retinal haemorrhage or papilloedema, which indicate accelerated hypertension. Accelerated hypertension refers to a severe increase in blood pressure to 180 over 120 or higher, often above 220 over 120, with signs of retinal haemorrhage or papilloedema. It is usually associated with new or progressive target organ damage and is also known as malignant hypertension. We should also refer if there are life threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. We should also refer people for same day specialist assessment if phaeochromocytoma is suspected. This may present with features such as labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or sweating. So, as we can see, not all patients with a blood pressure of 180 over 120 or higher will need urgent specialist referral. So, what do we do with patients who have severe hypertension, that is, who have a blood pressure of 180 over 120 or higher but do not meet the urgent specialist referral criteria? Let’s look at this group now. If a person has severe hypertension but no symptoms or signs indicating same day referral, we should carry out investigations for target organ damage as soon as possible. If target organ damage is identified, we should consider starting antihypertensive drug treatment immediately, without waiting for the results of ambulatory blood pressure monitoring or home blood pressure monitoring. If no target organ damage is identified, we should confirm the diagnosis by either repeating the clinic blood pressure within 7 days, or considering ambulatory blood pressure monitoring, or home blood pressure monitoring if ambulatory monitoring is not suitable or not tolerated, and ensuring a clinical review within 7 days. Before we move on to the final definitions, let’s summarise how to approach severe hypertension in practice. Severe hypertension is defined as a blood pressure of 180 over 120 or higher. At this level, the key question is whether there are symptoms or signs that indicate the need for same day specialist referral. Importantly, not all target organ damage means a hypertensive emergency. NICE recommends urgent same day referral only when severe hypertension is associated with specific high-risk features, such as retinal haemorrhage or papilloedema, or life-threatening symptoms like chest pain, confusion, heart failure, or acute kidney injury, or when phaeochromocytoma is suspected. So, in practice, we are not simply looking for any target organ damage, but for features of acute or ongoing organ damage that require immediate assessment. If these features are present, we call this hypertensive emergency andwe should refer the patient urgently for same day specialist care. If they are not present, this is often referred to as hypertensive urgency, as opposed to hypertensive emergency. Hypertensive urgency is more common, and the immediate risk of serious complications is generally low. In these cases, NICE advises that we should carry out investigations for target organ damage as soon as possible, but this does not necessarily mean hospital admission. Most patients can be managed safely in Primary Care with prompt investigations, close follow up, and appropriate initiation or adjustment of treatment. We need to remember that, in the absence of acute organ damage, blood pressure should be reduced gradually rather than rapidly to avoid complications such as cerebral or renal hypoperfusion. So overall, the main message is to identify red flag features that require urgent referral, and to use our clinical judgement. Now, before ending this short episode, let’s briefly clarify some definitions used in the guideline. Stage 1 hypertension is defined as clinic blood pressure between 140 over 90 and 159 over 99, with corresponding ambulatory or home averages between 135 over 85 and 149 over 94. Stage 2 hypertension is defined as clinic blood pressure of 160 over 100 or higher but below 180 over 120, with ambulatory or home averages of 150 over 95 or higher. Stage 3, or severe hypertension, is defined as clinic systolic blood pressure of 180 or higher, or diastolic blood pressure of 120 or higher. White coat effect is when the clinic blood pressure is higher by more than 20 over 10 millimetres of mercury compared with readings taken outside the clinic. Finally, at the opposite end of the spectrum, masked hypertension occurs when clinic blood pressure is normal, that is, below 140 over 90, but is higher outside the clinic on ambulatory or home monitoring. So that is it, a review of a section of the NICE guideline on hypertension. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Hypertension Part 1 Diagnosis | 29 Apr 2026 | 00:06:46 | |
The video version of this podcast can be found here: · https://youtu.be/8QEsYYKKGu0 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Hypertension in adults: diagnosis and management [NG136] can be found here:
· https://www.nice.org.uk/guidance/NG136
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only. Today, we are focusing on the diagnosis and initial assessment. In subsequent episodes, we will cover the other sections. Right, let’s jump into it. And let’s start about the measurement of blood pressure. Because automated devices may not measure blood pressure accurately if there is pulse irregularity, for example due to atrial fibrillation, we should palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, we should measure blood pressure manually using direct auscultation over the brachial artery. When measuring blood pressure in the clinic or in the home, we should standardise the environment and provide a relaxed and temperate setting, with the person quiet and seated, and their arm outstretched and supported. Furthermore, we should make sure that we use an appropriate cuff size for the person’s arm. Now, let’s look at postural hypotension. In people with symptoms of postural hypotension, including falls or postural dizziness, we should measure blood pressure with the person lying on their back, although we can consider a seated position if it is inconvenient to measure blood pressure with the person lying down. We should then measure blood pressure again after the person has been standing for at least one minute. If the person’s systolic blood pressure falls by 20 millimetres of mercury or more, or their diastolic blood pressure falls by 10 millimetres of mercury or more after standing for at least one minute, we should consider likely causes, including reviewing their current medication. We should also manage appropriately, for example giving advice on preventing falls, and we should measure subsequent blood pressures with the person standing. Additionally, we should consider referral to specialist care if symptoms of postural hypotension persist despite addressing the likely causes. If the drop in blood pressure is smaller than the diagnostic thresholds, and the person still has suggestive symptoms, we should repeat the test. This is especially important if the initial reading was taken from a seated position. This is because the drop in blood pressure from sitting to standing may be smaller than from lying down to standing, which can lead to false negatives. So, this time, we should start with the person lying flat, and then measure their blood pressure again after they stand up. We should then consider specialist referral if blood pressure measurements do not confirm postural hypotension despite suggestive symptoms. Let’s look at how we make the diagnosis of hypertension. When considering the diagnosis, we should measure blood pressure in both arms. If the difference between arms is more than 15 millimetres of mercury, we should repeat the measurements and if the difference remains more than 15, we should use the arm with the higher reading for future measurements. Now, if clinic blood pressure is 140 over 90 or higher, we should take a second measurement during the same consultation. If the second reading is substantially different from the first, we should take a third measurement. We then record the lower of the last two readings as the clinic blood pressure. If the clinic blood pressure is between 140 over 90 and 180 over 120, we should offer ambulatory blood pressure monitoring to confirm the diagnosis. If ambulatory blood pressure monitoring is not suitable or not tolerated, we should offer home blood pressure monitoring instead. While waiting to confirm the diagnosis, we should check their cardiovascular risk assessment using a validated tool and we should also carry out investigations for target organ damage. If the clinic blood pressure is 180 over 120 or higher, we should consider whether they need urgent referral. We will cover both the urgent referral criteria and the investigations for target organ damage in the next episode. When using ambulatory blood pressure monitoring, we should ensure that at least two measurements are taken per hour during the person’s usual waking hours, for example between 8am and 10pm. We should use the average of at least 14 measurements during waking hours to confirm the diagnosis. When using home blood pressure monitoring, we should ensure that two consecutive readings are taken for each recording, at least one minute apart, with the person seated and that blood pressure should be recorded twice daily, ideally in the morning and evening and that monitoring should continue for at least four days, but ideally for seven days. In home blood pressure monitoring we should discard the first day’s readings, and use the average of the remaining measurements to confirm the diagnosis. We will confirm hypertension if the clinic blood pressure is 140 over 90 or higher, and the ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average is 135 over 85 or higher. If hypertension is not diagnosed but there is evidence of target organ damage, we should consider investigating for alternative causes. If hypertension is not diagnosed, we should recheck clinic blood pressure at least every five years, more frequently if readings are close to 140 over 90. However, we should measure blood pressure at least once a year in adults with type 2 diabetes who do not have previously diagnosed hypertension or renal disease. Additionally, we should consider the need for specialist investigations in people who have signs and symptoms suggesting a secondary cause of hypertension. So that is it, a review of a section of the NICE guideline on hypertension. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Type 2 Diabetes Guideline – Part 5: Insulin Treatment and Complications | 22 Apr 2026 | 00:07:26 | |
The video version of this podcast can be found here: · https://youtu.be/URcxCjFEFRM This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:
· https://www.nice.org.uk/guidance/ng28
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only. The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections. Today, we are focusing on insulin-based treatment and the management of complications. In recent episodes, we covered the earlier sections. Right, let’s jump into it. First, let’s look at insulin-based treatments. When we start insulin in adults with type 2 diabetes, we should provide structured education. This education should cover aspects like injection technique, self-monitoring, dose titration, fitness to drive advice, managing hypoglycaemia, and managing acute changes in glucose. When initiating insulin, we should continue metformin in people already taking it. We should stop any other medicines used solely to manage hyperglycaemia. And we should discuss the risks and benefits of continuing medicines that have other benefits, for example cardiovascular protection or weight management. As initial insulin therapy, we should offer a basal insulin intended for once or twice daily use. If HbA1c is very high, especially 75 mmol per mol or higher, we should consider starting with basal insulin plus a short or rapid acting insulin. This can be given as separate injections, or as a premixed, biphasic insulin preparation. When choosing the insulin preparation, we should take into account whether the person needs help with injections, whether there is concern about nocturnal hypoglycaemia, and whether once daily injections would be preferred. If more than one basal insulin type is equally suitable, we should choose the least expensive option. We should consider premixed preparations that include insulin analogues rather than human insulin if the person wants to inject immediately before meals, if hypoglycaemia is a problem, or if glucose rises significantly after meals. At each review, we should check whether someone on basal insulin also needs bolus insulin before meals, or a move to a premixed biphasic regimen. At each review, if someone is on premixed biphasic insulin and their targets are not met, we should check whether they need to switch to a different premix or move to a basal bolus regimen. Now let’s move to complications. At annual review, we should advise adults with type 2 diabetes that they are at higher risk of periodontitis. We should explain that treating periodontitis can improve blood glucose control and can reduce the risk of hyperglycaemia. We should advise regular oral health reviews, and if periodontitis is diagnosed, we should offer dental appointments at a frequency based on their needs. We should think about gastroparesis in adults with erratic blood glucose control or unexplained bloating or vomiting, while considering alternative diagnoses. If vomiting is caused by gastroparesis, we should explain that there is no strong evidence that antiemetic treatments are effective. Some people may benefit from domperidone, erythromycin, or metoclopramide. We should be clear that domperidone has specific safety risks, particularly cardiac risk and drug interactions, so we need to prescribe cautiously. For treatment, we should consider alternating erythromycin and metoclopramide. We should only consider domperidone in exceptional circumstances, when it is the only effective option, and in line with safety guidance. If gastroparesis is suspected, we should consider referral to specialist services if the diagnosis is uncertain or vomiting is persistent or severe. For painful diabetic peripheral neuropathy, we should follow the relevant guideline. If someone loses their warning signs of hypoglycaemia, we should think about autonomic dysfunction. We should also consider autonomic involvement of the gut in unexplained nocturnal diarrhoea. If someone has autonomic neuropathy, we should be aware that orthostatic hypotension is more likely when taking antihypertensive medication. If someone has unexplained bladder emptying problems, we should investigate possible autonomic neuropathy affecting the bladder. Management should focus on the symptoms present, for example interventions for abnormal sweating or nocturnal diarrhoea. For prevention and management of diabetic foot problems, we should follow the diabetic foot problems guideline. As part of the annual review, we should offer to discuss erectile dysfunction when relevant, including addressing contributory factors such as cardiovascular disease and discussing treatment options. We should consider a phosphodiesterase 5 inhibitor and initially choose the option with the lowest acquisition cost, taking contraindications into account. If treatment is unsuccessful, we should refer to services that can offer other medical, surgical, or psychological options. In terms of eye disease, at diagnosis, we should refer adults immediately to the local eye screening service and encourage regular attendance. We should arrange emergency ophthalmology review for sudden loss of vision, rubeosis iridis, pre retinal or vitreous haemorrhage, or retinal detachment. We should refer to ophthalmology in line with diabetic eye screening pathway standards, and follow the diabetic retinopathy guideline. In this guideline, the recommendations on diagnosing and managing hypertension have been removed. For hypertension in people with type 2 diabetes, we should follow the hypertension in adults guideline, because management is broadly the same as for other people unless specified otherwise. Finally, we should not offer antiplatelet therapy, such as aspirin or clopidogrel, for people with type 2 diabetes who do not have cardiovascular disease. For primary and secondary prevention of cardiovascular disease, we should follow the relevant cardiovascular disease and acute coronary syndromes guidelines. So that is it, a review of a section of the NICE guideline on type 2 diabetes. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Type 2 Diabetes Guideline – Part 4: Introducing Medicines and Treatment Escalation | 15 Apr 2026 | 00:07:29 | |
The video version of this podcast can be found here: · https://youtu.be/dp6d3yH7AJs This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:
· https://www.nice.org.uk/guidance/ng28 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only. The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections. Today, we are focusing on how to introduce medicines, how to review them, and what to do when further treatment is needed after the initial regimen. In recent episodes, we covered the earlier sections of the guideline. In future episodes, we will move on to insulin-based treatment in more detail and the management of complications. Right, let’s jump into it. First, let’s look at introducing medicines. We should introduce medicines one at a time and check tolerability and effectiveness before moving on. When starting initial therapy with modified release metformin and other medicines, we should begin with metformin and confirm it is tolerated. If we are using an SGLT 2 inhibitor, we should start it once metformin is at the maximum tolerated dose. If we are also planning to use a GLP 1 receptor agonist or tirzepatide, we should introduce this once the SGLT 2 inhibitor is at the maximum tolerated dose. So even though the initial plan may involve more than one medicine, we still introduce them sequentially one at a time and monitor carefully. Now, let’s look at preventing diabetic ketoacidosis with SGLT 2 inhibitors. Before starting an SGLT 2 inhibitor, we should assess the risk of DKA. Risk factors include a previous episode of DKA, acute illness, dehydration, or following a very low carbohydrate or ketogenic diet. We should address modifiable risks before starting treatment. For example, if someone is on a ketogenic diet, we may need to delay the SGLT 2 inhibitor until their diet changes. We should also advise people that a very low carbohydrate diet increases the risk of DKA while on an SGLT 2 inhibitor. They should speak to a healthcare professional before starting such a diet, and treatment may need to be temporarily suspended. Next, let’s look at general principles when reviewing treatment. Before switching or adding medicines, we should optimise the current regimen. That means checking doses, adherence, side effects, and revisiting lifestyle advice. Now, let’s look at reviewing metformin. If someone is already taking standard release metformin, we can continue it. If it is not tolerated, or if the person prefers, we should switch to modified release metformin. Now, let’s look at reviewing other medicines. If a person has reached their target, we should consider continuing the medicines that contributed to that success. We should consider continuing SGLT 2 inhibitors for their cardiovascular or renal benefits, even if HbA1c targets are not fully achieved. We should stop GLP 1 receptor agonists or tirzepatide if the person becomes underweight, with a BMI below 18.5. We should also stop them if they are not helping the person reach glycaemic targets and they are not being used for cardiovascular benefit. We must take into account adverse effects from combinations, such as hypoglycaemia and we should not combine a GLP 1 receptor agonist or tirzepatide with a DPP 4 inhibitor. Now let’s move on to further medication, group by group. For people with no relevant comorbidity who need further treatment, we should add a DPP 4 inhibitor. If this is contraindicated, not tolerated, or not effective, we should add a sulfonylurea, pioglitazone, or insulin-based treatment. For people with heart failure who need further treatment, we should also add a DPP 4 inhibitor. If that is not suitable or not effective, we should add a sulfonylurea or insulin-based treatment. For people with atherosclerotic cardiovascular disease who develop this after initial treatment, we should add subcutaneous semaglutide, up to 1 mg once weekly, for cardiovascular and renal benefit. If further glycaemic control is needed, we should add a sulfonylurea, pioglitazone, or insulin-based treatment. For people with early onset type 2 diabetes who need further treatment, we should consider adding a GLP 1 receptor agonist or tirzepatide. If these are not suitable, we should add a DPP 4 inhibitor. If that is also not suitable or not effective, we should add a sulfonylurea, pioglitazone, or insulin-based treatment. If they are already taking a GLP 1 receptor agonist or tirzepatide and still need further control, we should add a sulfonylurea, pioglitazone, or insulin. For people living with obesity, if weight management is a key issue, we should follow the obesity guidance. If after at least 3 months of initial therapy further glycaemic control is needed, and they are not already on a GLP 1 receptor agonist or tirzepatide, we should consider adding one. If these are contraindicated, not tolerated, or ineffective, we should add a DPP 4 inhibitor. If that is not suitable, we should add a sulfonylurea, pioglitazone, or insulin. If they are already on a GLP 1 receptor agonist or tirzepatide and still need further control, we should add a sulfonylurea, pioglitazone, or insulin. For people with chronic kidney disease who need further treatment, we should consider adding a DPP 4 inhibitor. If they are already on one, or it is not suitable, we should consider adding pioglitazone, or a sulfonylurea if eGFR is above 30, or insulin. Finally, for people with frailty who need further treatment to control symptoms and reach targets, we should consider adding a DPP 4 inhibitor. If they are already on one or it is not suitable, we should consider adding pioglitazone, a sulfonylurea, or insulin. When choosing in frailty, we must remember that sulfonylureas and insulin increase the risk of hypoglycaemia and falls. So that is it, a review of a section of the NICE guideline on type 2 diabetes. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE News - March 2026 | 08 Apr 2026 | 00:05:41 | |
The video version of this podcast can be found here: · https://youtu.be/-kla7F8yibM This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in March 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for February 2026 can be found here:
· https://www.nice.org.uk/guidance/published?from=2026-03-01&to=2026-03-31&ndt=Guidance&ndt=Quality+standard The new guideline on Kidney cancer: diagnosis and management [NG256] can be found here: · https://www.nice.org.uk/guidance/ng256 The guideline on suspected cancer: recognition and referral can be found here: · https://www.nice.org.uk/guidance/ng12/ Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in March 2026, focusing on what is relevant in Primary Care only. This month, none of the updated guidelines were relevant to primary care. Only one new guideline had some relevance: kidney cancer: diagnosis and management. We will cover this briefly, focusing mainly on diagnosis and referring to the relevant section of the NICE guideline on suspected cancer, recognition and referral. Right, let’s jump into it. Before we go into kidney cancer itself, let’s briefly set the scene by looking at the NICE suspected cancer guideline. It is designed to help us recognise when symptoms may represent cancer and when to refer patients urgently. In urological cancers, we need to be aware that many cancers, including kidney and bladder cancer, may present with relatively non-specific symptoms. However, one symptom stands out as particularly important: that is, haematuria. Visible haematuria is the single most important red flag symptom for urological cancers. NICE recommends that we should make an urgent suspected cancer referral for bladder or renal cancer in adults aged 45 and over with unexplained visible haematuria, either without a urinary tract infection, or if it persists or recurs after treatment of a urinary tract infection. So, this is an important point. Visible haematuria, especially when unexplained, should always be taken seriously. At the same time, we should remember that haematuria can also be associated with prostate cancer. NICE advises that we should consider a PSA test and a digital rectal examination in patients with visible haematuria as well as those with lower urinary tract symptoms or erectile dysfunction. However, prostate cancer assessment follows a separate pathway, so today we will just focus on renal cancer. Now, what about non-visible haematuria? This is less specific, but still important in certain groups. NICE recommends that we should consider an urgent suspected cancer referral in people aged 60 and over with unexplained non visible haematuria if this is associated with symptoms such as dysuria, or abnormal blood results such as a raised white cell count. So the threshold is higher, but it is still clinically relevant. However we should note that this relates to suspected bladder cancer rather than kidney cancer, as the urgent criteria for renal cancer are based on visible haematuria. And while we are here, NICE also advises that we should consider a non urgent referral for bladder cancer, I repeat, a non urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection. Additionally, the suspected cancer guideline also emphasises safety netting. If a patient does not meet the referral criteria but symptoms persist or evolve, we should reassess and reconsider referral, always using our clinical judgement alongside the guideline. Now, with that context in mind, let’s move on to the new kidney cancer guideline itself. Diagnosing kidney cancer in Primary Care can be challenging. In fact, patients with kidney cancer may present late or with non-specific symptoms which may overlap with other conditions. So in practice, the diagnosis pathway for kidney cancer in Primary Care relies heavily on the features that trigger referral under the guideline on suspected cancer. This means that visible haematuria remains central. In addition, we also need to be aware that kidney cancer may present with more general symptoms, like flank or abdominal pain, weight loss, or fatigue. However, these are non-specific, and on their own may not meet referral thresholds. So again, clinical judgement and safety netting are really important. Another important point is the role of incidental findings. Some kidney cancers are detected incidentally on imaging performed for other reasons, although, in these cases, the pathway is usually driven by secondary care. In Primary Care, our role is mainly in recognising the features and making the referral and after that, most of the diagnostic pathway takes place in secondary care. There, once kidney cancer is suspected, the main test used is a CT scan of the abdomen and pelvis, or, if necessary, an MRI scan. On occasions, a contrast-enhanced ultrasound scan can be considered. So to summarise this section. Kidney cancer diagnosis in Primary Care is largely based on recognising features that trigger referral under the suspected cancer guideline. Visible haematuria remains the most important red flag symptom. Non-visible haematuria can also be relevant for bladder cancer in higher risk groups. And because symptoms can be vague, safety netting and clinical judgement are essential. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Type 2 Diabetes Guideline – Part 3: Medicines Management and Initial Treatment | 01 Apr 2026 | 00:07:13 | |
The video version of this podcast can be found here: · https://youtu.be/7LiKkriN9tc This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:
· https://www.nice.org.uk/guidance/ng28
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only. The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections. Today, we are focusing on medicines management, including sick day rules and choosing initial medicines. In recent episodes, we covered the initial sections of the guideline and in future episodes, we will move on to further drug treatment and the management of complications. Right, let’s jump into it. When discussing medicines, we should go through the benefits and risks of each option. This includes: · The effect on HbA1c and weight. · The effect on cardiovascular and renal outcomes. · Whether there are contraindications, such as pioglitazone in heart failure or metformin when eGFR is below 30. · Practical issues that might affect adherence. · And cost. If two medicines from the same class are equally suitable, we should use the least expensive option. If a person has more than one comorbidity, for example atherosclerotic cardiovascular disease and obesity, we should make a shared decision about which condition to prioritise. When discussing GLP 1 receptor agonists or tirzepatide we should explain the guidance on use in pregnancy and breastfeeding. We should explain that weight loss may improve fertility and that effective contraception must be used while taking these medicines. And if pregnancy is planned, contraception should continue for a period after stopping treatment. Now let’s move on to sick day rules. We should include clear sick day guidance in each person’s individual treatment plan. Depending on the medicines they are taking, this should cover: · Whether medicines need to be adjusted during illness or surgery. · Whether medicines such as metformin or SGLT 2 inhibitors should be temporarily stopped if there is a risk of dehydration, vomiting, or diarrhoea. · How to adjust insulin doses. · And how to restart treatment after recovery. Before initiating treatment, we should assess cardiovascular and renal status, and the person’s future cardiovascular risk. If frailty is a concern, we should assess this before starting medicines. Frailty can change the balance between benefits and harms. Let’s now move on to initial medicines. This section sets out what we should start at diagnosis, before insulin is needed. The recommendations are grouped by clinical profile. Let’s go through them one by one. First, people with no relevant comorbidities. For them, we should offer dual therapy with modified release metformin and an SGLT 2 inhibitor from the outset. If metformin is contraindicated or not tolerated, we should offer an SGLT 2 inhibitor alone. So the default starting point is dual therapy, not metformin alone. Next, people with heart failure. For adults with type 2 diabetes and heart failure, regardless of ejection fraction unless otherwise specified, we should again offer modified release metformin and an SGLT 2 inhibitor. If metformin cannot be used, we should offer an SGLT 2 inhibitor alone. Now let’s look at people with atherosclerotic cardiovascular disease. Here, we should offer modified release metformin, an SGLT 2 inhibitor, and subcutaneous semaglutide, up to 1 mg once weekly, for its cardiovascular, renal, and glycaemic benefits. If metformin is contraindicated or not tolerated, we should offer an SGLT 2 inhibitor plus subcutaneous semaglutide. So in this group, initial therapy is triple therapy, reflecting the very high cardiovascular risk. Next, people with early onset type 2 diabetes. Early onset means diagnosis under the age of 40. For these adults, we should offer modified release metformin and an SGLT 2 inhibitor, and we should consider adding either a GLP 1 receptor agonist for its cardiovascular, renal, and glycaemic benefits, or tirzepatide for its glycaemic benefits. If metformin is not suitable, we should offer an SGLT 2 inhibitor and consider adding a GLP 1 receptor agonist or tirzepatide. This reflects the higher lifetime risk in early onset disease and the need for more intensive early management. Now, let’s look at people living with obesity. For adults with type 2 diabetes who are living with obesity, we should offer modified release metformin and an SGLT 2 inhibitor. If metformin is contraindicated or not tolerated, we should offer an SGLT 2 inhibitor alone. Obesity itself does not automatically change the initial dual therapy recommendation, but it will influence later choices. Next, people with chronic kidney disease. We need to tailor treatment according to eGFR. If eGFR is above 30, we should offer modified release metformin and an SGLT 2 inhibitor. If metformin is not suitable, we should offer an SGLT 2 inhibitor alone. If eGFR is between 20 and 30, we should offer either dapagliflozin or empagliflozin, together with a DPP 4 inhibitor. If eGFR is below 20, we should consider a DPP 4 inhibitor. If a DPP 4 inhibitor is contraindicated, not tolerated, or not effective, we should consider pioglitazone or an insulin-based treatment. So in advanced kidney disease, the pathway shifts away from metformin and SGLT 2 inhibitors, depending on renal function. Finally, people with frailty. For adults with type 2 diabetes and frailty, we should offer modified release metformin. We should only offer an SGLT 2 inhibitor if the person’s level of frailty does not place them at risk of adverse effects, such as volume depletion or hypotension. If metformin is contraindicated or not tolerated, we should assess frailty carefully. If frailty does not increase the risk of adverse events, we should consider an SGLT 2 inhibitor alone. If frailty does increase risk, we should consider a DPP 4 inhibitor instead. So that is it, a review of a section of the NICE guideline on type 2 diabetes. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Type 2 Diabetes Guideline – Part 2: HbA1c Targets and Glucose Monitoring | 25 Mar 2026 | 00:06:36 | |
The video version of this podcast can be found here: · https://youtu.be/LsB8J96adC0 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:
· https://www.nice.org.uk/guidance/ng28
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only. The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections. Today, we are focusing on blood glucose management, including HbA1c targets and glucose monitoring. In the last episode, we covered patient education, dietary advice, and bariatric surgery. In future episodes, we will move on to further drug treatment and the management of complications. Right, let’s jump into it. Let’s start with HbA1c measurement and targets. We should measure HbA1c every 3 to 6 months, tailored to the person, until levels are stable on unchanging therapy. Once HbA1c and treatment are stable, we should measure it every 6 months. If HbA1c is unreliable, for example because of abnormal haemoglobin or altered red cell turnover, we should use alternative methods. These include quality-controlled plasma glucose profiles, total glycated haemoglobin if abnormal haemoglobins are present, or fructosamine. If there is a mismatch between HbA1c and other glucose readings, we should investigate and seek specialist advice if needed. Now let’s talk about targets. We should agree an individual HbA1c target with each person. This should be a shared decision. We should encourage people to reach and maintain their target, unless doing so causes adverse effects, including hypoglycaemia, or reduces their quality of life. For people managed with lifestyle alone, or with medicines that do not cause hypoglycaemia, we should support them to aim for an HbA1c of 48 mmol per mol, or 6.5 percent. For people taking medicines associated with hypoglycaemia, we should support them to aim for 53 mmol per mol, or 7 percent. If HbA1c rises to 58 mmol per mol, or 7.5 percent or higher, we should reinforce advice about diet, lifestyle and adherence, and intensify treatment, aiming again for 53 mmol per mol or 7 per cent. We should consider relaxing HbA1c targets on a case-by-case basis. This is particularly important for older or frail adults, people with reduced life expectancy, those at high risk of hypoglycaemia, or those with significant comorbidities. If someone achieves an HbA1c lower than their agreed target and is not having hypoglycaemia, we should encourage them to maintain it. However, we should remember that a low HbA1c may sometimes be a sign of other issues, such as weight loss or deteriorating kidney function. Now let’s move to self-monitoring of capillary blood glucose. We should not routinely offer self-monitoring to everyone with type 2 diabetes. We should offer it if the person is on insulin, has hypoglycaemic episodes, is taking medicines that increase the risk of hypoglycaemia while driving or operating machinery, or is pregnant or planning pregnancy. Additionally, we should consider short term self-monitoring when starting corticosteroids, or to confirm suspected hypoglycaemia. During acute illness, we should review treatment because blood glucose levels can worsen. If someone is self-monitoring, we should carry out a structured review at least once a year. This should include checking their technique, how often they test, whether they understand the results, the impact on their quality of life, whether it is still beneficial, and the equipment they are using. Now let’s look at continuous glucose monitoring. NICE says that we should offer intermittently scanned continuous glucose monitoring, often called flash monitoring, to adults on multiple daily insulin injections if they have recurrent or severe hypoglycaemia, impaired hypoglycaemia awareness, a disability that prevents finger prick testing, or if they would otherwise need to test at least eight times a day. We should also offer flash monitoring to adults on insulin who would otherwise need help from a care worker or healthcare professional to monitor their glucose. We should consider real time continuous glucose monitoring instead of flash if it is available at the same or lower cost. Continuous glucose monitoring should be provided by a team with expertise, and it must be part of a wider self-management plan. People using continuous glucose monitoring still need to check capillary blood glucose at times. This is to confirm accuracy and as a back up if the device fails or glucose levels are changing quickly. They should be given enough test strips to do this safely. If someone cannot or does not want to use continuous monitoring, we should offer capillary blood glucose monitoring instead. We should review the use of continuous monitoring regularly as part of the diabetes care plan. If there are concerns about how it is being used, we should explore any problems and offer further education or support. Finally, a word on hyperglycaemia. If an adult with type 2 diabetes develops symptoms of hyperglycaemia, we should consider insulin or a sulfonylurea, and then review treatment once blood glucose returns to target. So that is it, a review of the first section of the NICE guideline on type 2 diabetes. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE 2026 Type 2 Diabetes Guideline – Part 1: Education, Lifestyle and Bariatric Surgery | 18 Mar 2026 | 00:07:18 | |
The video version of this podcast can be found here: · https://youtu.be/y-hTBUYkInk This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:
· https://www.nice.org.uk/guidance/ng28
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only. The link to the NICE guideline is the episode description. Right, let’s jump into it. The diabetes guideline is a comprehensive document, so I am going to break it down into manageable sections. Today, we will focus on the first part of the NICE guideline, covering tailoring care, structured education, dietary advice, and bariatric surgery. In future episodes, we will move on to drug treatment and the management of complications. First, let’s start with tailoring care to the person. NICE recommends an individualised approach for adults with type 2 diabetes. Care should be tailored to the person’s needs and circumstances. This includes their personal preferences, their other medical conditions, the risks from polypharmacy, and their likelihood of benefiting from long term treatments. This is especially important for people with multimorbidity. At each review, we should reassess the person’s situation and think about whether any medicines are no longer effective and could be stopped. When planning care, we should take into account any disabilities, including visual impairment. For discussions about overweight and obesity, NICE directs us to the guideline on overweight and obesity management, including how to classify overweight and obesity and how to address the drivers behind it. There is also a specific section in the guideline on eating disorders for those who have both type 2 diabetes and an eating disorder, covering advice on collaborative care, blood glucose management, and insulin use. Next is structured education. NICE says we should offer structured education to all adults with type 2 diabetes at diagnosis. Family members or carers should also be involved where appropriate. Education should be reinforced and reviewed every year and it should be explained clearly that structured education is a core part of diabetes care. Education programmes should be evidence based and suitable for the person. They should have clear aims and learning objectives, and support people to develop the knowledge and skills to self-manage their diabetes. Programmes should follow a structured curriculum, be delivered by trained educators, and outcomes should be regularly monitored. Group education is the preferred option, but there must be an alternative of equal standard for people who cannot attend or prefer not to take part in group sessions. Education programmes should meet local cultural, language, cognitive and literacy needs. All members of the diabetes team should know what programmes are available locally, and these programmes should be integrated into the overall care pathway. Now let’s move on to dietary advice. Adults with type 2 diabetes should receive individualised and ongoing nutritional advice from a healthcare professional with expertise in nutrition. Dietary advice should be sensitive to the person’s culture, beliefs, willingness to change, and the impact on quality of life. In general, people with type 2 diabetes should follow the same healthy eating advice as the general population. This includes choosing high fibre, low glycaemic index carbohydrates such as fruit, vegetables, wholegrains and pulses, choosing low fat dairy products, eating oily fish, and limiting saturated and trans fats. For low energy or very low energy diets aimed at remission, the guideline directs us to the specific guidance on the NHS Type 2 Diabetes Path to Remission Programme and the overweight and obesity management guideline. Dietary advice should be integrated into a personalised diabetes management plan, including physical activity and weight management. Carbohydrate intake, alcohol intake, and meal patterns should be individualised. Reducing the risk of hypoglycaemia is particularly important for people using insulin or insulin secretagogues. People can substitute a limited amount of sucrose containing foods for other carbohydrates in their meal plan, but they should avoid excess calorie intake. NICE advises against using foods marketed specifically for people with diabetes. For people admitted to hospital or another care setting, there should be a meal planning system that provides consistency in carbohydrate content. Finally, let’s talk about bariatric surgery. For people with recent onset type 2 diabetes, we should follow the recommendations on surgical interventions in the overweight and obesity management guideline. This guideline is separate to the diabetes guideline but we will cover it briefly here. It says that we should offer adults a referral for a comprehensive assessment by a specialist multidisciplinary overweight and obesity management service to see whether bariatric surgery is suitable if they have a BMI of 40 or more, or a BMI between 35 and 39.9 with a significant health condition that could improve with weight loss. These conditions include cardiovascular disease, hypertension, fatty liver disease, obstructive sleep apnoea, and type 2 diabetes. The person must also agree to long term follow up after surgery, including lifelong annual reviews. For people of South Asian, Chinese, other Asian, Middle Eastern, Black African, or African Caribbean background, we should use a BMI threshold that is 2.5 lower than these values, because cardiometabolic risk occurs at lower BMI in these groups. We should refer for expedited assessment for bariatric surgery to people with a BMI of 30 or more who have recent onset type 2 diabetes, defined as diagnosed within the past 10 years, provided they are also being assessed within a specialist overweight and obesity management service. For people from South Asian, Chinese, other Asian, Middle Eastern, Black African, or African Caribbean backgrounds, we should use BMI thresholds that are 2.5 lower when deciding on expedited assessment. So that is it, a review of the first section of the NICE guideline on type 2 diabetes. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE News - February 2026 | 11 Mar 2026 | 00:08:45 | |
The video version of this podcast can be found here: · https://youtu.be/YX_YmP-yRfM This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in February 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for February 2026 can be found here:
The updated guideline on Type 2 diabetes in adults: management [NG28] can be found here: · https://www.nice.org.uk/guidance/ng28 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in February 2026, focusing on what is relevant in Primary Care only. This month there is just one updated guideline relevant to us, but it’s a major one: type 2 diabetes. A few months ago we reviewed the draft version of the guideline. Now that the final version has been published, over the next few weeks I’ll be creating separate episodes covering the different sections in more depth. So today, I’ll just give you an overview, highlighting the differences between the draft recommendations and the final version. Right, let’s jump into it. Firstly, let’s have a look at the first line treatment in people with no relevant comorbidities. In the draft guideline, NICE recommended starting metformin plus an SGLT2 inhibitor from the outset, with SGLT2 monotherapy if metformin was not tolerated. The final guideline confirms this, but now specifies that patients should be started on modified release metformin rather than just metformin. This change applies throughout the guideline. Wherever standard release metformin was previously recommended, it now says modified release metformin. Is this the death of the standard release preparation? Possibly in the long term. Anyone starting treatment should be on the modified release version, so numbers on standard release metformin will gradually fall. However, NICE also states that patients already on standard release can continue, or switch if necessary. Now let’s look at first line treatment in specific clinical groups, starting with heart failure. In the draft guideline, the recommendation was metformin plus an SGLT2 inhibitor, and it suggested that semaglutide could be added for weight management in selected people with preserved ejection fraction and no frailty. In the final guideline, it’s still modified release metformin plus an SGLT2 inhibitor, with SGLT2 monotherapy if metformin is not tolerated. However, for people with heart failure who need further treatment, the guideline moves straight to adding a DPP4 inhibitor first, then a sulfonylurea or insulin if needed. There is no recommendation in this section to add a GLP1 receptor agonist specifically for heart failure. Next, people with atherosclerotic cardiovascular disease. The draft guideline recommended early triple therapy with metformin plus an SGLT2 inhibitor plus semaglutide, continuing for cardiorenal benefit even if glycaemic targets were not met. In the final guideline, this is confirmed but made more specific. Here, we should offer modified release metformin plus an SGLT2 inhibitor plus subcutaneous semaglutide up to 1 milligram once a week for cardiovascular, renal and glycaemic benefits. If metformin is not tolerated, we will use an SGLT2 inhibitor plus semaglutide. It also explicitly recommends starting semaglutide if atherosclerotic cardiovascular disease develops at any stage after initial therapy. Next is the obesity group. In the draft guideline, semaglutide was recommended after three months, with additional filters such as preserved ejection fraction and no frailty. In the final guideline, NICE broadens this. It recommends either a GLP1 receptor agonist or tirzepatide after at least three months of initial therapy if further treatment is needed. Now let’s look at chronic kidney disease. There are three eGFR bands here: above 30, 20 to 30, and below 20. For eGFR above 30, we will use modified release metformin. SGLT2 inhibitors are still prioritised early for kidney and cardiovascular protection, and dapagliflozin and empagliflozin are specifically named because of licensing reasons. The 20 to 30 eGFR band is where we see a change. In the draft guideline, if eGFR was between 20 and 30, NICE advised offering dapagliflozin or empagliflozin alone. In the final guideline, it now says that if eGFR is 20 to 30, we should offer dapagliflozin or empagliflozin plus a DPP4 inhibitor. So, this is now explicit dual therapy rather than SGLT2 monotherapy. The rationale explains why. If the eGFR is below 30, cardiorenal protection of SGLT2 inhibitors remains, but the glucose lowering effect is reduced, so a DPP4 inhibitor is recommended for HbA1c control. For eGFR below 20, the draft guideline advised using a DPP4 inhibitor first, then considering pioglitazone or insulin, and it stated that sulfonylureas should not be used if eGFR was below 30. In the final guideline it remains the same, a DPP4 inhibitor first and then pioglitazone or insulin. However, there is no blanket rule about sulfonylureas in the CKD section although we need to know that hypoglycaemia risk increases as renal function falls. . The draft also recommended not using empagliflozin or dapagliflozin if eGFR was less than 20. The final guideline does not phrase it that way. It simply directs us to DPP4 inhibitors rather than a blanket ban of SGLT2 inhibitors when eGFR is below 20. And now, the final group is frailty. The draft guideline recommended metformin alone, effectively deprioritising SGLT2 inhibitors as frailty increases SGLT2 risks. In the final version, modified release metformin remains first line, but there is no automatic ban of SGLT2 inhibitors at baseline. Instead, the escalation sequence is first a DPP4 inhibitor and then consider pioglitazone, a sulfonylurea or insulin, taking into account hypoglycaemia and falls risk. Regarding GLP1 receptor agonists and tirzepatide, the draft implied they were generally inappropriate in frailty due to weight loss and gastrointestinal effects. However, the final guideline is more neutral. It does not specifically recommend them for frailty, but it states there is no inherent safety risk. If another indication exists, they can still be used even in frailty. Now, let’s look at some other sections of the guideline. Looking at GLP1 receptor agonists, the draft recommended stopping them if glycaemic or weight goals were not achieved, unless the person had atherosclerotic cardiovascular disease or early onset diabetes. In the final guideline, NICE recommends stopping GLP1 receptor agonists or tirzepatide if BMI falls below 18.5 or if they do not help with the glycaemic targets as long as they are not being taken for cardiovascular benefit. So, the emphasis shifts from weight thresholds towards glycaemic targets and cardiovascular benefit. Regarding combining GLP1 receptor agonists and DPP4 inhibitors, both the draft and the final guideline advise against it. The final guideline also extends this to tirzepatide. In the insulin section, the draft stated that GLP1 receptor agonists could be combined with insulin in Primary Care without specialist approval. The final guideline does not explicitly restate the specialist approval point. It simply states that when initiating insulin, we should continue metformin, stop other medicines used solely for glycaemic control, and discuss continuing medicines used for cardiovascular protection or weight management. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Osteoporosis Treatment: When Bones Need Backup | 04 Mar 2026 | 00:08:28 | |
The video version of this podcast can be found here: · https://youtu.be/tdY5bOFmzbg This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. This video refers to the clinical guideline by the National Osteoporosis Guideline Group. (details below). 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 them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the treatment of osteoporosis, always focusing on what is relevant in Primary Care only. The information is based on the clinical guideline by the National Osteoporosis Guideline Group. The link to it is below. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on osteoporosis can be found here:
· https://www.nice.org.uk/guidance/cg146
The Clinical guideline for the prevention and treatment of osteoporosis by the National Osteoporosis Guideline Group can be found here:
· https://www.nogg.org.uk/sites/nogg/download/NOGG-Guideline-2024.pdf?v3
The NICE technology appraisal on Bisphosphonates for treating osteoporosis can be found here:
· https://www.nice.org.uk/guidance/ta464 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to review the treatment of osteoporosis, always focusing on what is relevant in Primary Care only. I have based this episode on the clinical guideline by the National Osteoporosis Guideline Group. The link to it is the episode description. Right, let’s jump into it. We will start by saying that we need a strategy to decide who gets treated, which is what we call “intervention thresholds.” We need to remember that the NICE guideline on assessing the risk of fragility fracture and Osteoporosis does not itself define fixed treatment thresholds. Instead, we are advised to follow local or national guidance when deciding when to treat. So, for the purpose of this video, I will explain the thresholds given by the National Osteoporosis Guideline Group. Here the intervention threshold (for people under 70) is set at a fracture risk equivalent to a same-age woman who has already had a fracture. As people age, the threshold for treatment rises, so at the age 70 years and above, fixed thresholds are applied. When FRAX is calculated we can get a result that shows low risk, intermediate risk, high risk and very high risk of a Major Osteoporotic Fracture. If the fracture risk is low, we will offer lifestyle advice. If a person’s calculated risk sits near that intervention threshold, then that is intermediate risk and we should consider a bone mineral density (BMD) measurement with DXA to refine the estimate. If after the bone mineral density result the risk is high, we move forward with treatment otherwise, we will reassess later. If the fracture risk meets or exceeds the intervention threshold, that person is considered high risk and eligible for treatment. If the risk is very high, for example if they have multiple risk factors — we may consider referral for more aggressive treatment. Let’s now focus on the non-drug measures recommended for preventing and managing osteoporosis. They should be recommended for everyone, whether or not we eventually use drugs. First — diet and nutrition, ensuring adequate calcium intake. Ideally this is achieved through food, but if needed, we can use supplements to reach recommended levels. We should also make sure vitamin D is addressed. For people at risk of low vitamin D — for example, those with limited sun exposure, people who are housebound, or living in care homes — we should offer vitamin D supplementation. Next —We should encourage regular weight-bearing and muscle-strengthening exercise, tailored to each person’s ability. This supports bone strength, maintains muscle mass, and helps prevent falls. Speaking of falls — for those with osteoporosis or fragility fractures, or at risk of fracture, we must assess their fall risk. For patients identified as at risk of falling, we should offer an exercise programme to improve balance and muscle strength. We must also address lifestyle factors. We should advise smoking cessation in smokers and recommend moderation of alcohol intake. For all patients we should also screen for and manage other medical conditions that may contribute to bone fragility, such as endocrine problems, malabsorption, chronic illness or immobility. Now let’s move on to the pharmacological treatment options for osteoporosis, based on the National Osteoporosis Guideline Group recommendations, and the NICE Technology Appraisal on Bisphosphonates for treating osteoporosis There are several effective drug treatments available, but for most patients, bisphosphonates remain the first-line option. These include oral alendronic acid, risedronate and ibandronate, as well as intravenous zoledronic acid and ibandronate if recommended by a specialist. How do bisphosphonates work? Bisphosphonates slow down the rate of bone breakdown by inhibiting osteoclast activity. This helps stabilise bone density and reduces the risk of fractures. What about risks and how do we minimise them? Common side effects include gastrointestinal irritation with oral bisphosphonates, and muscle or joint aches. Much rarer risks include atypical femoral fractures and osteonecrosis of the jaw. To minimise these, we ensure correct administration: oral tablets should be taken with a full glass of water on an empty stomach, with the patient remaining upright for at least 30 minutes. We also maintain good dental hygiene, have a dental check-up and complete major dental work before starting treatment where possible, and reassess the need for long-term therapy at appropriate intervals. Alongside bisphosphonates, denosumab is another established anti-resorptive option. If we use denosumab, we must plan from the start how we will eventually stop or switch treatment, because stopping it abruptly without follow-up therapy can lead to rebound bone loss and an increased risk of vertebral fractures. For patients at the highest fracture risk, we should seek specialist input. These patients may benefit from anabolic, or bone-forming treatments such as romosozumab, or other anabolic or sequential regimens. Now let’s look at how we manage osteoporosis treatment over time, that is, the long-term strategy. First: when we start a drug treatment for osteoporosis — for example a bisphosphonate or denosumab — we need a clear plan for how long that treatment should continue, how we’ll monitor it, and when we’ll reassess risk. For oral bisphosphonates, we generally treat for at least five years and for intravenous bisphosphonates, at least three years. In patients at higher risk — for instance people over 70, or those who’ve had hip or vertebral fractures, or patients on high-dose steroids — longer treatment might be needed. Also, if they sustain a further fragility fracture while on treatment, we will also keep going. In lower-risk patients, after five years of oral bisphosphonates (or three years of IV bisphosphonates), we may consider a treatment pause for 18 to 36 months, depending on individual risk. Second: we must reassess fracture risk periodically. This means that we should repeat the fracture risk assessment if the patient has a new fracture, regardless of when the treatment started. If we paused treatment, we should re-assess the fracture risk after 18 months to 3 years — depending on individual circumstances. Third: some situations require special consideration.
And finally, fourth: after a fragility fracture or in people at high or very high fracture risk, treatment should start promptly, because the risk of re-fracture is often greatest soon after the first event. So that is it, a review of the treatment of osteoporosis. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Osteoporosis: Assessing Fracture Risk | 25 Feb 2026 | 00:07:03 | |
The video version of this podcast can be found here: · https://youtu.be/GmCg9TskZNA This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. This video refers to a number of medical articles on ADHD published by a number of organisations (details below). 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 any of them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover ADHD increasing incidence, especially in adults, always focusing on what is relevant in Primary Care only. The information is based on a number of published medical articles. The links to them are below. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on osteoporosis can be found here:
· https://www.nice.org.uk/guidance/cg146 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are looking at the NICE guideline on osteoporosis, specifically how we diagnose it and how we assess the risk of fragility fractures, always focusing on what is relevant in Primary Care only. The links to the NICE guideline is the episode description. Right, let’s jump into it. Let’s start by saying that we should consider assessing fracture risk in all women aged 65 and over, and all men aged 75 and over. Additionally, we should also consider assessing fracture risk in women under 65 and men under 75 if they have risk factors. Examples of these risk factors include: • a previous fragility fracture, • current or frequent recent use of oral or systemic glucocorticoids, • a history of falls, • a family history of hip fracture, • a low BMI, below 18.5, • smoking, • drinking more than 14 units of alcohol per week • and any cause of secondary osteoporosis Causes of secondary osteoporosis can include endocrine conditions such as hypogonadism in either sex — including untreated premature menopause — and treatment with aromatase inhibitors or androgen-deprivation therapy. They also include hyperthyroidism, hyperparathyroidism, hyperprolactinaemia, Cushing’s disease, and diabetes. Other causes include gastrointestinal conditions such as coeliac disease, inflammatory bowel disease, chronic liver disease, chronic pancreatitis, and other causes of malabsorption. Then we have rheumatological conditions like rheumatoid arthritis and other inflammatory arthropathies as well as haematological diseases such as multiple myeloma, and haemoglobinopathies. And finally we have respiratory conditions like cystic fibrosis and COPD and other conditions like CKD and immobility due to neurological disease or injury. We should not routinely assess fracture risk in people under the age of 50 unless they have major risk factors — such as current or recent glucocorticoid use, untreated premature menopause, or a previous fragility fracture — because they are unlikely to be at high risk. Now, how should we actually assess the risk of fracture? We can use either FRAX — which we can use without a bone mineral density (BMD) value if a DXA scan hasn’t been done — or QFracture, to estimate the ten-year absolute risk. FRAX can be used for people aged 40 to 90, with or without a bone mineral density (BMD) value. QFracture can be used for people aged 30 to 84, but a bone mineral density (BMD) value cannot be added into that tool. If someone is older than the age range covered by these tools, we should assume they are at high risk. Additionally. we should interpret fracture-risk estimates with caution in people over 80, because a ten-year prediction may underestimate their short-term risk. We should not routinely measure bone mineral density with a DXA scan before doing a FRAX or QFracture assessment. These tools estimate a ten-year fracture risk using simple clinical information and help us decide whether a scan is actually needed. Skipping this step can lead to unnecessary DXA scans in people who are clearly low risk. It can also lead to missed scans in those whose risk is borderline, and it is therefore an inefficient use of resources. We only need to measure bone density when the FRAX or QFracture score is close to the intervention threshold, where a DXA result could change the treatment decision. So, the NICE guideline recommends using FRAX or QFracture first, and then requesting a DXA scan only if it is likely to influence management. If we do a DXA scan, once we have the bone mineral density result, we should recalculate the absolute risk using FRAX with the bone mineral density value included. The intervention threshold is the level of risk at which treatment is recommended. The NICE guideline does not define that threshold; instead, we, as clinicians, should follow local protocols or national guidance. I will cover this in a different episode on osteoporosis treatment. We should also consider measuring BMD before starting treatments that can rapidly reduce bone density, such as sex-hormone deprivation therapy for breast or prostate cancer. People under 40 should have BMD measured to assess fracture risk only if they have a major risk factor, such as multiple fragility fractures, a major osteoporotic fracture, or current or recent use of high-dose oral or systemic glucocorticoids — meaning more than 7.5 milligrams of prednisolone, or equivalent, per day for three months or longer. We should consider recalculating fracture risk in the future if the original risk was close to the intervention threshold and only after at least two years, or if the person’s risk factors change. Again, for intervention thresholds we will need to follow local protocols or national guidelines. We should also remember that risk-assessment tools can underestimate fracture risk in certain situations. This includes people with multiple fractures, previous vertebral fractures, high alcohol intake, high-dose glucocorticoid use, or other causes of secondary osteoporosis. As mentioned earlier, causes of secondary osteoporosis include endocrine, gastrointestinal, rheumatological, haematological, respiratory, metabolic, renal, and neurological conditions, as well as prolonged immobility. Finally, we should keep in mind that fracture risk can also be affected by factors not included in the risk tools — for example, living in a care home, or taking drugs that impair bone metabolism, such as anticonvulsants, SSRIs, thiazolidinediones, proton-pump inhibitors, and antiretroviral medications. So that is it, a review of the NICE guideline on osteoporosis. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Eos-in the Know: A Quick Guide to Eosinophilia | 18 Feb 2026 | 00:08:33 | |
The video version of this podcast can be found here: · https://youtu.be/V93jdGfnLIk This video refers to guidelines produced by a number of organisations (details below). 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 any of them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do if eosinophilia is found, always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
My summary of the guidance consulted can be found here: · https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84 The resources consulted can be found here: · Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage · Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0 · Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf · King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdf Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter eosinophilia on a full blood count, always focusing on what is relevant in Primary Care only. I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description. Right, let’s jump into it. Eosinophilia refers to an increased number of eosinophils in the blood. Although thresholds may vary slightly between laboratories, eosinophilia is generally defined as an eosinophil count greater than 0.5 × 10⁹ per litre. Eosinophils are white blood cells involved in allergic responses, parasitic infections, and various inflammatory processes, so an elevated count can indicate a wide range of underlying conditions. Let’s have a look at some of the possible causes of eosinophilia. They include: • Asthma: particularly allergic asthma, which commonly has high eosinophil levels because of their role in airway inflammation and hypersensitivity reactions. • Then we have Skin disease such as eczema, atopic dermatitis, urticaria, and psoriasis: because these conditions involve allergic or immune-mediated inflammation, which often stimulates eosinophils. • Infections, especially those due to parasites, as well as fungal infections, tuberculosis and malaria. Parasitic infections are a very typical cause, but some fungal and bacterial infections can also trigger eosinophilia through chronic inflammation. • Another possible cause is Drugs, including penicillin, allopurinol, amitriptyline, and carbamazepine, although virtually any medication can be a possible trigger. Drug-induced eosinophilia often occurs as part of a hypersensitivity reaction. • Then we have Connective tissue diseases such as rheumatoid arthritis given that autoimmune and vasculitic conditions can increase eosinophils due to chronic inflammation. • We also have Solid malignancies, for example breast, renal, stomach, and lung cancer. This is because certain cancers release cytokines that stimulate eosinophil production. In some cases eosinophilia may be a paraneoplastic manifestation. • Then, Myeloproliferative disorders including leukaemia and lymphoma. Here eosinophilia can happen either because eosinophils are part of the malignant clone or due to cytokine-driven overproduction. • another cause, Respiratory diseases such as bronchiectasis and cystic fibrosis, again caused by the ongoing inflammatory response. • Then, Endocrine conditions such as Addison’s disease. This is because cortisol suppresses eosinophils and in Addison’s, the low cortisol will result in a high eosinophil count. • and finally we have Post-splenectomy. This is because the spleen normally helps regulate and remove eosinophils from circulation, so splenectomy will result in an increased eosinophil count. If the eosinophil count is greater than 2.5 × 10⁹/L, we will look for signs of organ damage. This is because very high eosinophil levels can lead to direct tissue injury. Activated eosinophils release toxic inflammatory mediators, and cytokines that can cause inflammation and fibrosis in virtually any organ. The heart, lungs, skin, gastrointestinal tract, and nervous system are particularly vulnerable. Damage can progress rapidly and we should consider urgent admission if there are red flags Red flags include: • Severe symptoms secondary to organ involvement, such as • difficulty breathing, • chest pain, • abdominal pain, or • neurological symptoms. • as well as other complications, including tissue damage, venous thromboembolism, or evidence of end-organ injury such as acute kidney injury or heart failure. Even in the absence of red flags, criteria for urgent referral to haematology are: • A leucoerythroblastic blood film, which suggests bone marrow infiltration, haematological malignancy or severe bone marrow stress. • And absolute eosinophil count greater than 5 × 10⁹/L, as this level significantly increases the risk of hypereosinophilic syndromes and progressive organ damage. If the urgent criteria are not met and the patient is clinically well, we will check the travel and drug history and assess for any evidence of atopy, such as asthma, eczema, or allergic rhinitis. We will then repeat the blood test within one to two weeks to confirm whether the eosinophilia is persistent and to look for possible underlying causes. Initial investigations will include: • As already mentioned, a repeat full blood count, to confirm that the eosinophilia is persistent and to check for other abnormalities which may suggest a bone marrow disorder. • A blood film, which can reveal abnormal cell morphology, blast cells, or features suggesting reactive versus clonal eosinophilia. • Inflammatory markers such as ESR and CRP, which help identify underlying infection, inflammation, or autoimmune disease. • Immunoglobulin E, as a high IgE is common in allergic disease, parasitic infections, and some hypereosinophilic syndromes. • An autoimmune profile, since eosinophilia can occur in connective tissue diseases and vasculitis. • Renal and liver function tests, because organ dysfunction can be both a cause and a consequence of eosinophilia. • A bone profile, as a high calcium may suggest granulomatous disease such as sarcoidosis or certain malignancies. This is because granulomatous conditions and some cancers increase the production of active vitamin D or stimulate bone breakdown, both of which increase calcium levels. • We will also check for LDH, which can be high in haematological malignancies and in high cell turnover. • Vitamin B12 and folate, since a raised B12 can be a clue to myeloproliferative disease, while a deficiency can contribute to abnormal blood counts. • A chest X-ray, particularly if tuberculosis, pulmonary eosinophilia, or sarcoidosis are suspected. • Stool culture and microscopy for ova, cysts, and parasites, as parasitic infections are a common and important cause of eosinophilia worldwide. • Serological antibodies for threadworm or other nematode infections, especially if there are suggestive symptoms. • and finally, Serological antibodies for schistosomiasis, depending on travel history and ideally after discussion with microbiology, as the timing can influence accuracy. Schistosomiasis is a parasitic infection acquired through contact with freshwater in endemic regions in Africa, the Middle East, South America, and parts of Asia, which emphasises why travel history is so important. If the cause is found, we will treat it accordingly. However, we will refer to haematology routinely if the eosinophilia remains unexplained and it is greater than 1.5 × 10⁹/L for three months or longer, or if it is rising without an obvious cause. These patterns raise concern for hypereosinophilic syndromes or underlying haematological disease. So that is it, a review of the assessment and management of eosinophilia. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - NICE News - January 2026 | 11 Feb 2026 | 00:05:14 | |
The video version of this podcast can be found here: · https://youtu.be/us-qmMn8gsk This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in January 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for January 2026 can be found here:
The updated guideline on Suspected cancer: recognition and referral [NG12] can be found here: · https://www.nice.org.uk/guidance/ng12 The updated guideline on Overweight and obesity management [NG246] can be found here: · https://www.nice.org.uk/guidance/ng246 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in January 2026, focusing on what is relevant in Primary Care only. And this time we have two updated guidelines relevant to us in General Practice: the guidelines on Suspected cancer and on Overweight and obesity management. The changes are minimal so today we have a very short episode. Right, let’s jump into it. And let’s start with the guideline on obesity and overweight management. The update is narrow and specific and clarifies that height-to-weight ratios should only be used to classify the degree of central adiposity in children and young people aged 5 years and over. Before this amendment, the guideline included height-to-weight ratios for children, but it did not explicitly state that these ratios should not be used in under 5s. This is because height-to-weight ratios in younger children, may not be validated or appropriate. In fact, in children under 5 years: · Body proportions change very rapidly as part of normal growth and development · There is wide normal variation in body shape and fat distribution and · Height to weight ratios do not accurately reflect central adiposity in this age group and therefore using these ratios risks overestimating or underestimating adiposity However, in children aged 5 years and over: · Body proportions become more stable · Patterns of central fat distribution are more consistent · And the available evidence supports height to weight ratios in this age group as they are more likely to reflect true central adiposity No other recommendations, were changed. Everything else remains as it was in the previous published guideline. Now let’s move to the guideline on suspected cancer. In January 2026 the update information for the NICE guideline on suspected cancer states that NICE has removed an incorrect recommendation related to blood tests for suspected myeloma. However, when you look at the guideline as it stands, things appear a little confusing, so it is worth looking at this in more detail. Originally, the guideline listed a broad panel of blood tests for suspected myeloma in primary care. This included serum protein electrophoresis and serum free light chain testing, alongside a full blood count, calcium, and plasma viscosity or ESR. Bence Jones urine testing was suggested as an alternative if serum free light chain testing was not available. These tests were recommended for people with features such as persistent bone pain or an unexplained fracture. Subsequently, NICE amended the wording of this section to place greater emphasis on serum protein electrophoresis and serum free light chain testing as the key initial investigations. So the obvious question is this. Has NICE really now removed the recommendation to offer blood tests for suspected myeloma altogether? At face value this looks like guidance that is moving backwards and forwards. The confusion is increased by the fact that if you look at the recommendations organised by site of cancer, under haematological cancers, the guideline still clearly lists blood tests for suspected myeloma. So what is actually happening here? In theory, the update information reflects the official and authoritative change to the guideline. It may be that parts of the published recommendations text have not yet been fully revised or synchronised on the NICE website. However, I have also reviewed other sections of the NICE website, including committee discussions and rationale documents, and I have not been able to find any explanation for this change. That also raises the possibility that the update statement itself may be an error. In practical terms, my view is that we should probably continue to request blood tests for suspected myeloma until the guideline text has been fully updated and this discrepancy is clarified. That is, we should request a full blood count, calcium, plasma viscosity or ESR, paraprotein, using serum protein electrophoresis and serum free light chains. If serum free light chain testing is not available, we can use a Bence–Jones test to check for free light chains contained in urine. I have raised a query directly with NICE, and we should have further clarification soon. For now, this is very much a case of watching this space. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Cut to the Clot: Raised HCT Explained | 04 Feb 2026 | 00:10:40 | |
The video version of this podcast can be found here: · https://youtu.be/4NysH3aEPMM This video refers to guidelines produced by a number of organisations (details below). 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 any of them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I neutropenia always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
My summary of the guidance consulted can be found here: · https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84 The resources consulted can be found here: · Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage · Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0 · Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf · King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdf Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter a high haematocrit, including initial assessment, follow up and management, always focusing on what is relevant in Primary Care only. I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description. Right, let’s jump into it. And we will start by saying that haematocrit measures the proportion of blood volume taken up by red blood cells. It can be expressed either as a percentage—from 0 to 100 or as a decimal proportion, from 0 to 1. Because it reflects the relative volumes of red cells and plasma, the haematocrit is influenced not only by the absolute number of red blood cells but also by the amount of circulating plasma. Any change in either component will affect the final value. A high haematocrit raises the possibility of polycythaemia. Polycythaemia can be diagnosed when the haematocrit is greater than 0.52 in men and greater than 0.48 in women. These thresholds help identify affected people, but they do not, by themselves, tell us the cause. Polycythaemia is sometimes referred to as erythrocytosis, but this is not entirely accurate. Erythrocytosis specifically refers to an increased number of red blood cells in the circulation. Polycythaemia, on the other hand, is defined by a raised haematocrit, not by a direct count of red blood cells. As a result, it is possible to have a high haematocrit without true erythrocytosis. This distinction matters because there are two types of polycythaemia. The first is absolute polycythaemia, where an increased red cell mass is genuinely present, that is, true erythrocytosis. The second is relative or apparent polycythaemia, where the haematocrit is high not because there are more red cells, but because the plasma volume is reduced. Dehydration, diuretics, or plasma loss can all create this picture, leading to a raised haematocrit despite a normal red cell mass. It is also common in obese men, and it is also associated with smoking, alcohol, hypertension and stress. Despite the potentially reversible causes of relative or apparent polycythaemia, these patients are also at risk of occlusive vascular episodes. On the other hand, we have absolute polycythaemia, which reflects a true increase in red cell mass. This can be divided into primary and secondary causes. The primary cause is Polycythaemia Vera (PV). Well over 90% of patients with PV have an acquired mutation in the JAK2 gene, which plays an important role in regulating erythropoiesis. Because of this mutation, the bone marrow becomes hypersensitive to growth signals and produces red blood cells even when erythropoietin levels are low. In other words, these patients do not need as much erythropoietin to drive red cell production. The main features of Polycythaemia Vera are therefore: • a positive JAK2 mutation test, • a low serum erythropoietin level. Polycythaemia Vera is also commonly associated with low ferritin, because the accelerated and unregulated production of red cells consumes large amounts of iron. Being a myeloproliferative disorder, Polycythaemia Vera may also show raised white blood cells and/or platelets, reflecting the involvement of the bone marrow. Secondary polycythaemia, on the other hand, results from a physiological increase in erythropoietin production. The kidneys release more erythropoietin in response to reduced oxygen levels, so secondary polycythaemia can be an appropriate response to chronic hypoxia, as seen in COPD, congenital or acquired heart disease, and in smokers. It can also be an inappropriate response when erythropoietin is produced by tumours, such as certain renal or liver tumours, or even uterine fibroids, which can secrete erythropoietin autonomously. Other possible causes of secondary polycythaemia include anabolic steroids and testosterone therapy, as androgens stimulate erythropoietin production through hormonal pathways. In cases of secondary polycythaemia, the pattern is different: • the JAK2 mutation is negative, • erythropoietin levels are high, and • ferritin, white blood cells and platelets are normal. So what do we do when we receive a high haematocrit result? Well, Criteria for urgent referral are a haematocrit greater than 0.60 in men or greater than 0.56 in women. We should also refer urgently if the patient has had a recent thrombosis, shows any abnormal bleeding, or reports neurological or visual symptoms. These features raise concern for hyperviscosity or an underlying myeloproliferative disorder, both of which require immediate specialist assessment. If the criteria for urgent referral are not met, the next step is to confirm the result by repeating the blood test. In order to differentiate between apparent and absolute polycythaemia, the blood sample should be taken without a tourniquet, and we should ensure that the patient has not been fasting, is well hydrated, and has been advised about alcohol intake and smoking, as these factors can artificially raise the haematocrit. In this repeat blood test, we should request: • A repeat full blood count, to confirm whether the raised haematocrit is persistent and to check for associated abnormalities in white cells or platelets. • A blood film, which can reveal morphological clues to myeloproliferative disease or other haematological disorders. • We should screen for diabetes, hyperlipidaemia and hypertension, as these cardiovascular risk factors often coexist with secondary causes of polycythaemia and may contribute to vascular complications. • As mentioned earlier, we should also check Ferritin, to assess iron stores, which may be depleted in Polycythaemia Vera due to increased red cell production. • and finally renal and liver function tests, since kidney or liver disease may contribute to secondary polycythaemia or influence erythropoietin production. Additionally, if we suspect absolute polycythaemia, the following tests should be done: • Genetic testing for the JAK2 mutation, which is positive in the great majority of patients with Polycythaemia Vera. • And erythropoietin levels, which help distinguish primary from secondary causes, being low in PV and elevated in secondary polycythaemia. However, in the UK, JAK2 mutation testing and serum erythropoietin levels are not routinely available in primary care. In most areas, these investigations are carried out by haematology teams, as they form part of the specialist work-up for myeloproliferative disorders. While some regions may allow primary-care access, this is not standard practice, and therefore, if absolute polycythaemia is suspected or the haematocrit remains persistently elevated, the appropriate course of action is to refer the patient to haematology, who will then arrange JAK2 and erythropoietin testing as part of their assessment. So, let’s summarise these patients’ management again: If we encounter someone with a high haematocrit, we will see if they meet the urgent referral criteria, that is, a haematocrit greater than 0.60 in men or greater than 0.56 in women. We should also refer urgently if the patient has had a recent thrombosis, shows any abnormal bleeding, or reports neurological or visual symptoms. If the urgent criteria are not met, we will repeat the FBC and arrange routine screening investigations. Criteria for routine referral are an unexplained, persistently elevated haematocrit above 0.52 in men or above 0.48 in women, taking into account that referral should be considered at lower thresholds if there is associated iron deficiency. “Persistently” means at least two readings above these levels taken four weeks apart. Alternatively, routine referral is also justified if the haematocrit is above 0.52 in men or above 0.48 in women without waiting for a second test if there are associated symptoms of concern such as pruritus, raised white cell count and/or platelets, splenomegaly, or if there is a past, not recent history of arterial or venous thrombosis. From a clinical perspective, we will suspect apparent polycythaemia if there is a history of factors such as dehydration, smoking, alcohol excess, diuretics, or other causes of haemoconcentration. We will suspect absolute secondary polycythaemia if there is chronic hypoxia from conditions such as COPD, smoking, or cardiac disease, if the patient is taking anabolic steroids or testosterone therapy, or if there is a possibility of erythropoietin -producing tumours in the kidney or liver. If none of these clues is present, we may be dealing with absolute primary polycythaemia, or Polycythaemia Vera. These patients should be referred to haematology, since confirming the diagnosis requires tests that are not routinely available in general practice, ike JAK2 mutation testing and serum EPO levels. So that is it, a review of the initial assessment and management of neutropenia. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - Platelet Down: A Quick Look at Thrombocytopenia | 28 Jan 2026 | 00:08:48 | |
The video version of this podcast can be found here: · https://youtu.be/TQB5tJvM0VM This video refers to guidelines produced by a number of organisations (details below). 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 any of them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do if thrombocytopenia is found, always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
My summary of the guidance consulted can be found here: · https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84 The resources consulted can be found here: · Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage · Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0 · Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf · King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdf Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter thrombocytopenia on a full blood count, always focusing on what is relevant in Primary Care only. I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description. Right, let’s jump into it. Thrombocytopenia is the platelet count is low, which is defined as a platelet count below 150 × 10⁹ per litre. But before we assume a true low platelet count, we need to remember that thrombocytopenia can often be an artefact. This happens when platelets clump together in the EDTA sample tube, giving a falsely low automated count. So, the first step is always to confirm the result with a repeat full blood count and a blood film. The blood film not only rules out platelet clumping but can also provide important clues about the underlying cause. There are many potential causes of thrombocytopenia so, let’s have a look at them: First, we have alcohol excess. Chronic alcohol use can directly suppress bone marrow production and shorten platelet lifespan. It is also frequently associated with chronic liver disease, where the spleen often becomes enlarged due to portal hypertension destroying more platelets than usual — a process known as hypersplenism. Then we have recreational drugs, which can also impair platelet production or trigger immune-mediated destruction. Then, travel history is also very important. Malaria, for example, often presents with thrombocytopenia, sometimes even before fever or parasitaemia becomes obvious. Tuberculosis can also cause thrombocytopenia, either through bone marrow involvement or immune-mediated mechanisms. Then we should consider liver and renal disease. In chronic liver disease we have already explained that hypersplenism is the most common cause of thrombocytopenia in liver disease. In renal disease, platelet lifespan is reduced because uraemia makes platelets more fragile, causing them to break down more quickly. In addition, bone marrow suppression may also occur. Then we have medications as another common culprit. NSAIDs, heparin, digoxin, quinine, anti-epileptics, antipsychotics and proton pump inhibitors are all recognised causes. Most drug-induced thrombocytopenia is caused by either: • immune-mediated platelet destruction, or • direct suppression of platelet production in the bone marrow. Heparin is the main exception because it causes thrombocytopenia through a unique immune reaction that activates platelets, leading to their consumption and a fall in the platelet count. Another possible cause are nutritional deficiencies, especially vitamin B12 and folate deficiency, which can impair bone marrow production and lead to thrombocytopenia, often alongside other cytopenias. We also need to consider viral causes. For example, Epstein–Barr virus frequently causes a temporary drop in platelets, which typically resolves within a few weeks. HIV and hepatitis B or C can cause persistent thrombocytopenia either through direct bone marrow suppression, immune-mediated destruction, or associated splenomegaly. Then, malignancy is also on the list, because both haematological cancers and solid tumours can infiltrate or suppress the bone marrow. Then we have bone marrow failure syndromes, such as aplastic anaemia, which will often present with thrombocytopenia together with anaemia and neutropenia. Another cause is immune thrombocytopenic purpura, or ITP, which is an autoimmune condition that destroys platelets. In adults, ITP can be acute or chronic, and the platelet count can fall to very low levels even when the patient looks otherwise well. Finally, autoimmune conditions such as SLE can present with thrombocytopenia as part of a broader immunological process. Now that we have had a look at the causes, how should we manage these patients? We have already mentioned that we should confirm thrombocytopenia with a repeat FBC and blood film. If the thrombocytopenia is confirmed, we will need to check if there are urgent criteria. First of all, we should arrange urgent same-day hospital assessment when the platelet count is below 20 × 10⁹ per litre and any concerning clinical features are present. These include: • Active bleeding, even if minor, because bleeding risk rises sharply at very low platelet levels. • An abnormal blood film, such as the presence of blasts suggesting acute leukaemia, or red cell fragments suggesting microangiopathic haemolysis, as these findings indicate potentially life-threatening conditions. • And finally an altered consciousness or confusion, which may point to serious systemic illness, intracranial bleeding, severe infection, or thrombotic microangiopathy. We should make an urgent outpatient haematology referral if the platelet count is below 50 × 10⁹ per litre, even without symptoms. This is because at this level, the risk of spontaneous bleeding increases, and many underlying causes — such as ITP, bone marrow failure, or haematological malignancy — require urgent assessment. Additionally, when the platelet count is below 50, it is unsafe to continue antiplatelet agents or anticoagulants, so these should be stopped unless a specialist advises otherwise. We should also make an urgent outpatient haematology referral when the platelet count is between 50 and 100 and certain concerning features are present. These include splenomegaly, lymphadenopathy, other cytopenias, pregnancy, or planned surgery. This is because all of these situations increase the risk of serious underlying disease or increase the risk of bleeding. However, if the platelet count is above 50 and none of the urgent referral criteria are present, we should then arrange the following baseline investigations: Firstly, we begin with a repeat full blood count and a blood film to confirm the thrombocytopenia, rules out platelet clumping, and look for abnormal cell morphology. Then we will check Vitamin B12 and folate levels to rule out deficiency. Ferritin and iron studies are also helpful, given that iron deficiency can occasionally contribute to low platelets. Inflammatory markers, such as ESR and CRP, which can suggest infection, inflammation, or an underlying autoimmune process. An autoimmune profile to exclude autoimmune-mediated platelet destruction. Renal, liver and thyroid function tests to identify chronic liver disease, renal failure and thyroid disease given that both hypo- and hyperthyroidism — can contribute to thrombocytopenia. Then, viral serology for HIV, hepatitis B and hepatitis C as these viruses can be associated thrombocytopenia. And finally, we should perform any other investigations suggested by the history or examination, for example, malaria testing after relevant travel, a TB workup, coagulation studies if there is bleeding, etc. After the initial baseline investigations, if no obvious cause is found, the platelet count is above 50 and none of the urgent referral criteria are present, we can repeat the full blood count after 4 to 6 weeks. If thrombocytopenia persists and remains unexplained, we should then refer the patient routinely to haematology. So that is it, a review of the assessment and management of thrombocytopenia. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Chole-Stuck: Cholestatic LFTs explained | 21 Jan 2026 | 00:08:46 | |
The video version of this podcast can be found here: · https://youtu.be/lhtciu3O8tc The video on raised bilirubin pattern can be found here: · https://youtu.be/ndAus37PfsE The video on hepatitic pattern abnormal LFTs can be found here: · https://youtu.be/rIX46swVSfg This episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology. 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 them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do when we encounter abnormal LFTs with a cholestatic pattern, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
My summary guide can be downloaded here: · https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS
The resources consulted can be found here: BSG- British Society of Gastroenterology: · bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests · Guidelines on the management of abnormal liver blood tests (bsg.org.uk) o First published on: o BMJ article: o Guidelines on the management of abnormal liver blood tests | Gut (bmj.com)
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter abnormal LFTs with a cholestatic pattern, always focusing on what is relevant in Primary Care only.
This episode is based on the British Society of Gastroenterology guidelines on abnormal Liver function tests. A link to it is in the episode description.
Right, let’s jump into it. And let’s start by remembering that there are three common patterns of abnormal liver function tests or LFTs:
As we have said, LFTs showing a cholestatic pattern normally present with a high ALP and GGT. Alkaline phosphatase, or ALP, is produced mainly in the liver but is also found in bone, intestines, kidneys and the placenta. Levels are physiologically higher in childhood because of rapid bone growth, and in pregnancy due to placental production. Raised ALP can come from either hepatic or non-hepatic sources. The main source of non-hepatic ALP is bone. ALP increases in bone disease because it is produced by osteoblasts, the cells responsible for forming new bone. Any condition that increases osteoblast activity or bone turnover—such as healing fractures, Paget’s disease, bone metastases, or vitamin D deficiency—causes osteoblasts to increase their activity, releasing more ALP into the circulation. We should remember that the most common cause of an asymptomatic, non-hepatic raised ALP is vitamin D deficiency. And let’s remember that vitamin D deficiency increases bone turnover because low vitamin D reduces calcium absorption from the gut. To maintain normal calcium levels, parathyroid hormone rises and stimulates bone breakdown to release calcium. This increase in bone remodelling activates osteoblasts leading to a rise in ALP. But as we are focusing on liver function tests, what is the source of a raised hepatic ALP? From a pathophysiological perspective, hepatic ALP rises when bile flow is impaired, also known as cholestasis. And, why does cholestasis cause a rise in ALP? It happens because alkaline phosphatase is found in high concentration in the cells lining the bile ducts. When bile flow is impaired, pressure builds up in the biliary system and the bile duct epithelium becomes irritated. This stimulates these cells to produce and release more ALP into the bloodstream. This is the reason why ALP rises in, for example, gallstone disease, strictures, or cholangitis. On the other hand, γ-glutamyltransferase, or GGT, is found in the liver but not in bone. Therefore, when ALP is raised, measuring GGT helps determine whether the source is hepatic or non-hepatic. A raised ALP with a normal GGT suggests a bone-related cause, whereas a raised ALP with a raised GGT supports a hepatic origin and should prompt further assessment of cholestatic liver disease. GGT rises in cholestasis because it is also highly concentrated in the cells lining the bile ducts. When pressure builds up in the biliary system, these cells release more GGT into the bloodstream. In addition, cholestasis causes oxidative stress because retained bile acids are toxic to liver cells. In response, the liver increases GGT production, as GGT is involved in antioxidant and detoxification pathways, leading to the characteristic rise in cholestatic liver disease. A high GGT can also be due to obesity, excess alcohol, or medications. In obesity and NAFLD, fat accumulation within the liver creates oxidative stress, so the liver up-regulates GGT to protect hepatocytes from free radical damage. In this context, an elevated GGT reflects metabolic stress rather than structural cholestasis. In alcohol use, ethanol metabolism produces toxic intermediates that also generate oxidative stress, which further stimulates GGT production as part of the liver’s detoxification response. We will not go into detail on how to proceed with an isolated raised ALP, that is, with a normal GGT, as today we are focusing on cases where there is clear hepatic involvement, meaning that both ALP and GGT are high in a true cholestatic pattern. How should we investigate and manage these patients? When we manage patients with any abnormal liver function tests, we must begin by recognising red flags that require urgent action. According to the British Society of Gastroenterology guidelines, if there are signs of synthetic liver failure – such as unexplained clinical jaundice, a low albumin, or a raised INR – or if there is a suspicion of malignancy, for example unexplained weight loss or marked cholestasis, then the patient should be urgently referred or admitted for specialist assessment. If the pattern is cholestatic, we will proceed with a full liver screen. This is because cholestatic abnormalities are often related to structural biliary disease, autoimmune cholestatic conditions, or infiltrative disorders, and these require a broader diagnostic approach than simple repeat testing. What tests should be done in a full liver screen? A full liver screen should include an ultrasound scan of the liver and biliary tree, which is the first-line imaging test. Ultrasound helps identify biliary dilatation, gallstones, strictures, masses, or features of chronic liver disease. In addition to imaging, blood tests should include hepatitis B and C screening, an autoantibody screen, serum immunoglobulins, ferritin and transferrin saturation, and, often and where clinically appropriate, a coeliac screen, alpha-1 antitrypsin levels, and caeruloplasmin. These tests collectively help detect autoimmune cholestatic diseases such as primary biliary cholangitis, metabolic conditions such as haemochromatosis or Wilson’s disease, and chronic viral hepatitis. It is also worth emphasising that this full liver screen is recommended not only for cholestatic abnormalities but also for patients who present with a hepatitic pattern, as the BSG guideline advises a comprehensive assessment irrespective of the pattern or the degree of derangement once initial red flags have been excluded. The management in primary care is fairly simple, because the British Society of Gastroenterology recommends that once initial investigations have been completed, these patients should be referred to secondary care for further assessment. This applies both when a cholestatic picture come with abnormalities in the liver screen and also if the ALP and GGT remain persistently high even in the context of normal investigations. Referral is indicated because persistent cholestatic abnormalities indicate underlying pathology that usually cannot be adequately diagnosed or managed in primary care and requires specialist input. So that is it, a review of abnormal LFTs with a cholestatic pattern. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - Platelet Points: Making Sense of Thrombocytosis | 14 Jan 2026 | 00:07:41 | |
The video version of this podcast can be found here: · https://youtu.be/3QL2R2IV83o This video refers to guidelines produced by a number of organisations (details below). 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 any of them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do if thrombocytosis is found, always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
My summary of the guidance consulted can be found here: · https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84 The resources consulted can be found here: · Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage · Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0 · Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf · King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdf Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter thrombocytosis on a full blood count, always focusing on what is relevant in Primary Care only. I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description. Right, let’s jump into it. Thrombocytosis is when the number of platelets is high, which is usually defined as a raised platelet count above 450 × 10⁹/L. But before moving on, let’s clarify the terminology: should we call it thrombocytosis or thrombocythemia? There is an important difference. Thrombocytosis is much more common and arises as a secondary response to another condition, which is why it is also known as reactive thrombocytosis. In contrast, thrombocythemia, also called primary or essential thrombocythemia, is far less common and represents a myeloproliferative disorder in which the bone marrow produces platelets in an uncontrolled, abnormal way. Another important distinction is that patients with reactive thrombocytosis have normal platelets, so their risk of thrombosis and bleeding is relatively low. On the other hand, patients with thrombocythemia have abnormal platelets, which increases their risk of both blood clots and bleeding complications. From a clinical perspective, thrombocythemia often presents with splenomegaly and a platelet count greater than 1000 × 10⁹/L. So, let’s have a look at the possible causes. Causes of thrombocytosis include: • Iron Deficiency Anaemia: which is one of the most common causes of reactive thrombocytosis. When iron levels are low, the bone marrow increases its overall activity in an attempt to compensate for the anaemia. Although iron deficiency limits the production of red blood cells, platelet production is not restricted in the same way. As a result, the bone marrow produces more platelets. In addition, inflammatory signals associated with chronic iron deficiency can further stimulate thrombopoietin pathways, increasing platelet numbers even more. This is why thrombocytosis often resolves once the iron deficiency is corrected. • Another cause is Malignancy, because some tumours release inflammatory cytokines that eventually increase platelet formation. This reactive response is common in several solid cancers, particularly the “LEGO” cancers, that is: • Lung • Endometrium • Gastric • and Oesophageal cancer • Another cause is general Inflammation, where cytokines stimulate excessive platelet production. • Also Infection, which can cause transient reactive thrombocytosis. • Post-splenectomy and hyposplenism, such as in coeliac disease, since the spleen normally helps remove circulating platelets. • Post-operative states, where inflammation and stress responses increase platelet counts. • And finally, a primary myeloproliferative disorder, such as essential thrombocythemia. How should we respond to thrombocytosis? The criteria for urgent haematology referral are: • A platelet count exceeding 1000 × 10⁹/L, which raises concern for a myeloproliferative disorder and a significant risk of thrombosis. • Splenomegaly, which may indicate a primary haematological process such as essential thrombocythemia or myelofibrosis. • A recent history of thromboembolism, as thrombocytosis can contribute to recurrent clotting events. • A platelet count above 600 × 10⁹/L in a patient at high risk of thromboembolism or cardiovascular disease, since the combination significantly increases clinical risk. • Neurological symptoms, which may reflect microvascular complications associated with very high platelet counts. • Any signs of malignancy, given that multiple cancers can cause reactive thrombocytosis. • any other significant abnormal full blood count indices, which may suggest a bone marrow disorder rather than a reactive process. • And finally, if there is Abnormal bleeding. And let’s stop here for a moment and discuss how it is possible that thrombocytosis can be associated to a high risk of both thrombosis and bleeding. On one hand, thrombosis risk in thrombocytosis is due to the high number of circulating platelets, which makes clots more likely. In addition, inflammation causing reactive thrombocytosis can also create a prothrombotic environment. Together, these factors increase the thrombosis risk. On the other hand, bleeding risk in thrombocytosis can occur for two main reasons. First, in primary or essential thrombocythemia, the platelets produced by the bone marrow are structurally and functionally abnormal and these abnormal platelets do not work effectively, so clot formation is impaired. Secondly, thrombocytosis may affect the von Willebrand factor. Von Willebrand factor is a protein that helps platelets stick to damaged blood vessels and to each other, making it essential for the first steps of clot formation. However, when platelet counts become very high, the excess platelets bind and remove the most active forms of von Willebrand factor from the circulation. This leads to a functional depletion known as acquired von Willebrand syndrome. It explains the paradoxical situation in which a patient can have thrombocytosis and yet be at increased risk of bleeding. If none of the urgent referral criteria are present, we will investigate for underlying causes by arranging the following initial tests: • A repeat full blood count, to confirm that the thrombocytosis is persistent. • A blood film, which may reveal abnormal platelet morphology or other features suggestive of a myeloproliferative process. • Inflammatory markers such as ESR and CRP, since inflammation is a common cause of reactive thrombocytosis. • Ferritin and iron studies, as iron deficiency frequently elevates platelet counts. • And we will consider a coeliac screen, because coeliac disease can lead to hyposplenism or iron deficiency, both of which are associated with thrombocytosis. If the patient is asymptomatic and no obvious cause is identified, we will repeat the full blood count 4 to 6 weeks later. If the thrombocytosis persists above 450 × 10⁹/L, we will refer to haematology routinely for further assessment. So that is it, a review of the assessment and management of thrombocytosis. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - NICE News - December 2025 | 07 Jan 2026 | 00:07:34 | |
The video version of this podcast can be found here: · https://youtu.be/p6YSowcUuEo This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in December 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for December 2025 can be found here:
The updated guideline on Child maltreatment: when to suspect maltreatment in under 18s [CG89] can be found here: · https://www.nice.org.uk/guidance/ng253
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in December 2025, focusing on what is relevant in Primary Care only. And this time we have just one updated guideline that is relevant to us in General Practice: the guideline on when to suspect maltreatment in children. Right, let’s jump into it. In December 2025, NICE updated the guideline Child maltreatment: when to suspect maltreatment in under 18s. The core change in this update is the addition of a definition of the term “independently mobile.” Before this update, the NICE guideline used the term “independently mobile” in several key recommendations, but did not define what that term meant. We were expected to interpret it based on our own judgement. This led to variation in practice, particularly when assessing injuries such as bruises, lacerations, and abrasions. Different clinicians could reasonably reach different conclusions about whether a child met this threshold, even when looking at the same clinical picture. The term was sometimes difficult to interpret as to whether it meant rolling, crawling, bottom-shuffling, cruising, or walking, given that there was no shared or agreed definition in the guideline. The definition has been developed using a formal consensus process and “independently mobile” is now clearly defined as a child who can move around independently without support, rather than relying on being placed or carried. Therefore, a child should be considered independently mobile if they can do any of the following:
Children under 12 weeks typically lack the muscle strength, coordination and neurological maturity needed for independent mobility. However, age alone should not be used to determine whether a child is independently mobile. This definition has now been added in three areas, specifically in recommendations on: • bruising and petechiae, • lacerations, abrasions and scars, • and burn or scald injuries. Compared with the previous version, the key difference is clarity, not threshold. The level of concern for injuries has not been raised or lowered. Instead, we now have a shared understanding of which children fall into the higher-risk group when assessing unexplained or concerning injuries. Otherwise no other major changes were made to recommendations on child abuse and neglect. Right, this is the end of the update itself. And, as we have a brief episode today, let’s now look at a brief summary of this guideline. And the first thing to say is that the aim of the guideline is to help us recognise features that should raise concern and prompt further safeguarding action. We are not expected to confirm abuse, but to recognise the risks and act appropriately. Let’s now briefly review some examples of when to suspect or consider maltreatment. These are situations that may need urgent safeguarding action or discussion with local safeguarding leads. We should suspect maltreatment when there are injuries with no explanation, or an explanation that does not fit, especially: – bruising, cuts, abrasions, burns or scalds in a child who is not independently mobile, – bruises with clear shapes, such as hands, grips, or ligatures, – burns or scalds with clear patterns or signs of forced immersion, – multiple injuries or injuries of different ages, – injuries that are symmetrical or in unusual locations, – and injuries that are in areas normally covered by clothing. We should also suspect maltreatment with serious injuries without adequate trauma, including: – fractures, especially multiple fractures or rib fractures in infants, – fractures of different ages, – intracranial injury without a major accidental cause, – retinal haemorrhages or unexplained eye injuries, – and spinal, abdominal, or chest injuries that are unexplained, even if there are no external signs. Additionally, we should suspect sexual abuse when there are clear indicators, including: – genital, anal, or perianal injury without an accidental explanation, – and pregnancy in a child under 13 years, which is a strong indicator of maltreatment. Pregnancy in 13- to 15-year-olds should prompt assessment for sexual abuse. We should suspect neglect when there are strong indicators, such as: – repeated failure to provide basic care, food, warmth, or safety, – and failure to seek medical help that puts the child at risk. We should also consider possible neglect, if there is, for example: – poor hygiene or inappropriate clothing, – an unsafe home environment, – missed immunisations or health reviews, – and severe or ongoing infestations, And we should be concerned if parents or carers: – fail to give essential medication, – repeatedly miss important appointments, – or do not seek medical help when appropriate. Also, Poor school attendance without a clear reason and repeated or unusual healthcare attendances, especially across multiple services, should also raise concern. Additionally, we should consider fabricated or induced illness when: – reported symptoms do not match clinical findings, – and when symptoms only occur in the presence of carers, and investigations are repeatedly normal. We should consider maltreatment when there are behavioural or emotional concerns, such as: – sudden changes in behaviour, – extreme fear, withdrawal, or aggression, – self-harm or eating problems without a clear cause, – sexualised behaviour that is not age appropriate, – repeated self-harm, and ongoing wetting or soiling not explained by a medical condition. We should also consider maltreatment when there are concerning parent–child interactions, including: – hostility, rejection, or lack of emotional warmth, – unrealistic expectations of the child, – and refusal to allow the child to speak alone when appropriate. Running away from home or living away from caregivers without agreement should also raise concern. And to end, the key messages for us are that we should follow safeguarding procedures and seek advice early. A pattern over time is often more important than a single event and we should trust our professional judgement and discuss concerns if we are unsure. Remember that this is not an exhaustive list, but a summary of some relevant cases to be aware of. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Unconjugated Chaos: Making Sense of High Bilirubin | 31 Dec 2025 | 00:08:57 | |
The video version of this podcast can be found here: · https://youtu.be/ndAus37PfsE The video on hepatitic pattern abnormal LFTs can be found here: · https://youtu.be/rIX46swVSfg This episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology. 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 them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do when in respect of an isolated high bilirubin with otherwise normal liver function tests, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
My summary guide can be downloaded here: · https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS
The resources consulted can be found here: BSG- British Society of Gastroenterology: · bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests · Guidelines on the management of abnormal liver blood tests (bsg.org.uk) o First published on: o BMJ article: o Guidelines on the management of abnormal liver blood tests | Gut (bmj.com) Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter an isolated high bilirubin with otherwise normal liver function tests, always focusing on what is relevant in Primary Care only.
This episode is based on the British Society of Gastroenterology guidelines on abnormal Liver function tests. A link to it is in the episode description.
Right, let’s jump into it. And let’s start by remembering that there are three common patterns of abnormal liver function tests or LFTs:
Let’s also remember that bilirubin is the by-product of the breakdown of haemoglobin. When red blood cells are broken down, bilirubin is produced and released into the bloodstream. It exists in two forms: unconjugated bilirubin and conjugated bilirubin. Unconjugated bilirubin is water-insoluble and travels to the liver bound to albumin. Once in the liver, it is converted into conjugated bilirubin, making it water-soluble so it can be excreted into bile. A high unconjugated bilirubin level is usually due to increased production, as in haemolysis, or reduced conjugation within the liver. A high conjugated bilirubin level, on the other hand, is normally due to liver disease or biliary obstruction, where the liver is unable to process or excrete bilirubin normally. Many path labs will routinely report only the total bilirubin, but they will provide a breakdown into conjugated and unconjugated fractions if the level is abnormal or if it is specifically requested. Under normal circumstances, the majority of bilirubin should be conjugated. Therefore, if most of the bilirubin is unconjugated, and there is no evidence of haemolysis, the cause is almost always Gilbert’s syndrome. In Gilbert’s syndrome, the enzyme responsible for conjugating bilirubin has reduced activity. As a result, unconjugated bilirubin accumulates, often fluctuating with fasting, stress, illness, or dehydration. Importantly, it is not associated with liver disease or ill health, and patients should be fully reassured that it is a benign lifelong condition. But we will come back to that a little later. How do we manage these patients? When we manage patients with any abnormal liver function tests, we must start by recognising red flags that require urgent action. According to the BRITISH SOCIETY OF GASTROENTEROLOGY guidelines, if there are signs of synthetic liver failure – for example, unexplained clinical jaundice, a low albumin, or a raised INR – or if there is a suspicion of malignancy, such as unexplained weight loss or marked cholestasis, then these patients should be urgently referred or admitted for specialist assessment. For patients whose only abnormality is an isolated raised bilirubin, and who have no worrying clinical signs, we can follow a more measured primary care approach:
So, why does fasting raise bilirubin in Gilbert’s syndrome? Firstly, because there is reduced hepatic energy availability. During fasting, blood glucose falls and the liver prioritises essential metabolic functions. Bilirubin conjugation is not a high-priority process, so the already-reduced enzyme activity present in Gilbert’s syndrome becomes even less effective. Secondly, there is increased bilirubin production because fasting slightly increases the breakdown of haemoglobin and other haem-containing proteins, increasing bilirubin entering the system. And thirdly, there is reduced hepatic uptake of bilirubin from the bloodstream because of changes in liver blood flow and transporter activity.
The BRITISH SOCIETY OF GASTROENTEROLOGY guidelines emphasise that for the pattern “isolated raised bilirubin with otherwise normal liver tests”, Gilbert’s syndrome is the most common cause.
If haemolysis is suspected, the patient should be referred to a haematologist, because haemolysis can have many underlying causes and diagnosing the exact cause requires specialist tests that are not usually available in primary care. However, if the isolated raised bilirubin persists and the cause remains unclear, or if any additional liver function test abnormalities emerge, then we should follow the British Society of Gastroenterology guideline recommendation for further investigation. This may mean following the pathway for a hepatitic pattern or a cholestatic pattern, depending on the case. But in any event:
And eventually, the decision will be between monitoring versus referral. If after all of the above investigations the clinical picture remains consistent with Gilbert’s syndrome, we can continue with periodic monitoring in primary care. On the other hand, if the isolated raised bilirubin is persistent and unexplained, we should refer the patient for specialist assessment. So that is it, a review of an Isolated raised bilirubin with otherwise normal liver function tests. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - ADHD Treatment in Focus: More Than Just a Pill | 24 Dec 2025 | 00:08:50 | |
The video version of this podcast can be found here: · https://youtu.be/w4d4qc7aHn4 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. This video also refers to a number of medical articles on ADHD published by a number of organisations (details below). 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 any of them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover ADHD treatment options, especially in adults, always focusing on what is relevant in Primary Care only. The information is based on a number of published medical articles. The links to them are below. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The resources consulted can be found here:
1. NICE. Attention deficit hyperactivity disorder: diagnosis and management (NG87): https://www.nice.org.uk/guidance/ng87?utm 2. Ostinelli EG et al. “Comparative efficacy and acceptability of pharmacological, psychological, and neurostimulatory interventions for ADHD in adults: a systematic review and component network meta-analysis.” The Lancet Psychiatry, 2025. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00360-2/fulltext?utm 3. Gosling CJ et al. “Benefits and harms of ADHD interventions: umbrella review of systematic reviews and meta-analyses.” BMJ, 2025. https://www.bmj.com/content/391/bmj-2025-085875?utm 4. Cortese S et al. “Attention-deficit/hyperactivity disorder (ADHD) in adults.” World Psychiatry, 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12434367/?utm 5. Wakelin C et al. “A review of recent treatments for adults living with attention-deficit/hyperactivity disorder.” 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10730462/?utm 6. Kooij JJS et al. “Updated European Consensus Statement on diagnosis and treatment of adult ADHD.” European Psychiatry, 2019. https://pubmed.ncbi.nlm.nih.gov/30453134/?utm 7. Nimmo-Smith V et al. “Non-pharmacological interventions for adult ADHD: a systematic review.” Psychological Medicine, 2020. https://pubmed.ncbi.nlm.nih.gov/32036811/?utm 8. Mechler K et al. “Evidence-based pharmacological treatment options for ADHD in children, adolescents and adults.” Neuroscience & Biobehavioral Reviews, 2022. https://www.sciencedirect.com/science/article/pii/S016372582100142X?utm 9. AWMF S3 Guideline. “Attention-Deficit/Hyperactivity Disorder (ADHD) in Children, Young People and Adults.” 2020. 10. Wolraich ML et al. “Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.” Pediatrics, 2019. 11. Faraone SV et al. “The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder.” Neuroscience & Biobehavioral Reviews, 2021. https://pubmed.ncbi.nlm.nih.gov/33549739/?utm https://www.sciencedirect.com/science/article/pii/S014976342100049X?utm https://www.adhd-federation.org/publications/international-consensus-statement.html?utm 12. CADDRA. Canadian ADHD Practice Guidelines, Version 4.1. 2020. https://www.caddra.ca/canadian-adhd-practice-guidelines/?utm 13. Therapeutics Initiative. “ADHD in adults.” Therapeutics Letter 144, 2023. https://www.ti.ubc.ca/2023/09/29/144-adhd-adults/?utm 14. May T et al. “The Australian evidence-based clinical practice guideline for ADHD.” Australian Journal of General Practice / AADPA, 2023. https://adhdguideline.aadpa.com.au/?utm https://pmc.ncbi.nlm.nih.gov/articles/PMC10363932/?utm 15. Coghill D & colleagues / Australian Prescriber. “Pharmacological management of attention deficit hyperactivity disorder in children and adolescents.” Australian Prescriber, 2025. 16. Thapar A et al. “Attention-deficit/hyperactivity disorder.” Nature Reviews Disease Primers, 2024. https://www.nature.com/articles/s41572-024-00495-0?utm Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to talk about ADHD treatment options, especially in adults, always focusing on what is relevant in Primary Care only. I have based this episode on a number of published medical articles. The links to them are in the episode description. Right, let’s jump into it. Modern guidelines emphasise that ADHD management is multimodal — including psychoeducation, environmental adaptations, psychological interventions, and, where indicated, medication. For children and adolescents, NICE and other guidelines recommend starting with psychoeducation and behavioural or parent training, then adding medication when impairment remains significant. However, for adults, guidelines are very clear: medication is usually first-line when symptoms cause persistent, moderate to severe impairment, supported by psychoeducation and practical help. So, when is medication indicated? For children and adolescents, medication — usually methylphenidate — is recommended only when ADHD is clearly diagnosed, the impairment is significant, and non-drug approaches aren’t enough. In other words, it’s generally reserved for moderate to severe ADHD, rather than mild cases. However, for adults, medication is indicated when there is a clear diagnosis of ADHD with symptoms present since childhood, even if they were never recognised at the time. The symptoms must be causing clinically significant impairment, and other conditions — like depression, bipolar disorder, or substance misuse — shouldn’t fully explain what’s going on. And finally, the person needs to want to try medication after discussing the risks and benefits. Guidelines such as NICE and the European consensus explicitly state that, in adults, medication is the main evidence-based treatment for core ADHD symptoms, offered alongside education and support. Which medications should we use, and how effective are they? There are two main classes. First, stimulants, such as methylphenidate in various modified-release forms, and amphetamine formulations like lisdexamfetamine. Second, non-stimulants, including atomoxetine, guanfacine—which has more evidence in children and adolescents—and others like bupropion, clonidine, and viloxazine, though adult data for these are more limited. A landmark meta-analysis of randomised trials found that, in adults, amphetamines produced the largest improvements in clinician-rated symptoms. They were at least as well tolerated as methylphenidate, and more effective than atomoxetine and modafinil. A recent BMJ umbrella review, which examined multiple meta-analyses, concluded that in the short term—up to about twelve weeks—both stimulants and some non-stimulants produce medium to large reductions in symptoms. Evidence beyond one year is more limited, but it does not suggest a loss of effect. The World Federation of ADHD consensus summarises this by stating that ADHD medication is clearly effective for reducing symptoms, and that stimulants are more effective than non-stimulants. Are there any long-term benefits of regular medication use? Well, in terms of symptom control, longitudinal studies and reviews show that continued medication is associated with sustained improvements in symptoms and functioning in both children and adults, as well as improvements in overall life satisfaction. Furthermore, there is also evidence for broader life outcomes. The World Federation of ADHD consensus concluded that drug treatment is linked to substantial reductions in a range of adverse outcomes, including transport accidents, substance misuse and cigarette smoking, educational underachievement, depression and suicide attempts, and even criminal behaviour and teenage pregnancy. Taken together, this suggests that for many patients, long-term use of ADHD medication does more than just reduce symptoms. It appears to lower the risk of serious negative life events and improve quality of life. And now, let’s touch briefly on non-drug treatments. For children and adolescents, guidelines emphasise psychoeducation and parent-training programmes, school-based interventions, and behavioural approaches such as reward systems and structured routines. For adults, the main non-drug options include psychoeducation about ADHD, CBT tailored to ADHD, that is, focusing on time management, planning, and emotional regulation, and finally, coaching and skills training, along with workplace or academic adaptations. So how effective are these approaches? A systematic review of non-pharmacological interventions in adults found that particularly CBT and skills training produce small to moderate improvements in symptoms and functioning. However, the World Federation consensus is quite blunt: non-medication treatments are generally less effective than medication for core ADHD symptoms, although they remain very useful for addressing residual difficulties once medication has been optimised. Now that we know the benefits of treatment, what are the possible side effects, and how do we monitor treatment? Common side effects of both stimulants and atomoxetine include reduced appetite and weight loss, sleep disturbances, mild increases in heart rate and blood pressure, headache, dry mouth, gastrointestinal symptoms, and occasionally irritability or mood lability. There are also possible psychiatric adverse effects. Rarely, stimulants and atomoxetine can precipitate anxiety, irritability, mood elevation, or even psychotic symptoms, particularly in vulnerable people or at higher doses. To reduce this risk, guidelines recommend careful monitoring, dose adjustments, and stopping the medication if significant symptoms appear. Overall, the World Federation consensus concludes that “the adverse effects of medications for ADHD are generally mild and can be addressed by changing the dose or the medication,” while the consequences of untreated ADHD are often serious and long-lasting. In terms of cardiovascular safety, for most people without pre-existing heart disease, stimulants and atomoxetine cause only small increases in blood pressure and heart rate, and serious cardiovascular events are rare. So what does this mean in practice? Guidelines recommend taking a brief cardiac and family history, checking blood pressure and pulse, and making sure there are no red flags before starting medication. If someone has a known heart condition, or if the assessment raises any concerns, then we should ger cardiology input before prescribing. Regarding misuse, diversion, and dependency we need to be aware that stimulants have abuse potential, particularly in fast-acting formulations, which is why long-acting preparations and careful monitoring are recommended. However, the consensus statement notes that while stimulants can be diverted or misused, therapeutic doses in people with ADHD are actually associated with lower rates of later substance-use disorders, not higher. In summary, for adults with significant ADHD, medication is the most effective treatment for core symptoms. When used long-term with proper monitoring, it’s associated not only with better concentration, but with lower rates of other serious negative outcomes. At the same time, side effects are common but usually mild and manageable. So that is it, a review of ADHD treatment options. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Epidemic or Enlightenment? The ADHD Surge Explained | 17 Dec 2025 | 00:08:30 | |
The video version of this podcast can be found here: · https://youtu.be/aDbEwtY3hw0 This video refers to a number of medical articles on ADHD published by a number of organisations (details below). 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 any of them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover ADHD increasing incidence, especially in adults, always focusing on what is relevant in Primary Care only. The information is based on a number of published medical articles. The links to them are below. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The resources consulted can be found here:
1. Shah P et al. “Potential impact of social media and COVID-19 restrictions on adult attention-deficit rates.” BJPsych Bulletin, 2025. https://pubmed.ncbi.nlm.nih.gov/41208391/ 2. Adult Psychiatric Morbidity Survey 2023–24, Chapter 9: ADHD (NHS England, 2024). 3. McKechnie DGJ et al., UK primary-care database study, 1998–2018 – summarised by NIHR as “Significant rise in ADHD diagnoses in the UK” (2023). https://www.nihr.ac.uk/news/significant-rise-adhd-diagnoses-uk?utm 4. Gimbach S et al. “ADHD medicine consumption in Europe after COVID-19.” Public Health / Pharmacoepidemiology, 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC10854136/?utm 5. Rzeszutek M et al. “Global Trends in ADHD Medication Use: Multiple Contexts and Populations.” Journal of Clinical Medicine, 2025. https://www.mdpi.com/2077-0383/14/20/7338?utm 6. Martin AF et al. “The changing prevalence of ADHD? A systematic review.” Journal of Affective Disorders, 2025. https://www.sciencedirect.com/science/article/pii/S0165032725008638?utm 7. Staley BS et al. “ADHD Diagnosis, Treatment, and Telehealth Use in Adults — United States, 2023.” MMWR (CDC), 2024. https://www.cdc.gov/mmwr/volumes/73/wr/mm7340a1.htm?utm 8. Butt DA et al. “Prevalence and Incidence Trends of Attention Deficit Hyperactivity Disorder in Canada.” Canadian Journal of Psychiatry, 2024. https://journals.sagepub.com/doi/10.1177/07067437231213553?utm 9. Therapeutics Initiative. “ADHD in adults.” Bulletin 144, 2023. https://www.ti.ubc.ca/2023/09/29/144-adhd-adults/?utm 10. Bradlow RCJ et al. “Adult attention deficit hyperactivity disorder in Australia: how its current commercial model for diagnosis and treatment is encouraging misdiagnosis.” Medical Journal of Australia, 2025. 11. Woon LSC et al. “Online interest in ADHD predicts ADHD medication prescriptions in Australia from 2004 to 2023: a time-series analysis revealing COVID-19-related acceleration.” (2025). https://pmc.ncbi.nlm.nih.gov/articles/PMC12138142/?utm 12. May T et al. “The Australian evidence-based clinical practice guideline for ADHD.” Australian Journal of General Practice / Australian guidelines consortium, 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10363932/?utm 13. Cortese S et al. “Attention-deficit/hyperactivity disorder (ADHD) in adults.” World Psychiatry / World Psychiatric Association, 2025. PMC+2Wiley Online Library+2 https://pmc.ncbi.nlm.nih.gov/articles/PMC12434367/?utm Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to talk about the increasing number of ADHD diagnoses, especially in adults, always focusing on what is relevant in Primary Care only. I have based this episode on a number of published medical articles. The links to them are in the episode description. Right, let’s jump into it. And the first question to ask is: why are we covering this topic now? You may be aware that in the UK, the government has recently announced a formal review into surging mental-health and neurodevelopmental diagnoses, including ADHD and autism. This has sparked media coverage and public debate: are we seeing a real increase in ADHD, or are normal struggles being unnecessarily medicalised? In other words, is this an epidemic of overdiagnosis, or does the rise in cases simply reflect that we’re starting to catch up with reality? So now, it’s more important than ever to look at what the research actually shows, especially around adult ADHD diagnoses. And although we in primary care are not directly responsible for the full diagnosis and treatment process, the way we assess and support these patients at their first point of contact can make a huge difference. It shapes how they experience their care, whether they feel understood, and whether they receive the guidance and support they need. Let’s start by reminding ourselves that attention-deficit/hyperactivity disorder, or ADHD, is a neurodevelopmental condition that affects a person’s ability to regulate attention, manage impulses, and maintain consistent levels of activity. In adults, ADHD often looks very different from the stereotype of a hyperactive child. Adults tend to present with chronic distractibility, difficulty organising tasks, emotional impulsivity, forgetfulness, restlessness, and problems sustaining attention at work or in relationships. These symptoms can have real-world consequences, including difficulties with work and relationships, financial problems, and a persistent sense of underachievement. The consensus is that ADHD is highly heritable and is associated with higher rates of anxiety, depression, and substance misuse. It’s also linked to measurable differences in executive brain function. And by this, we mean that the prefrontal cortex — the area responsible for focus, planning, impulse control, and emotional regulation — works differently in people with ADHD. Brain-imaging studies have repeatedly shown altered activity in this area. So what this really means is that ADHD symptoms aren’t just behavioural. They reflect real differences in brain function. Importantly, ADHD is not a condition people usually “grow out of.” For around two-thirds of children with ADHD, symptoms continue into adulthood, although sometimes in a more subtle or internalised form. So, why are adult ADHD diagnoses increasing? Research shows that adult ADHD is now better recognised. Historically, many adults — especially women — were simply missed in childhood because their symptoms were less disruptive, or because diagnostic criteria were focused on school performance rather than adult functioning. A recent study from the UK found that adult referrals for ADHD assessment increased threefold between 2019 and 2023, with peaks during and after the COVID-19 pandemic. This is likely because the pandemic disrupted daily routines and removed coping structures, making previously manageable symptoms more difficult, and prompting more adults to seek help. As diagnoses have increased, some people — including medical professionals — have expressed concerns that the condition might be overdiagnosed. After all, clinicians have always been wary of patients self-diagnosing, and the fact that some ADHD assessments rely on self-reported symptoms can create doubts for those who aren’t familiar with how structured and evidence-based these assessments actually are. The numbers are stark. A large 20-year UK primary-care cohort study found that recorded ADHD diagnoses increased roughly twenty-fold, while ADHD medication prescribing rose fifty-fold. Some of the biggest proportional increases were seen in adults, particularly men aged 18 to 29. Is this surprising? Not necessarily. ADHD is more common than many people realise. Multiple published reviews estimate the prevalence in children and adolescents to be between two and eight percent, and a major 2023 re-analysis placed it at 5.41 percent. However, many studies showing steep increases in diagnosis have still reported prevalence rates well below this expected five percent. Additionally, the most recent Adult Psychiatric Morbidity Survey shows that in England, although 13.9 percent of adults screened positive for probable ADHD, only 1.8 percent reported receiving a formal diagnosis. That suggests that many adults with ADHD still remain unidentified. So, while there may be some isolated overdiagnosis, overall, the evidence suggests that ADHD remains underdiagnosed — particularly in adults. What about internationally? Have there been similar rises across other Western countries? The short answer is yes. Across Europe and other high-income countries, studies consistently show that ADHD medication use among adults has grown sharply, often by several hundred percent over the last decade, with a particularly striking rise in adult women. And a recent analysis in the United States showed that six percent of adults report a current ADHD diagnosis, and importantly, about half of them were first diagnosed in adulthood. This increase in diagnosis, which may simply reflect that we are catching up with the reality of neurodivergence. Factors contributing to this better recognition include: • greater understanding that ADHD persists into adulthood, • the use of more adult-appropriate diagnostic criteria, and • higher public awareness with reduced stigma. What does an ADHD diagnosis actually mean for patients? For many adults, receiving a diagnosis finally helps them make sense of lifelong challenges. And research consistently shows that after diagnosis, people often experience: • improved self-esteem, • better workplace functioning, • more stable relationships, and • a reduced risk of comorbid anxiety and depression. It also gives them the opportunity to seek treatment. Treatment for ADHD is multimodal and includes: • education and coaching, • CBT, • lifestyle structuring, • and, when appropriate, medication — which remains one of the most effective interventions for ADHD symptoms in adults. And by the way, if you want to learn more about ADHD treatment options, stay tuned — a full video on ADHD treatment is coming soon. So that is it, a review of the increased number of ADHD diagnoses. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - NICE News – November 2025 | 10 Dec 2025 | 00:07:40 | |
The video version of this podcast can be found here: · https://youtu.be/dZpq3W-lkSQ This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in November 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for November 2025 can be found here:
The new guideline on suspected sepsis in people aged 16 or over can be found here: · https://www.nice.org.uk/guidance/ng253
The new guideline on suspected sepsis in under 16s can be found here: · https://www.nice.org.uk/guidance/ng254
The new guideline on suspected sepsis in pregnant or recently pregnant people can be found here: · https://www.nice.org.uk/guidance/ng255
The visual summary for suspected sepsis: evaluation and management, all ages, settings and population groups can be found here:
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in November 2025, focusing on what is relevant in Primary Care only. And this time we have three brand-new guidelines on a single topic: Sepsis. There are three separate guidelines because each one focuses on a different group: people aged 16 and over, children and young people under 16, and those who are pregnant or recently pregnant. Right, let’s jump into it. And we will start by saying that we will focus on the recommendations for people over 16 but I’ll also point out what’s different for the under-16 group and for pregnant people. If infection is suspected, the first question to ask ourselves is: Could this be sepsis? And then assess for a potential source, for risk factors, and for any signs of clinical concern in circulation, breathing, or behaviour, ideally using a structured system. The main 6 observations that we should assess are: temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation. However, we need to remember that some groups of people with sepsis may not develop a raised temperature and that, in terms of oximetry, poor peripheral circulation due to shock can make peripheral oxygen saturation difficult to measure. Additionally, we need to be aware that some pulse oximeters can underestimate or overestimate readings, especially if the level is borderline and that overestimation has been reported in people with dark skin. Additionally, we should examine for:
We should always keep in mind groups who are more vulnerable: people over 75, those with frailty or co-morbidities, learning disabilities, immunosuppression, indwelling lines or catheters, recent surgery or invasive procedures, and those with adverse social or economic factors that may delay presentation. In hospital or ambulances, the National Early Warning Score 2, or NEWS2, is recommended. NEWS2 measures the same six values, temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation. and then assigns points based on how abnormal they are. I will not go through every score and its clinical implications but there is NEWS2 calculator app reproduced from the Royal College of Physicians that I would really recommend downloading. However, in primary care we can consider NEWS2 or any other structured observation tool. The guideline gives us a set of criteria to assess the risk of severe illness. There are high risk and moderate risk criteria. The high-risk criteria for people over 16 are as follows: · A new altered mental state · A respiratory rate of 25 breaths per minute or more · New need for oxygen to maintain saturation more than 92% (or more than 88% in chronic hypercapnic respiratory failure) · A Systolic BP of 90 mmHg or less or more than 40mmHg below normal · A heart rate of more than 130 beats per minute · Not passed urine in previous 18 hours, or for catheterised patients, passed less than 0.5 ml/kg of urine per hour · Mottled or ashen appearance · Cyanosis and · A non-blanching petechial or purpuric rash These are the high-risk criteria only. For simplicity, I will not go through all the moderate risk criteria, but they are similar to the high-risk ones but with values slightly less abnormal. Once sepsis is suspected, for primary care, the key point is to arrange rapid referral or admission to hospital. In remote or rural areas where transfer exceeds one hour, the guideline states that systems should exist so GPs can give the first dose of antibiotics when high-risk criteria are met. For borderline or uncertain cases, we should provide clear safety-netting, and ensure patients and carers understand warning symptoms and when to seek help. Let’s quickly touch on sepsis in children. Risk stratification for children is a lot more complex and is based on age bands — under 5, 5 to 11, and 12 to 15 — each with its own physiological thresholds. Because of the complexity, I will not go through all the high-risk criteria here, but we need to remember that severity is judged not just on vital signs, but on age-appropriate risk criteria combined with history, examination and clinical judgement. Adult early-warning scores such as NEWS2 should not be applied to children. If a child meets any high-risk criterion, they require urgent admission to hospital. For lower-risk children, we must still decide between safe management in the community with safety-netting or urgent admission if concerns arise. For this, communication must be tailored to the child and their carers, with clear explanations as to what to do if the situation does not improve. Let’s now move to people who are pregnant, or within six weeks postpartum. They fall under a separate guideline because pregnancy changes physiology and the pattern of infection. For pregnant or recently pregnant people, NEWS2 is not appropriate either. Instead, we should use a pregnancy-specific risk table with high-risk, moderate-to-high-risk, and low-risk criteria. These criteria include the usual physiological markers but they use pregnancy-specific thresholds and they also emphasise obstetric sources of infection, such as endometritis, wound infections, urinary infection, retained products, and mastitis. Again, I will not go through all the criteria here but NICE has produced a visual summary of the risk criteria for all groups. The link to it is in the episode description. Going back to the assessment of suspected sepsis for people that are pregnant or recently pregnant, if any high-risk criterion is present, emergency admission will be required. For us in primary care, the key points are that pregnancy or up to six weeks postpartum automatically places the patient in a higher-risk group, we must use pregnancy-specific criteria rather than adult scores, the threshold for calling an ambulance and pre-alerting services is lower, and finally, we should always think of obstetric sources of infection alongside the usual ones. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - LFTs Gone Viral: ALT/AST Spikes Explained | 03 Dec 2025 | 00:07:49 | |
The video version of this podcast can be found here: · https://youtu.be/rIX46swVSfg This episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology and a number of NHS organisations in the UK. Here I focus on the hepatitic pattern of abnormal LFTs. 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 them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the interpretation, initial follow up management, of adults presenting with a hepatitic pattern in their LFT’s, always focusing on what is relevant in Primary Care only. This episode is based on the British Society of Gastroenterology guidelines on LFTs. A link to it is in the episode description.. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
My summary guide can be downloaded here: · https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS
The resources consulted can be found here: BSG- British Society of Gastroenterology: · bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests · Guidelines on the management of abnormal liver blood tests (bsg.org.uk) o First published on: o BMJ article: o Guidelines on the management of abnormal liver blood tests | Gut (bmj.com) Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to go through the interpretation, initial follow up management, of adults presenting with a hepatitic pattern in their LFT’s, always focusing on what is relevant in Primary Care only. This episode is based on the British Society of Gastroenterology guidelines on LFTs. A link to it is in the episode description.
Right, let’s jump into it. We have to start by remembering that liver disease develops silently and at earlier stages liver enzymes may be normal, and, if they are high, the degree of abnormality is not necessarily related to the severity of the underlying condition. We also need to remember that AST and ALT are enzymes present in the liver cells and the levels increase in response to cell injury or death. ALT is considered more liver-specific while AST is also present in skeletal, cardiac and smooth muscle and so may be elevated in patients with an MI or myositis. An AST:ALT ratio of >1 is a non-invasive marker of liver fibrosis. In early liver disease, AST and ALT can be normal, but the high AST:ALT ratio is usually present even if both values are normal. So, what should we do when confronted by abnormal LFTs? First of all, we should not think that the extent of abnormality of the LFTs correlates necessarily with the severity of the problem. Common conditions leading to chronic liver disease like NAFLD, and hepatitis C are frequently associated with only mild or moderate LFT abnormalities. Also, we should not think that the duration of the abnormal LFTs is a reflection of clinical significance, so repeating the LFTs hoping that they will improve is not necessarily the way to go. We need to remember that in many chronic liver diseases such as hepatitis C and NAFLD, the LFTs returning to normal do not necessarily imply the resolution of the disease. Therefore, the recommendation is that most patients with abnormal LFTs should have a full liver screen irrespective of level and duration of the abnormality. What is a full liver screen? This should include an USS, hepatitis B and C screening, an autoantibody screen, serum immunoglobulins, both ferritin and transferrin saturation and, often, a coeliac screen, alpha-1-antitrypsin levels and caeruloplasmin. And finally, let’s remember that there are three common patterns of abnormal LFTs:
The three most common causes of liver disease are alcohol-related liver disease, non-alcoholic fatty liver disease and viral hepatitis. How do we manage these patients? First of all, if there are signs of synthetic liver failure like unexplained clinical jaundice, a low albumin or a high INR or if there is suspicion of malignancy, for example because of weight loss or marked cholestasis, we should urgently refer or admit the patient. If the patient has a hepatitic picture with a high ALT and AST, the management will depend on the level of liver fibrosis, which we can estimate using non-invasive fibrosis markers. The majority of patients presenting with a hepatitic pattern will have either NAFLD or ARLD. So let’s start with NAFLD. Following a liver USS, for patients with NAFLD or liver disease of unknown cause, we will estimate the risk of fibrosis using the FIB4 or NAFLD fibrosis score. These scores have cut off points for low, intermediate and high risk of fibrosis. If there is a low risk of advanced fibrosis, we will just manage the risk factors in Primary Care and reassess periodically, generally every 2 to 5 years. In primary care, the treatment for NAFLD is weight loss, alcohol advice, the reduction of cardiovascular risk and the management of co-morbidities. If the risk of fibrosis is intermediate, these patients should have second-line tests such as an enhanced liver fibrosis blood test, also known as an ELF test, or imaging such as a FibroScan or elastography. However, patients with very high scores representing a high risk of fibrosis, should be referred to hepatology without waiting to do an ELF test, Fibroscan or elastography. Let’s now look at ARLD. For patients with ARLD we will assess their alcohol intake, using the AUDIT C or the full AUDIT questionnaire if necessary. Depending on the severity of the alcohol intake, we will give them a brief intervention, refer them to alcohol services or to hepatology for further investigations. The treatment of ARLD is to stop drinking harmfully, and for many this usually means complete abstinence. Weight loss sometimes also helps because there is a synergy between alcohol and obesity. For example, when the BMI is >35, the risk of liver disease doubles for any given alcohol intake. But, finally, what should we do if the patient has a hepatitic pattern with a high ALT and AST without an obvious cause, that is, when the liver screen is normal and there is no evidence of NAFLD on USS or excess alcohol? In those cases, we will need to re-examine the history to exclude potential drug-induced causes. Also, ultrasound is only sensitive for steatosis when hepatocytes are more than 30% steatotic so patients with milder steatosis might have a normal USS. So, if these patients are obese or have metabolic risk factors and we suspect that they may still have NAFLD despite the normal USS, we should assess them in accordance with the NAFLD pathway. But at the end of the day, if AST or ALT remain high without an obvious cause, we will need to refer them to secondary care for further investigations. So that is it, a review of abnormal LFTs with a hepatitic pattern. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NeutroPeeled: A Quick Guide to Neutropenia | 26 Nov 2025 | 00:11:00 | |
The video version of this podcast can be found here: · https://youtu.be/goK_Q4P2qpk This video refers to guidelines produced by a number of organisations (details below). 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 any of them.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I neutropenia always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
My summary of the guidance consulted can be found here: · https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84 The resources consulted can be found here: · Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage · Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0 · Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf · King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdf
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover neutropenia, including initial assessment, follow up and management, always focusing on what is relevant in Primary Care only. I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description. Right, let’s jump into it. Neutrophils are the most numerous subtype of white blood cell and they are the body’s first responders to bacterial infections. Neutropenia is when the neutrophil count is low. A normal neutrophil count in adults ranges from 2.0 to 7.5. However, an isolated low neutrophil count is extremely common in clinical practice. A result between 1.5 and 2.0 × 10⁹/l, while technically below the normal reference range, is rarely clinically significant. Many healthy people fluctuate in this borderline range due to factors such as minor viral infections, recent exercise, or simply natural day-to-day variation in blood counts. We also have to remember that normal ranges differ across populations. People of Afro-Caribbean or Middle Eastern heritage often have a normal baseline neutrophil count between 1.0 and 1.8 × 10⁹/l. This is known as constitutional or ethnic neutropenia, which is of no clinical consequence. It is a benign, lifelong finding and does not increase susceptibility to infection. For these patients, referral is usually only needed if the neutrophil count falls below 1.0 × 10⁹/l on repeat testing. For everybody else and for the purpose of this episode, we will define neutropenia as a neutrophil count below 1.5. Possible causes of neutropenia are as follows: • first we have drugs: such as phenytoin, carbimazole, antipsychotics, and co-trimoxazole, which can suppress neutrophil production in the bone marrow or trigger immune-mediated neutrophil destruction. Some drugs are directly toxic to the bone marrow, while others induce antibody formation against neutrophils. • then we have Malignancy: including conditions like myeloma or any cancer that infiltrates the bone marrow. This reduces the marrow’s ability to produce neutrophils. Additionally, chemotherapy and radiotherapy further compound this by damaging rapidly dividing cells, leading to predictable and sometimes profound neutropenia. • Also Vitamin B12 and folate deficiency: which impair DNA synthesis. Because neutrophils and their precursors divide rapidly, they are particularly sensitive to this. • then we have Iron deficiency: which reduces the efficiency of haematopoiesis in general. Although iron deficiency is normally associated with anaemia, iron is also required for normal development of all blood cell lines, including neutrophils. Severe or prolonged deficiency can therefore lead to mild neutropenia. •Another cause ca be Autoimmune diseases: which can cause neutropenia through immune-mediated destruction by autoantibodies that target neutrophils or their precursors. • then we have viral infections: including EBV, HIV, and hepatitis B and C, which can directly suppress bone marrow activity or cause redistribution of neutrophils from the bloodstream into tissues. Many other viruses also transiently inhibit neutrophil production during acute illness, making mild neutropenia very common. • Also, another possible cause is excess alcohol: which is toxic to the bone marrow and can impair the proliferation and differentiation of myeloid precursors. Chronic alcohol use is also associated with nutritional deficiencies, particularly folate, compounding the effect on marrow function. • then we have Liver disease and cirrhosis: which can lead to neutropenia through hypersplenism causing increased sequestration and destruction of blood cells in the spleen. Another mechanism is metabolic effect of cirrhosis on overall bone marrow function. And finally, as we have already explained there is: • Ethnic variation: like constitutional or ethnic neutropenia in people of Afro-Caribbean and Middle Eastern descent. Again, this is a benign inherited pattern without any impairment in immune function. How should we manage these patients? We should send the patient to hospital as an emergency if: • There is any evidence of sepsis, because neutropenic patients are at high risk of overwhelming infection. This means they can deteriorate rapidly, often without the typical signs of infection. • Additionally, we should also send the patient to hospital as an emergency if the neutrophil count is below 1.0 × 10⁹/l and any of the following factors are present: – First, if the patient is on chemotherapy. This is because chemotherapy-induced neutropenia can progress quickly, and these patients are at particularly high risk. In this setting, infection can become severe within hours leading to sepsis. – Also, if there is lymphadenopathy because enlarged lymph nodes raise concern for an underlying haematological malignancy, such as lymphoma or leukaemia, or for a significant viral infection causing significant bone marrow involvement. – Also if there is splenomegaly because an enlarged spleen suggests increased sequestration and destruction of blood cells, or infiltration by malignancy or infection. Splenomegaly with neutropenia can be suggestive of serious conditions such as myeloproliferative disorders, autoimmune cytopenias, or advanced liver disease with hypersplenism. – And finally, we should also send the patient to hospital as an emergency if the neutrophil count is below 1.0 × 10⁹/l if there are other cytopenias. For example, if anaemia or thrombocytopenia is also present, this points toward a significant bone marrow problem which increases the risk of complications. We should make an urgent haematological referral on a cancer pathway if: • The neutrophil count is below 0.5 × 10⁹/l and the patient is otherwise well. This is because a neutrophil count this low is concerning even in the absence of symptoms. Counts below 0.5 significantly increase the risk of serious infection, and they also raise the possibility of an underlying bone marrow disorder. Conditions such as acute leukaemia, myelodysplastic syndromes, or bone marrow infiltration can initially present with isolated severe neutropenia before other clinical signs appear. If the neutrophil count is above 0.5 × 10⁹/l and the patient is clinically well, we can safely take a stepwise approach. The first action is to repeat the blood test within one week, as many cases of mild neutropenia are transient. At the same time, and as part of the initial work-up, which other investigations should we request? We should investigate the underlying cause by organising the following tests: • As already mentioned, a repeat full blood count. This in order to confirm whether the neutropenia is sustained and to check for other full blood count abnormalities. • A blood film: which can identify abnormal cell morphology, immature cells, or blasts suggestive of bone marrow disease. It can also help detect features consistent with infection, nutritional deficiency, or autoimmune processes. • Vitamin B12 and folate: because as we said earlier, deficiency can lead to ineffective neutrophil production. • Ferritin and iron studies: given that iron deficiency not only causes anaemia, but can also reduce neutrophil production. • Autoimmune screen because some autoimmune conditions can cause immune-mediated destruction of neutrophils or affect bone marrow function. • HIV testing: because HIV can lead to neutropenia through direct bone marrow suppression, chronic immune activation, or associated infections. In these cases, HIV treatment can reverse the neutropenia and improve overall immunity. • and finally, we should also request Hepatitis B and C serology: given that chronic viral hepatitis can impair bone marrow function and is also associated with splenomegaly, hypersplenism, and autoimmune cytopenias. After we have done these tests, if the patient is well and the cause of the neutropenia remains unknown, our next steps will depend on the degree and persistence of the low neutrophil count. Firstly, if the neutrophil count remains below 1.0 × 10⁹/l we will refer urgently to outpatient haematology. This is because even in the absence of symptoms, this level carries a meaningful risk of infection and warrants specialist assessment. If the neutrophil count is between 1.0 and 1.5 × 10⁹/l, we will monitor the full blood count for 4–6 weeks. This is because many cases in this borderline range are temporary, and monitoring over several weeks helps determine whether the neutropenia is improving, stable, or worsening. Then we will refer to haematology routinely if any of the following occur: – First, if the neutrophil count remains below 1.5 × 10⁹/l (or below 1.0 × 10⁹/l in African-Caribbean patients, due to constitutional neutropenia). This is to rule out the possibility of a chronic underlying cause. – Also if there are other full blood count abnormalities suggesting that more than one blood cell line may be affected, raising concern for broader marrow pathology. – and finally, if there is a history of infections or ulcers. This is because recurrent infections, mouth ulcers, or delayed healing are clinical signs that the neutropenia may be functionally significant, even if the absolute count is only mildly reduced. These symptoms suggest impaired neutrophil activity or insufficient neutrophil reserves, and they strengthen the case for specialist review. So that is it, a review of the initial assessment and management of neutropenia. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - NICE News - October 2025 | 19 Nov 2025 | 00:05:42 | |
The video version of this podcast can be found here: · https://youtu.be/IzuigE4BNVM This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in October 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for October 2025 can be found here:
The updated Quality standard on head injury [QS74] can be found here: · https://www.nice.org.uk/guidance/qs74 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in October 2025, focusing on what is relevant in Primary Care only. And this time there hasn’t been an awful lot that is relevant to Primary care, only an update to the quality standard on head injury. Right, let’s jump into it. The updated quality standard on head injury covers the assessment, management and rehabilitation after a head injury. While much of it applies to secondary care, there are important areas where we play an important role in general practice This updated quality standard focuses on the NICE guideline on head injury and rehabilitation for chronic neurological disorders. For GPs, the main message is on recognition and referral. When a patient presents after a head injury, the standard reinforces the importance of same-day assessment and appropriate referral for imaging. The thresholds for CT scans are unchanged, but we should ensure rapid referral if the criteria are met. But what exactly are these referral criteria? Let’s have a look at them. The criteria can be divided between emergency referrals and urgent referrals, depending on whether imaging should be done within 1 hour or within 8 hours. Let’s look at the emergency referral criteria first. They may appear fairly obvious but it is still worthwhile going through them:
Now, let’s look at the urgent referral criteria, that is, when a CT head scan should be done within 8 hours:
In practice this means that if a patient comes with head trauma, we will need to identify if any of these thresholds are met and refer them appropriately via A&E for imaging. Our role is not to decide whether a CT is indicated or not, but to pick up risk factors, and expedite referral. Now, going back to the quality statements, the rest of them simply emphasise the role of rehabilitation. In this respect in Primary Care, we should ensure that referral to community neuro-rehabilitation or therapy services happens in a timely fashion and that rehabilitation plans, and shared care arrangements are in place. In summary: the update doesn’t change the imaging thresholds but for us, it emphasises follow-up, rehabilitation, and long-term management after a head injury. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Sacubitril/Valsartan for Heart Failure: The Secret Behind Its Power | 12 Nov 2025 | 00:03:43 | |
The video version of this podcast can be found here: · https://youtu.be/30qLbVnKHW8 My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I give a brief overview of the mechanism of action of sacubitril valsartan for heart failure. The NICE guidance on Chronic Heart Failure is covered in these episodes: Part 1- Diagnosis: https://youtu.be/hjKE4JAQM6c Part 2 – Drug management: https://youtu.be/UGD7-osSlv0 Part 3 – Additional management: https://youtu.be/i0L-Nv4bJzs I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here: · https://www.nice.org.uk/guidance/ng106
Additional information on ARNIs can be found here:
Transcript Hello and welcome! I’m Fernando, a GP in the UK. What are Angiotensin receptor–neprilysin inhibitors? They are a relatively new class of medications used specifically in the management of heart failure with reduced ejection fraction. At present, the only available one is sacubitril/valsartan. If you are interested in learning how Sacubitril/valsartan works, here is some background information. The first thing to understand is that the pathophysiology of heart failure involves an abnormal activation of the renin-angiotensin-aldosterone system (RAAS). This leads to vasoconstriction, hypertension, increased aldosterone levels, increased sympathetic tone, and eventually, cardiac remodelling, all of which worsen the disease over time. ACEIs or ARBs play a major role in reducing HF morbidity and mortality by blocking this abnormal activation At the same time that the renin-angiotensin-aldosterone system is activated, the natriuretic peptide system is also activated, hence the elevated BNP and NT-pro BNP seen in heart failure. This compensatory mechanism leads to vasodilation, natriuresis, and diuresis. As a result, the natriuretic peptide system decreases blood pressure, lowers the sympathetic tone, and reduces aldosterone levels. The natriuretic peptide system functions antagonistically to the renin-angiotensin-aldosterone system and has favourable impact on heart failure. Natriuretic peptides are broken down by an enzyme called neprilysin. Sacubitril/valsartan is a combination product. Sacubitril is a pro-drug that, upon activation, acts as a neprilysin inhibitor. So, it works by blocking the action of neprilysin, thus preventing the breakdown of natriuretic peptides, which leads to a prolonged duration of the favourable effects of these peptides. However, because neprilysin also breaks down angiotensin II, inhibiting neprilysin will accumulate angiotensin II. For this reason, a neprilysin inhibitor cannot be used alone; it must always be combined with an ARB to block the effect of the excess angiotensin II. This is why Valsartan is used. Another important substance broken down by neprilysin is bradykinin; neprilysin inhibition will also cause a build-up of bradykinin. Therefore, sacubitril cannot be used with an ACEI due to an increased risk of angioedema if both these drugs are combines or given in a short timeframe. And this is why when switching between ACEI and sacubitril/valsartan, the patient must undergo a 36-hour washout period to lower the risk of angioedema. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - NICE on Heart Failure Part 3 – Beyond Pills: Staying Afloat | 05 Nov 2025 | 00:08:04 | |
The video version of this podcast can be found here: · https://youtu.be/i0L-Nv4bJzs This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the additional management of heart failure. In previous episodes we covered the initial assessment and diagnosis and the drug management of the different subtypes of heart failure. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here:
· https://www.nice.org.uk/guidance/ng106
Additional information on ARNIs can be found here:
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure, which was last updated in September 2025. Today’s episode focuses on the additional management of heart failure. If you haven’t already, I recommend that you check the previous episodes where we covered heart failure diagnosis and the drug management of the different subtypes of heart failure. Right, let’s jump into it. And as we have just said, today we’re going to focus on the additional management of heart failure. Now let’s start by looking at how to initiate and monitor medication use. When tailoring treatment, we should use the person’s medical history, frailty status, and prognosis to decide which specific medicine combinations to use and how to introduce them. In primary care, we should seek the advice from a heart failure specialist before starting someone on an angiotensin receptor–neprilysin inhibitor, that is, sacubitril/ valsartan. Before prescribing an ACE inhibitor, ARB, angiotensin receptor-neprilysin inhibitor (ARNI), or mineralocorticoid receptor antagonist, we will measure renal function and electrolytes. Once these drugs have been started, we should measure renal function and electrolytes:
If the serum creatinine increases by more than 50%, or potassium rises above 5.5 millimoles per litre, we will follow local guidelines. We will measure blood pressure, or ask the person to measure it themselves, before and after each dose increment. For people with symptoms of postural hypotension, we will measure blood pressure according to the NICE hypertension guideline, which essentially recommends ideally checking the initial blood pressure in the supine position, and then again after standing for at least 1 minute, in order to check for a drop in systolic blood pressure of 20 mmHg or more. Although checking the BP in a seated position can also be acceptable, we need to remember that measuring blood pressures from sitting to standing may miss some cases of postural hypotension, especially in older or frail people, and that measuring from lying to standing is more accurate for detecting a significant postural drop. When prescribing beta-blockers, we should not withhold treatment solely because of age, or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease, or COPD. We will assess heart rhythm, heart rate, and conduction abnormalities using a 12-lead ECG before deciding whether to prescribe a beta-blocker. We will not offer a beta-blocker to people with second-degree or third-degree heart block who do not have a pacemaker, or to those with bradycardia, that is, a heart rate below 50 beats per minute. We will assess heart rate and clinical status after each betablocker dose increment, and for people with symptoms and bradycardia, we will consider repeating a 12-lead ECG after each dose increment. For digoxin, we will not routinely monitor serum digoxin concentrations. But we should be aware that a digoxin level measured within 8 to 12 hours of the last dose may help confirm toxicity or non-adherence, but we must interpret results in the clinical context, since toxicity may occur even when the concentration is within the therapeutic range. Now, let us move on to clinical review. We will monitor all people with heart failure and provide: · a clinical general assessment including cardiac rhythm · a medication review checking for any necessary changes or side effects, · An assessment of renal function, and · Measurement of iron status and haemoglobin. This is just the very minimum, Additionally, we should provide more detailed monitoring for people with significant comorbidities, co-prescribed medications, or recent deterioration. The frequency of monitoring will depend on the clinical situation and the stability of the patient’s condition. If the clinical condition or medication has changed, we should monitor the patient more frequently — from days to every two weeks. For stable people with proven heart failure, we will monitor at least every six months. For people under 75 years old with heart failure with reduced ejection fraction and normal renal function — that is, an eGFR greater than 60— we can consider measuring NT-proBNP levels to monitor and optimise treatment. Now let’s look at other treatments and advice relevant to all types of heart failure. We will use diuretics to relieve congestive symptoms and fluid retention, and we will titrate the dose up or down as needed, always using the lowest effective dose. Amiodarone, should be started under specialist supervision and we will review the need to continue it every six months, and at each review, we will check liver and thyroid function tests and assess for side effects. For people with heart failure and atrial fibrillation, we will follow the NICE recommendations on anticoagulation for stroke prevention. For people in sinus rhythm, we will consider anticoagulation if there is a history of thromboembolism, left ventricular aneurysm, or intracardiac thrombus. We should offer annual influenza vaccination and a one-time pneumococcal vaccination to all people with heart failure. For people of childbearing potential, we should discuss contraception and pregnancy. If pregnancy is being contemplated or occurs, we will seek specialist advice from both cardiology and obstetrics. We will not routinely advise people with heart failure to restrict sodium or fluid intake. However, we should ask about salt and fluid consumption and provide advice when necessary, for example, by restricting fluids for dilutional hyponatraemia or by reducing intake for those with high salt or fluid consumption. Additionally, we will advise people to avoid salt substitutes that contain potassium in order to minimise the risk of hyperkalaemia. In terms of air travel, we can advise that it will be possible for most people, depending on their clinical condition at the time. Regarding driving, we will simply follow DVLA guidelines. We should offer people with heart failure a personalised, exercise-based cardiac rehabilitation programme which should include psychological and educational components. Finally, in terms of palliative care, we should not offer long-term home oxygen therapy solely for advanced heart failure. However, we should be aware that long-term oxygen may be offered for comorbidities such as COPD. If symptoms are worsening despite optimal specialist treatment, we will refer to palliative care in discussion with the heart failure multidisciplinary team So that is it, a review of the additional management of heart failure. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE on Heart Failure- Part 2 – Get the drugs right | 29 Oct 2025 | 00:08:21 | |
The video version of this podcast can be found here: · https://youtu.be/UGD7-osSlv0 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the drug management of the different subtypes of heart failure. The guidance on the remaining aspects of heart failure management will be covered in other episodes. In the previous episode we covered the initial assessment and diagnosis. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here:
· https://www.nice.org.uk/guidance/ng106
Additional information on ARNIs can be found here:
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure in adults, which was last updated in September 2025. Today’s episode focuses on the drug management of the different subtypes of heart failure. If you haven’t already, I recommend that you check the previous episode on heart failure diagnosis. The guidance on the remaining aspects of heart failure management will be covered in the next episode, so stay tuned. Right, let’s jump into it. And as we have just said, today we’re going to focus on the specific drug treatment for heart failure. Also, as we said in the previous episode, echocardiograms assess both systolic and diastolic function of the left ventricle. Categorising cardiac function is crucial because the treatment of heart failure will be different depending on the ejection fraction. We classify heart failure as follows:
So let’s have look at the treatment of each of these subtypes For people with heart failure with reduced ejection fraction, we will offer a combination of four medicines: · an ACE inhibitor, · a beta-blocker, · a mineralocorticoid receptor antagonist, and · an SGLT-2 inhibitor. For people who are on the maximum tolerated dose of each of these four medicines but continue to have symptoms of heart failure, we should consider switching the ACE inhibitor to an angiotensin receptor–neprilysin inhibitor. What are Angiotensin receptor–neprilysin inhibitors? They are a relatively new class of medications used specifically in the management of heart failure with reduced ejection fraction. At present, the only available one is sacubitril/valsartan, which combines two mechanisms of action: Sacubitril, which inhibits neprilysin — an enzyme that breaks down beneficial natriuretic peptides. By blocking neprilysin, sacubitril helps with vasodilation, sodium excretion, and reduced cardiac remodelling. And then we have Valsartan, an angiotensin II receptor blocker (ARB), which helps counteract the harmful effects of the renin–angiotensin–aldosterone system by reducing vasoconstriction, sodium retention, and aldosterone secretion. Together, the combination of sacubitril and valsartan improves cardiac function, reduces hospitalisations, and lowers mortality in patients with heart failure with reduced ejection fraction. OK, let’s go back to the general management of heart failure with reduced ejection fraction. And we need to note that if certain medicines are not tolerated, there are alternative treatment combinations that we should consider. For example, for people who have had angioedema after taking an ACE inhibitor, we will still offer a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor, and we should also consider an angiotensin receptor blocker, or ARB instead of the ACEI. This is because the risk of angioedema is lower with ARBs than with ACE inhibitors, although it is not zero so we should use caution and monitor the patient accordingly. An important safety add-on is that we should not use sacubitril/valsartan in anyone with a history of angioedema, as this is listed as a contraindication. People with heart failure with reduced ejection fraction who have symptoms of intolerance to ACE inhibitors, other than angioedema, should have a beta-blocker, an MRA, an SGLT2 inhibitor and sacubitril/valsartan. The initiation of sacubitril valsartan should be guided by a heart failure specialist Additionally, in people with heart failure with reduced ejection fraction, we should assess iron status and check for anaemia using: · transferrin saturation (TSAT), · serum ferritin, and · haemoglobin. For people with heart failure with reduced ejection fraction and haemoglobin less than 150 grams per litre, and iron deficiency, that is, a TSAT less than 20% or serum ferritin less than 100, we should offer intravenous iron therapy. This is because trial evidence shows that IV iron improves symptoms and quality of life and reduces HF hospitalizations in several settings, especially in patients with symptomatic heart failure with reduced ejection fraction. If iron deficiency anaemia is identified, we should not assume it is related to the person’s heart failure, and we should consider investigating for alternative causes. There are other drugs that can be initiated in a specialist setting. I will not cover them in detail, but specialist treatments options include ivabradine, hydralazine in combination with a nitrate, and digoxin. Additionally, in heart failure with reduced ejection fraction we should avoid verapamil, diltiazem, and short-acting dihydropyridine calcium-channel blockers. The “why” boils down to hemodynamics and outcomes:
For people with heart failure with mildly reduced ejection fraction, we should also consider treatment with the same four drugs as the reduced ejection fraction subtype, that is, an ACE inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor. For those who have symptoms of intolerance to ACE inhibitors, we should consider an ARB, a beta-blocker, an MRA, and an SGLT2 inhibitor. But we need to note that an angiotensin receptor–neprilysin inhibitor, that is, sacubitril/valsartan, is not recommended in heart failure with mildly reduced ejection fraction. It is recommended only in heart failure with reduced ejection fraction. SGLT2 inhibitors specifically recommended by NICE for heart failure with mildly reduced ejection fraction, are empagliflozin and dapagliflozin, for which we have specific NICE recommendations. Finally, for people with heart failure with preserved ejection fraction, ACE inhibitors and betablockers are not specifically recommended, but we should consider a mineralocorticoid receptor antagonist and an SGLT2 inhibitor, again with specific guidance on empagliflozin and dapagliflozin as the preferred SGLT2 inhibitors in this subtype. When treating heart failure in people with chronic kidney disease, if the eGFR is 45 or less, we should consider using lower starting doses and smaller dose increments for the medicine combinations already mentioned. If the person’s eGFR is below 30, the advice of a renal physician should be sought. So that is it, a review of the drug management of the different subtypes of heart failure. In the next episode, I will cover additional details and further management recommendations. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE on Heart Failure- Part 1 – Don’t Skip a Beat | 22 Oct 2025 | 00:07:08 | |
The video version of this podcast can be found here: · https://youtu.be/hjKE4JAQM6c This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the initial assessment and diagnosis. The guidance on the remaining aspects of heart failure management will be covered in future episodes. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here: · https://www.nice.org.uk/guidance/ng106
Additional information on ARNIs can be found here:
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure in adults, which was last updated in September 2025. Today’s episode focuses on the initial assessment and diagnosis. The guidance on the remaining aspects of heart failure management will be covered over forthcoming episodes so stay tuned. Right, let’s jump into it. And as we have just said, today we’re going to focus on how we diagnose heart failure. We will obviously begin by taking a thorough history, performing a clinical examination, and arranging appropriate tests to confirm the diagnosis. And we should start by measuring N-terminal pro-B-type natriuretic peptide, or NT-proBNP, in anyone with suspected heart failure. Because very high levels of NT-proBNP carry a poor prognosis, we will refer people with suspected heart failure and an NT-proBNP level above 2,000 nanograms per litre — or 236 picomoles per litre — urgently, for specialist assessment and an echocardiogram within two weeks. We should refer people with suspected heart failure and lower NT-proBNP levels, between 400 and 2,000 nanograms per litre — that’s 47 to 236 picomoles per litre — for specialist assessment and an echocardiogram but this time to be seen within six weeks. We need to be aware that an NT-proBNP level below 400 nanograms per litre, or 47 picomoles per litre, in an untreated person makes a diagnosis of heart failure less likely. We also need to remember that the level of serum natriuretic peptide does not differentiate between heart failure with preserved, mildly reduced, or reduced ejection fraction. When NT-proBNP levels are below 400 nanograms per litre, we should consider alternative causes for the symptoms. If there’s still concern that the symptoms might be related to heart failure, we should discuss the case with a heart failure specialist. We also need to be aware that there are factors that can affect the NT-proBNP level. Examples of factors that can reduce the level are: · Obesity · African or African–Caribbean ethnic background, or · Treatment with certain medications. These include: o Diuretics, o Beta-blockers o Mineralocorticoid receptor antagonists o ACE inhibitors, ARBs and o Angiotensin receptor-neprilysin inhibitors. And let’s just quickly say that Angiotensin receptor–neprilysin inhibitors, or ARNIs, are a relatively new class of medications used in the management of heart failure with reduced ejection fraction. At present, the only available one is sacubitril/valsartan which combines two mechanisms of action: § Sacubitril, which inhibits neprilysin — an enzyme that breaks down beneficial natriuretic peptides. By blocking neprilysin, sacubitril helps with vasodilation, sodium excretion, and reduced cardiac remodelling. § And then we have Valsartan, an angiotensin II receptor blocker (ARB), which helps counteract the harmful effects of the renin–angiotensin–aldosterone system by reducing vasoconstriction, sodium retention, and aldosterone secretion. Together, this combination of sacubitril and valsartan improves outcomes in patients with heart failure with reduced ejection fraction. Ok, going back to the factors that can affect NT-proBNP levels, we should remember that high levels can have causes other than heart failure — for example, pulmonary, renal, liver, or systemic disease, sepsis, COPD, diabetes, or liver cirrhosis. As we can see, the main tools to diagnose heart failure are the NT-proBNP blood test followed by a transthoracic echocardiogram. The purpose for performing transthoracic echocardiography is to exclude important valve disease, detect intracardiac shunts and assess both systolic and diastolic function of the left ventricle. Categorising cardiac function is important because the treatment of heart failure will be different depending on the ejection fraction. We classify heart failure as follows:
We will look at the specific drug treatment of each of these subtypes of heart failure in the next episode. And going back to the diagnosis, although transthoracic echocardiography is our first-line imaging option, if image quality is poor, alternative imaging methods such as radionuclide angiography, cardiac MRI, or transoesophageal echocardiography should be considered. Also, although NT-proBNP and echocardiography are the cornerstone of the diagnosis of heart failure, we should also consider further investigations to assess possible aggravating factors or alternative diagnoses. These include: · An ECG · A chest X-ray · Blood tests including renal, liver and thyroid function tests, a lipid profile, HbA1c, and a full blood count · And we will also do Urinalysis, and · Peak flow or spirometry. We do this because we should always try to exclude other disorders that may present in a similar manner. Once a diagnosis of heart failure has been made, we will assess its severity, causes, precipitating factors, type of cardiac dysfunction, and any correctable causes, and, in particular, for people with heart failure caused by valve disease, we will refer them for specialist assessment and advice. We should also review patients with a historical diagnosis of heart failure, and manage them according to the NICE guideline only if the diagnosis has been confirmed with an echocardiogram. If heart failure is still suspected but no underlying cardiac abnormality has been identified on imaging, we will refer to a heart failure specialist. So that is it, a review of the initial assessment and diagnosis of heart failure. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - NICE News - September 2025 | 15 Oct 2025 | 00:08:35 | |
The video version of this podcast can be found here: · https://youtu.be/qZPisPCp4eQ This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in September 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for September 2025 can be found here:
· https://www.nice.org.uk/guidance/published?from=2025-09-01&to=2025-09-30&ndt=Guidance&ndt=Quality+standard The updated Clinical guideline CG57 on Atopic eczema in under 12s: diagnosis and management can be found here: · https://www.nice.org.uk/guidance/cg57
The updated NICE guideline on Chronic heart failure in adults: diagnosis and management NG106 can be found here: · https://www.nice.org.uk/guidance/ng106
The updated Quality standard on Chronic heart failure in adults QS9 can be found here: · https://www.nice.org.uk/guidance/qs9
The new NICE guideline on Pneumonia: diagnosis and management NG250 can be found here: · https://www.nice.org.uk/guidance/ng250
The updated Quality standard on Pneumonia: diagnosis and management QS110 can be found here: · https://www.nice.org.uk/guidance/qs110 The updated NICE guideline on Suspected acute respiratory infection in over 16s: assessment at first presentation and initial management NG237 can be found here: · https://www.nice.org.uk/guidance/ng237
The updated Clinical guideline on Bipolar disorder: assessment and management CG185 can be found here: · https://www.nice.org.uk/guidance/cg185
The updated technology appraisal guidance on Tirzepatide for treating type 2 diabetes TA924 can be found here: · https://www.nice.org.uk/guidance/ta924
The updated Technology appraisal guidance on Tirzepatide for managing overweight and obesity TA1026 can be found here: · https://www.nice.org.uk/guidance/ta1026
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in September 2025, focusing on what is relevant in Primary Care only. In recent months, there hasn’t been much in the way of updates that directly affect us in General Practice. But September is very different — there’s a lot we need to pay attention to. These updates cover eczema, respiratory infections, pneumonia, bipolar disorder, tirzepatide, and, importantly, a new updated guideline on chronic heart failure. Right, let’s jump into it. The updated NICE guideline on atopic eczema in children under 12 has revised the section on complementary therapies, washing, and clothing. The new wording makes it clear that children with atopic eczema may bathe or shower once daily. Bathing can help remove crusts and skin debris and improve comfort, but it should always be followed by emollient application to prevent the skin from drying out. The update also clarifies that water softeners and silk garments do not improve eczema severity and therefore should not be recommended. So, in summary: daily bathing is acceptable and can be beneficial if followed by emollient use, and water softeners or silk clothing should not be recommended because they provide no proven benefit. The next section is on Chronic Heart failure. The updated NICE guideline has introduced substantial changes, particularly to how we treat and monitor different categories of heart failure. This is such an important area that I’ll only cover the highlights today, as I will cover it in more detail in a future episode. The main focus of the update was the drug management of the three subtypes of heart failure, that is, heart failure with reduced ejection fraction, mildly reduced ejection fraction, and preserved ejection fraction. For heart failure with reduced ejection fraction, that is, an ejection fraction 40% or less, the recommendations now reflect strong evidence for SGLT-2 inhibitors, which consistently reduce hospitalisations for heart failure and improve survival regardless of diabetes status. These drugs are now embedded alongside established treatments such as ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists. For heart failure with mildly reduced ejection fraction — that is, an ejection fraction between 41% and 49% — NICE issues new recommendations for the first time. This group used to be a bit of a grey area. The update highlights evidence that people with mildly reduced EF may benefit from SGLT-2 inhibitors in much the same way as those with reduced EF, and the guidance now advises considering them here too. For heart failure with preserved ejection fraction, meaning an ejection fraction of 50% or more, NICE also makes new recommendations. In the past, management was mostly limited to controlling symptoms and comorbidities. Now, on the back of trial evidence, SGLT-2 inhibitors are also recommended here because they reduce hospitalisations for heart failure, even if mortality benefit is less certain. In practice, this means SGLT-2 inhibitors will be used much more widely — not only in people with reduced EF, but also in those with mildly reduced or preserved EF. An updated NICE Quality Standard on chronic heart failure has also been published, bringing it into line with these changes. Next, there is a brand-new NICE guideline on pneumonia, which consolidates and replaces previous guidance, including antimicrobial prescribing guidelines. The biggest change for us in primary care relates to children: the recommended course of antibiotics for non-severe community-acquired pneumonia without complications or underlying disease has been reduced from 5 days to 3 days. This is because evidence shows that shorter courses are just as effective at resolving symptoms, while reducing the risk of side effects and, most importantly, lowering the risk of antibiotic resistance. Additionally, although more relevant to secondary care, there are new recommendations on corticosteroids in patients with high-severity community-acquired pneumonia when admitted to hospital. This reflects growing evidence that systemic steroids can improve outcomes in severe cases alongside standard antibiotic and supportive care. However, corticosteroids are not recommended for routine use in mild or moderate pneumonia, so it is something that we will not be doing routinely in Primary Care. There is also an updated Quality Standard on pneumonia, aligned with the new guideline and reflecting the changes I’ve just mentioned. Next, we have the updated NICE guideline on suspected acute respiratory infection which covers assessment at first presentation and initial management. The main change here is that the section on the clinical diagnosis of community-acquired pneumonia in primary care has been removed, because that information is now fully covered by the new pneumonia guideline. In practical terms, pneumonia-specific recommendations move to the pneumonia guideline, while the guideline on respiratory infections continues to provide guidance on the assessment and initial management of these infections more broadly. This guideline should also be read alongside NICE’s existing antimicrobial prescribing guidelines for acute cough, COPD exacerbations, sinusitis, and sore throat. The latest update is on the clinical guideline on bipolar disorder, which focuses on recommendations around valproate use, following new safety advice from the MHRA. The key change is that boys and men taking valproate must now be advised to use effective contraception throughout their treatment and for three months after stopping the drug. This means using condoms in addition to contraception used by a female sexual partner. Additionally, men who are planning a family within the next year should also discuss potential fertility risks and alternative treatment options. Previously, recommendations were already strict around valproate use in females of childbearing potential. Valproate must not be initiated in anyone under 55 unless two specialists agree there are no other suitable alternatives or that the reproductive risks do not apply. For them, it can only be prescribed if other treatments are unsuitable and the Pregnancy Prevention Programme is in place. The new update now extends this caution explicitly to male patients, confirming that valproate carries reproductive risks for both sexes. Finally, there are updates to the NICE technology appraisals on tirzepatide — marketed as Mounjaro — covering both type 2 diabetes and the management of overweight and obesity. The recommendations themselves remain unchanged. What has changed is that a commercial access agreement has now been added, together with updated pricing. This is intended to reduce the budget impact for the NHS and make implementation of the guidance more sustainable. As a reminder, let’s remember that for type 2 diabetes, tirzepatide continues to be recommended when triple therapy with metformin and two other oral drugs is ineffective, not tolerated, or contraindicated, and when a GLP-1 receptor agonist would otherwise be considered. For obesity, it remains recommended in adults who meet the BMI and comorbidity thresholds specified in the original appraisal and following a gradual NHS roll out process. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
| |||
| Podcast - Sugar, Spice & NICE Advice: The Draft NICE Guideline on Type 2 Diabetes- Part 3 | 08 Oct 2025 | 00:13:27 | |
The video version of this podcast can be found here: · https://youtu.be/AC3ncdm77Os This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below. The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will cover 4 clinical groups and the remaining groups were covered in last week’s episode. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE announcement on Type 2 diabetes management can be found here:
· https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced
The NICE draft guideline on Type 2 diabetes can be found here:
· https://www.nice.org.uk/guidance/gid-ng10336/documents/450
The visual summary of the NICE draft guideline on type 2 diabetes can be found here:
· https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the main changes as applied to 7 specific groups of patients. In the previous episode we covered the first 3 groups so today we will cover the rest. Right, let’s jump into it. And, as you know, the draft guideline is open for consultation until October, and the final guidance is due in February 2026, so let’s not forget that it is only a draft, and we should not be making clinical decisions based on it yet. Today’s episode is based on the visual summary created by NICE and the link to it is in the episode description. The visual summary includes specific guidance for 7 different groups of patients: 1. The group of patients with no relevant comorbidities, then 2. Obesity 3. Frailty 4. CKD 5. Heart failure 6. Atherosclerotic cardiovascular disease and 7. Early onset type 2 diabetes And today we will look at the last 4 groups that we did not cover last time. So let’s start with the CKD group. For people with CKD, like for many of the other groups. the draft guideline recommends starting treatment with metformin plus an SGLT-2 inhibitor. Because of licensing reasons, we are advised to choose either empagliflozin or dapagliflozin in this group. If metformin is contraindicated or not tolerated, the SGLT-2 inhibitor can be offered on its own. Treatment will also depend on kidney function, measured by eGFR. As we know, metformin in contraindicated if eGFR is less than 30, and, given that SGLT-2 efficacy decreases with advancing renal impairment, NICE recommends not using empagliflozin or dapagliflozin is eGFR is less than 20. Therefore, the first line treatment on this basis is as follows:
If further glycaemic lowering is needed after first line treatment, we can use other options including DPP-4 inhibitors (if not already used), sulfonylureas or insulin depending on renal function and safety profile. How does this differ from the previous guidance? Like in other groups, the big change here is the earlier, more proactive use of SGLT-2 inhibitors specifically for renal protection, not just glucose lowering. Previously, SGLT-2 inhibitors were used after metformin for people with established albuminuria or heart failure. Now, the draft guidance recognises the trial evidence showing that, apart from the cardiovascular benefits, SGLT2 inhibitors also reduce progression of CKD, and this benefit occurs even in people with moderately reduced eGFR and independently of albuminuria. The slower progression of CKD is because SGLT2 inhibitors reduce albuminuria, intraglomerular pressure and protect against hyperfiltration. Another nuance is that the draft now pushes dapagliflozin and empagliflozin explicitly into first-line therapy alongside metformin or alone if necessary, with thresholds set according to kidney function. And it also sets out a clear sequence for treatment as eGFR declines, including when to use DPP-4 inhibitors or move to insulin. What this means in practice is that:
Now, let’s move to the heart failure group. For adults with type 2 diabetes and heart failure, NICE also recommends that the initial therapy should be metformin plus an SGLT-2 inhibitor. If metformin is contraindicated or not tolerated, then an SGLT-2 inhibitor alone is advised. If additional therapy is needed to help with weight management, then a GLP-1 receptor agonist (specifically subcutaneous semaglutide) can be considered provided there is no frailty and the patient has a preserved ejection fraction. After that, for further glycaemic lowering, we can add a sulfonylurea or insulin, remembering that pioglitazone is contraindicated in heart failure The difference with the old guideline is that the draft makes metformin + SGLT-2 inhibitor the standard, aiming to get heart failure-related benefits earlier. As we know, trial data show that SGLT2 inhibitors reduce hospitalization for heart failure, improve symptoms, slow progression, and improve cardiovascular mortality, independent of glycaemic control. So, using them early helps not just glucose but also cardiac outcomes. But another big change is that the draft also acknowledges that weight loss (from GLP-1 RAs) can help reduce cardiac workload, reduce fluid overload, and improve quality of life in heart failure. Combining SGLT-2 inhibitors with semaglutide in patients for whom weight is an issue, is intended to deliver a dual benefit: cardiorenal protection and weight reduction. Previously, GLP-1 RAs were less likely to be used early in heart failure, and semaglutide had stricter criteria; now, semaglutide is explicitly considered earlier in heart failure when weight benefit is also a goal. Any limitations? Well, semaglutide will be limited to patients with obesity, preserved EF and no frailty. Frailty and ejection fraction matter because the benefits and risks of semaglutide vary (e.g. risk of dehydration and hypotension,) depending on heart function and overall general state. What the changes mean in practice is that:
Now, let’s look at the atherosclerotic cardiovascular disease group. For them, we will offer triple therapy with metformin plus an SGLT-2 inhibitor and the GLP-1 receptor agonist, semaglutide, for additional risk reduction and weight benefit. And it is worth mentioning that we should also consider semaglutide for any other group if at any stage, ASCVD develops after treatment has already been started. If extra glycaemic lowering is needed, we will add a sulfonylurea, pioglitazone, or insulin. As we know, we should not combine a GLP1 receptor agonist and a DPP4 inhibitor, but if a GLP-1 RA isn’t appropriate, we will add a DPP-4 inhibitor instead and before considering the other options of a sulfonylurea, pioglitazone, or insulin. This is different from the previous version because before GLP-1 RAs were not used for their cardiovascular benefit but their use was rather tied to glycaemic and BMI thresholds. The draft moves to routine early triple therapy with metformin, an SGLT-2 inhibitor, and semaglutide when ASCVD is present or develops, bringing GLP-1 therapy forward in the pathway. This change is due to trial evidence showing that GLP-1 receptor agonists not only improve weight, blood pressure and post-prandial glycaemia, but they also reduce atherosclerotic cardiovascular events, with semaglutide having one of the strongest evidence for this reduction within the class. Combining semaglutide with metformin and an SGLT-2 inhibitor early is designed to achieve both cardio renal benefits as well as a lower atherothrombotic risk. What it means in practice is that:
Finally, let’s move to the early-onset type 2 diabetes group. For NICE this group refers to type 2 diabetes diagnosed in people under the age of 40. First-line treatment here is metformin plus an SGLT-2 inhibitor like everybody else but, on top of that, the draft says that we should consider adding a GLP-1 receptor agonist early. If metformin is contraindicated or not tolerated, we will offer an SGLT-2 inhibitor and still consider adding a GLP-1 RA. If more glycaemic lowering is needed, the add-on choices are, again, a GLP 1 receptor agonist if not already prescribed, a sulfonylurea, pioglitazone, or insulin. If a GLP-1 RA isn’t appropriate we will add a DPP-4 inhibitor instead before considering a sulfonylurea, pioglitazone, or insulin. This is different from the previous guidance because before early-onset type 2 diabetes did not have its own explicit guidance. NICE is changing this because it has been shown that early-onset type 2 diabetes carries disproportionately higher lifetime risk. In fact, large reviews show that early-onset T2D is linked to higher rates of complications and premature mortality at any given age compared with later-onset disease, due to the additional years exposed to hyperglycaemia, faster β-cell decline, and earlier cardio-renal and microvascular complications. So this is why NICE now favours earlier, multi-mechanism therapy in this group, including GLP-1 receptor agonists for their cardiovascular benefits. What this means in practice is that we will start combination therapy sooner in the form of metformin + SGLT-2 inhibitor while, proactively considering a GLP-1 RA early, in many cases resulting in early triple therapy. We will also need to assess tolerance and to monitor side effects as well as reviewing targets explicitly, while being aware that in early-onset T2D, continuing GLP-1 RAs may be appropriate even when targets aren’t met. So that is it, an review of the draft NICE guideline on type 2 diabetes focusing on the visual summary. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Sugar, Spice & NICE Advice: The Draft NICE Guideline on Type 2 Diabetes- Part 2 | 01 Oct 2025 | 00:10:52 | |
The video version of this podcast can be found here: · https://youtu.be/M0s2Vvlia70 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below. The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will cover three clinical groups and the remaining groups will be done in next week’s episode. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The NICE announcement on Type 2 diabetes management can be found here:
· https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced
The NICE draft guideline on Type 2 diabetes can be found here:
· https://www.nice.org.uk/guidance/gid-ng10336/documents/450
The visual summary of the NICE draft guideline on type 2 diabetes can be found here:
· https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the main changes as applied to 7 specific groups of patients. Right, let’s jump into it. And, as you know, the draft guideline is open for consultation until October, and the final guidance is due in February 2026, so let’s not forget that it is only a draft, and we should not be making clinical decisions based on it yet. Today’s episode is based on the visual summary created by NICE and the link to it is in the episode description. The visual summary includes specific guidance for 7 different group of patients. In today’s episode we will cover three of the groups and we will finish the other groups in next week’s episode. There are 7 groups: 1. First, the group of patients with no relevant comorbidities, then 2. Obesity 3. Frailty 4. CKD 5. Heart failure 6. Atherosclerotic cardiovascular disease and 7. Early onset type 2 diabetes So let’s start with the no relevant comorbidities group. For adults with type 2 diabetes and no major comorbidities, the draft recommends metformin plus an SGLT-2 inhibitor from the outset. If metformin is contraindicated or not tolerated, then an SGLT-2 inhibitor alone should be offered. If further glycaemic lowering is required, the next step is to add a DPP-4 inhibitor and if this is not effective or tolerated, we can try a sulfonylurea, pioglitazone, or insulin. This is very different from the previous guidance, which began with metformin monotherapy, and only added other agents if HbA1c targets were not met. SGLT-2 inhibitors and GLP-1 receptor agonists were generally reserved for people with established cardiovascular or renal disease, or later in the treatment pathway. The draft changes our thinking on everything by recommending dual therapy right at diagnosis for all, even in people without comorbidities. Why is NICE changing the advice? As we have already explained, evidence shows that SGLT-2 inhibitors consistently reduce heart failure admissions, slow CKD progression, and lower cardiovascular death. Trials have showed these effects in people without established CVD they are now recommended for all, not just for the high-risk subgroups. What this means in practice is that now:
The next group is the obesity group: For people with type 2 diabetes who also have obesity, the draft recommends also starting with metformin plus an SGLT-2 inhibitor. However, if further treatment is needed to reach glycaemic targets, we will add a GLP-1 receptor agonist if initial therapy started 3 months ago or more. This will usually mean adding subcutaneous semaglutide, provided there are no concerns about frailty and they have preserved ejection fraction (i.e., heart function is acceptable). If metformin is contraindicated or not tolerated, the pathway is to offer an SGLT-2 inhibitor plus semaglutide. We are again reminded that GLP1 receptor agonists and DPP-4 inhibitors should not be combined. Therefore, if the patient is on a GLP-1 receptor agonist and further glycaemic control is needed, the next add-on therapies are sulfonylurea, pioglitazone, or insulin depending on the case. However, if a GLP-1 receptor agonist is contraindicated, not tolerated, or not appropriate, we will add a DPP-4 inhibitor first before considering other agents such as a sulfonylurea, pioglitazone, or insulin, as all of these can lead to weight gain. And let’s remember that previously, people with obesity were more likely to have a stepwise approach: metformin first, then add other agents and then move to GLP-1 RAs only if at last resort and if specific BMI thresholds were crossed. The draft changes this: it brings semaglutide forward, in obesity and when weight reduction is a priority, also giving more flexibility in continuing GLP-1s if weight or glycaemic goals are lagging—as long as obesity remains a priority. Why is NICE making this change?
What does it mean in practice?
And finally, the last group today, the frailty group. The draft guidance states that if the person’s level of frailty increases the risk of adverse events from SGLT-2 inhibitors, we will consider metformin alone initially. If metformin is contraindicated or not tolerated, we will consider a DPP-4 inhibitor instead. After metformin, if further glycaemic lowering is needed, we will give a DPP-4 inhibitor (if not already used); and if a DPP-4 inhibitor is contraindicated, not tolerated, or already being taken, we will offer pioglitazone, a sulfonylurea, or insulin, explicitly taking into account hypoglycaemia and falls risk with sulfonylureas and insulin. Alongside this, the draft highlights the need for a medication review, aiming for the smallest effective number of drugs in frailty. How does this differ from the previous guidance? Earlier frailty modifiers were less explicit, whereas now, the draft makes frailty a front-door decision point: it deprioritises SGLT-2 inhibitors when volume depletion, hypotension, or acute illness risk is high; it elevates DPP-4 inhibitors as a low-burden alternative; and it puts structured deprescribing on the page. It also flags the hypoglycaemia risk with sulfonylureas and insulin in frail adults, which pushes us to choose agents which are safer in that respect. NICE is making this change because frailty amplifies medication harms. For example, SGLT-2–related diuresis and BP lowering can precipitate dehydration, orthostatic symptoms, AKI, and falls; GLP-1 RAs can cause GI effects and anorexia that risk weight loss in the frail. By contrast, DPP-4 inhibitors are weight-neutral, have a low hypoglycaemia risk, minimal haemodynamic effects, and simple dosing. The emphasis on medication review reflects evidence that polypharmacy and hypoglycaemia are linked to falls, delirium, and hospitalisation in frail older adults. What this means in practice is that we will need to:
So that is it, an initial review of the new draft NICE guideline on type 2 diabetes focusing on the visual summary. In the next episode we will cover the remaining groups CKD, heart failure, atherosclerotic cardiovascular disease and early onset type 2 diabetes. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Sugar, Spice & NICE Advice: The Draft NICE Guideline on Type 2 Diabetes- Part 1 | 24 Sep 2025 | 00:12:02 | |
The video version of this podcast can be found here: · https://youtu.be/xB8BStN4Owg This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below. The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will review the general guidance and we will cover the various groups in future episodes. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE announcement on Type 2 diabetes management can be found here:
· https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced
The NICE draft guideline on Type 2 diabetes can be found here:
· https://www.nice.org.uk/guidance/gid-ng10336/documents/450
The visual summary of the NICE draft guideline on type 2 diabetes can be found here:
· https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the visual summary created by NICE. I will cover the information over several episodes, so stay tuned. Right, let’s jump into it. As you may know, the draft NICE guideline on type 2 diabetes is open for public consultation until October, and the final guidance is due in February 2026. It has attracted a lot of attention, but we need to remember that, for now, it is only a draft, which means it could still change. So, we should not be making clinical decisions based on it yet. Today’s episode is based on the NICE visual summary and the link to it is in the episode description. The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will review the general guidance and we will cover the various groups in future episodes. The first page of the draft visual summary sets out the general approach for all. NICE begins by emphasising that diet and lifestyle are the foundation of management, and these need to be reinforced at every stage of the treatment pathway, pointing out that medicines should come on top of, and not instead of, these lifestyle measures. When choosing drug therapy, the draft recommends discussing the benefits and risks of every option. That includes looking at each drug’s effectiveness for glycaemic control but also, and this is new compared with the previous guideline, weighing its impact on cardiovascular and renal outcomes. The guideline also stresses that if a person has more than one comorbidity, for example obesity, cardiovascular disease or chronic kidney disease, we should make a shared decision with the patient about which comorbidity to prioritise in choosing treatment. This means that we move away from a purely HbA1c-driven model towards a model focused on complications and their prevention. On reviewing medicines, the draft says that before changing therapy, we should first optimise the current regimen, bearing in mind that it may be appropriate to continue some treatment options, like SGLT-2 inhibitors or GLP-1 receptor agonists even if the effect on glycaemic control is not perfect. In fact, the draft advises continuing SGLT-2 inhibitors for their heart and kidney benefits even if they are not achieving glucose or weight targets. For GLP-1 receptor agonists, the draft changes the stop rules: we will stop if they do not help the person achieve glycaemic or weight goals but only, and this is important, if the person does not have cardiovascular disease or early-onset type 2 diabetes, understood as type 2 diabetes diagnosed under the age of 40. This a huge change. Previously, stopping criteria were more tightly linked to weight and HbA1c thresholds, for example, if the person had not lost at least 3% of body weight and dropped their HbA1c by 1% within six months. Now, because of the cardiovascular benefit of GLP-1 receptor agonists, it basically means that for people with atherosclerotic cardiovascular disease, it is continued long term, regardless of weight loss or HbA1c change. And a similar, more relaxed attitude also applies to people with early onset type 2 diabetes. But, why this recommendation? Well, this comes from trial evidence over the past decade. SGLT-2 inhibitors have consistently reduced hospitalisation for heart failure and slowed CKD progression, even when HbA1c effects were modest. Similarly, GLP-1 receptor agonists have reduced rates of major adverse cardiovascular events. Why these benefits? The pathophysiology is important here: SGLT-2 inhibitors reduce intraglomerular pressure, improve renal haemodynamics, induce diuresis, and reduce preload and afterload on the heart. On the other hand, GLP-1 receptor agonists improve weight, and have an effect on blood pressure and lipids. All these effects are the reason for the beneficial outcomes over and above glucose control What this means in practice is that:
Finally, NICE advises against combining GLP-1 receptor agonists with DPP-4 inhibitors, as this combination offers no additional benefit. Why is this? Let’s remember that DPP-4 inhibitors prevent breakdown of endogenous GLP-1, whereas GLP-1 receptor agonists directly activate GLP-1 receptors. Because the GLP-1 agonists already saturate the receptor and they are not affected by DPP-4 degradation, adding a DPP-4 inhibitor offers no additional glycemic or weight benefit. That’s why guidelines recommend using one or the other, but never both. And before we end, let’s also quickly list the main current recommendations in the draft guideline, making reference to the recommendations that have been either deleted or changed in a major way. 1. First, the recommendation to start metformin alone as first-line for most people without complications has gone. Now we will start dual Therapy with Metformin + SGLT-2 Inhibitor as Initial Therapy, the reason being the need to maximise the cardiorenal benefits of SGLT2 inhibitors. 2. Second, the restrictive conditions to start GLP1 receptor agonists have also gone. Now there is Earlier and More Explicit Use of GLP-1 Receptor Agonists, Specifically Semaglutide, in order to maximise the weight and cardiovascular benefits of GLP1 receptor agonists. In particular, semaglutide is the preferred option because it has the most consistent and strong evidence as well as being the most cost-effective. 3. Third, there is more weight on Stratification by Kidney Function and Frailty. As a result, the draft puts more weight on eGFR thresholds when deciding which medicines to use and it also identifies frailty as a modifier given that frailty increases treatment risks such as dehydration, side effects, hypoglycaemia, etc. 4. Continuation Criteria and Stop Rules for GLP-1 receptor agonists are now different, meaning that if a person has cardiovascular disease or early onset diabetes, the recommendation is to continue GLP-1 even if glycaemic or weight targets are not fully met. 5. The advice on how to introduce multiple medicines when initial therapy is combination therapy is also clearer. The draft specifies that medicines should be introduced one at a time. For example, first confirm tolerability of metformin, then of the SGLT-2 inhibitor, then if adding a GLP-1 RA, confirm tolerability of that in turn. 6. Another change is that the draft is more explicit about reviewing medicines: checking effectiveness, and discontinuing medicines that are not effective unless there is an additional benefit like cardiovascular or renal protection. 7. Then, insulin guidance has also had a major refresh. The new draft simplifies the advice into a more practical, class-based approach, giving more flexibility as to whether human or analogues insulins are recommended. This is pragmatic response to insulin product withdrawals and shortages. By focusing on broader insulin classes instead of individual types, the guidance is more flexible and easier to apply, even when supply issues arise. 8. Another significant change is that GLP-1 receptor agonists can now be combined with insulin without the need for specialist approval, making access easier and quicker in primary care. 9. The ordering and priority of Subsequent Therapy Options has also changed. The draft places DPP-4 inhibitors as the recommended option after Initial treatment. Sulfonylureas, pioglitazone, and insulin remain options but are considered after DPP4 inhibitors. 10. The recommendation against combining a GLP-1 receptor agonist with a DPP-4 inhibitor is repeated and is more strongly worded in the draft. The combinations does not add benefit so it should be avoided and removed if present. 11. The priority of additional therapies is also more dependent on the clinical group that the patient belongs to. This means that the draft makes the escalation pathway group-specific, and more prescriptive, with risks explicitly considered for each clinical category. And to summarise and close, let’s review again how we think about treatment escalation from a general perspective. The general pathway looks like this:
The main message to remember is that the rationale of the draft guideline is to avoid the old problem of incremental, reactive prescribing, that is, waiting for one drug to fail before adding another, often leaving patients years without treatment that could protect their heart and kidneys. So that is it, an initial review of the new draft NICE guideline on type 2 diabetes focusing on the visual summary. In the next episode we will cover the recommendations for specific clinical groups. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - NICE News - August 2025 including draft NICE guideline on diabetes | 17 Sep 2025 | 00:11:46 | |
The video version of this podcast can be found here: · https://youtu.be/mHyDaVHtb58 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in August 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. I also give an overview of the draft NICE guideline on type 2 diabetes open for consultation until October 2025 and due for publication in February 2026.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for August 2025 can be found here:
· https://www.nice.org.uk/guidance/published?from=2025-08-01&to=2025-08-31&ndt=Guidance&ndt=Quality+standard The updated quality standard Overweight and obesity management [QS212] can be found here: · https://www.nice.org.uk/guidance/qs212
The NICE announcement on Type 2 diabetes management can be found here:
· https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced
The NICE draft guideline on Type 2 diabetes can be found here:
· https://www.nice.org.uk/guidance/gid-ng10336/documents/450
The visual summary of the NICE draft guideline on type 2 diabetes can be found here:
· https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in August 2025, focusing on what is relevant in Primary Care only. Today there’s just one updated clinical area to cover, overweight and obesity. But I will also mention that the draft NICE guideline on type 2 diabetes has now been made public, so we will discuss that too. Right, let’s jump into it. And I know most of you will be keen to hear about the new diabetes guidance, and understandably so. But before we get to that, I would like to spend the first minute and a half on an area that’s often neglected: overweight and obesity. NICE has just released a new quality standard that replaces three separate guidelines, those on children, adults, and general clinical management, and brings them together into a single standard, reflecting new priorities and evidence. There are eight quality statements on obesity. In the first two statements, the focus is on better identification. For adults with long-term conditions, BMI should be recorded at least annually, and if BMI is under 35, waist-to-height ratio should also be measured. This represent a change from previous guidance where BMI alone was the main focus. Also, for children over the age of two, BMI should be recorded opportunistically. putting greater emphasis on early recognition. Statements three, four, and five are all about improving access to services, including people with learning disabilities. Local authorities and commissioners need to maintain an up-to-date list of services to offer patients, which should reduce barriers and ensure equity of access. Statements six, seven, and eight deal with clinical management. People prescribed weight management medicines should receive holistic care, covering diet, nutrition, and physical activity. Those who stop medicines or finish behavioural interventions should get long term follow up support, which recognises the importance of relapse prevention. And finally, adults discharged after bariatric surgery should be followed up at least annually within a shared-care model. This is also new because the need for ongoing shared care was not explicit before. And that is it in respect of overweight and obesity. Now let’s move to the real headline, the draft new NICE guideline on type 2 diabetes. This is the one everyone’s been talking about. The draft is open for public consultation until October, and the final guidance is due in February 2026. Today I’ll just give you a quick overview. But in a future episode, we’ll look at the proposed changes in slightly more detail, so stay tuned. Just remember, for now it’s only a draft, which means it could still change, and we should not be making clinical decisions based on it yet. First, the biggest shift: Treatment no longer starts with just metformin. Instead, the new draft guideline recommends combination therapy from day one—metformin plus an SGLT-2 inhibitor for almost all adults with type 2 diabetes. This is a major departure from monotherapy and reflects the fact that type 2 diabetes is not only about sugar control. SGLT-2 inhibitors confer cardiac and renal protection, reducing cardiovascular events and slowing kidney disease progression, benefits that metformin alone can’t offer. NICE has been clear that SGLT2 inhibitors remain underutilised in practice. Why? In many cases, clinicians have stuck with the traditional stepwise model of adding medicines only when HbA1c goes up. Others may be concerned about cost, side effects, or uncertainty over who exactly should benefit. The new guideline cuts through that by saying: everyone with type 2 diabetes will benefit, so we need to make SGLT-2 inhibitors part of the standard starting treatment. The message is that we should be thinking beyond blood glucose from the very beginning, and treating cardiovascular and renal risk right from the start. Second, we move away from risk-based prescribing. In the past, SGLT-2 inhibitors were reserved only for people with heart failure or at high cardiovascular risk, so their use was much more limited. As we have just said, the new draft guideline takes a completely different approach: now, SGLT-2 inhibitors are recommended for everyone with type 2 diabetes, regardless of their cardiovascular risk profile. The thinking here is simple — we know these drugs consistently reduce hospitalisations for heart failure and slow the progression of kidney disease, and those benefits apply across the board, not just in the highest-risk patients. On top of that, for people who already have established atherosclerotic cardiovascular disease, the guidance goes further by recommending that a GLP-1 receptor agonist, semaglutide, is added as well, creating a triple-therapy regimen right from the start. This combination gives comprehensive coverage: metformin for glucose control, SGLT-2 inhibitors for renal and heart protection, and GLP-1 agonists for both cardiovascular benefit and weight management. It’s simply a move towards using the right drug in the right place earlier, instead of holding them back as late-stage rescue therapies. Third, let’s talk about GLP-1 receptor agonists a bit more, because this is another big change. Previously, GLP-1 drugs were considered much later, often for people with obesity or those who hadn’t met glycaemic targets despite multiple therapies, and they were tied to strict BMI criteria. That’s no longer the case. Now, semaglutide is recommended much earlier:
And there’s another key change: continuation. In the old guideline, GLP-1 treatment was only continued if the person had lost at least 3% of body weight and dropped their HbA1c by 1% within six months. That rule is gone. Now, if semaglutide is prescribed for cardiovascular protection, it is continued long term, regardless of weight loss or HbA1c change. Only if it’s being used primarily for obesity or metabolic control do continuation decisions depend on whether agreed targets are met. In short, the focus has shifted from short-term numbers to long-term protection. Fourth, insulin guidance has also had a major refresh. The old guideline gave long, detailed lists of which insulin types to use in different scenarios. The new draft simplifies this into a more practical, class-based approach. Here’s what’s changed:
· However, if someone’s HbA1c is very high, usually 75 mmol/mol or above, then basal plus short-acting insulin can be considered straight away. Rapid-acting insulin analogues are considered if someone’s lifestyle, eating patterns, or risk of hypoglycaemia makes them a better fit than human short-acting insulin. Pre-mixed short-acting analogues are also an option if appropriate. In practice, this means more flexibility while keeping the pathway simple.
And this is important because these changes partly reflect a pragmatic response to insulin product withdrawals and shortages. By focusing on broader insulin classes instead of individual types, the guidance is more flexible and easier to apply, even when supply issues arise. Importantly, GLP-1 receptor agonists can now be combined with insulin without the need for specialist approval, making access easier and quicker in primary care. And finally, there has also been a change in how we think about escalation overall. Instead of relying on long lists of add-on options, the draft guideline now gives us a much clearer stepwise pathway. The idea is to simplify decision-making and the pathway looks like this:
The rationale here is to avoid the old problem of incremental, reactive prescribing — waiting for one drug to fail before adding another, often leaving patients years without treatment that could protect their heart and kidneys. So, in short: the new draft guideline is all about earlier combination therapy, universal access to SGLT-2 inhibitors, earlier and more consistent use of GLP-1 receptor agonists, a streamlined approach to insulin, simpler treatment pathways, always with a stronger focus on long-term cardiovascular and renal protection. In the next episode, I will discuss how the draft guideline is envisaged to be used in specific groups of patients, so make sure not to miss it. So that is it, a review of the NICE updates relevant to primary care, including an overview of the forthcoming draft guideline on Type 2 diabetes. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.
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| Podcast - T2DM guideline – Part 2 - When Metformin’s Not Enough: Needle Little Extra Help? | 10 Sep 2025 | 00:12:31 | |
The video version of this podcast can be found here: · https://youtu.be/z7eZ1MLItGw The previous episode on first line treatment of T2DM can be found here: · https://youtu.be/32Lf5UlyTOA This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by them. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The links to the NICE guideline can be found below.
In today’s episode, we are focusing on treatment options if further interventions are needed after first line treatment. If you haven’t already, I recommend that you check the previous episode on the first line drug management of type 2 diabetes.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The NICE guideline on Type 2 diabetes in adults: management [NG28] can be found here: · https://www.nice.org.uk/guidance/ng28
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In this episode, we’ll go through the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The link to it is in the episode description.
In today’s episode, we are focusing on glucose lowering treatment options if further interventions are needed after first line treatment.
If you haven’t already, I recommend that you check the previous episode on the first line drug management of type 2 diabetes.
Right, let’s jump into it. So we are going to look at treatment options if further intervention is needed—basically, what to do after first-line treatment. But first, let’s talk about reviewing drug treatments and when we will need to add an SGLT2 inhibitor at any point after starting first-line therapy. For adults with type 2 diabetes, no matter where they are in their treatment journey, if they have or develop chronic heart failure, established atherosclerotic cardiovascular disease, or become high risk for cardiovascular disease, if they are not already on it, we should offer an SGLT2 inhibitor that has proven cardiovascular benefits. This can be added on to their current treatment or used to replace an existing medication. And let’s remember that this is because there is strong evidence in large randomised controlled trials, that has shown that SGLT2 inhibitors not only improve blood glucose control but also reduce the risk of hospitalisation for heart failure, and in some cases lower cardiovascular mortality. These benefits are seen even in patients without diabetes, which highlights their role in protecting the cardiovascular system as well as the kidneys. Right, now, before we look into how to intensify treatment, let’s quickly cover what NICE says about monitoring and targets. Regarding diabetes monitoring, NICE recommends measuring HbA1c every 3 to 6 months until it’s stable on unchanging treatment. After that, once HbA1c is fully stable, measuring every 6 months is usually enough. When it comes to HbA1c targets, we should discuss and agree on an individual goal with each patient. The aim is to help them reach and maintain that target—unless trying to do so causes problems like hypoglycaemia or lowers their quality of life. Generally speaking, for those managing their diabetes with lifestyle changes or a single drug that doesn’t cause hypoglycaemia, the target is around 48 mmol/mol, or 6.5%. For patients on medications that do carry a risk of hypoglycaemia, the target is a bit higher, around 53 mmol/mol, or 7.0%. If an adult’s HbA1c isn’t controlled by a single drug and rises to 58 mmol/mol, or 7.5%, or above, then we need to review and reinforce their current treatment and after that, we usually move to intensify drug treatment by adding a second medication. Now let’s look at treatment options when further intervention is needed. For adults with type 2 diabetes, if monotherapy isn’t enough to keep HbA1c below their individual target, we can consider adding one of the following: · a DPP-4 inhibitor, · pioglitazone, · a sulfonylurea, · or an SGLT2 inhibitor. If dual therapy—usually metformin plus another oral drug—still isn’t controlling HbA1c below the agreed threshold, then we have two main options. We can either: · move to triple therapy by adding a DPP-4 inhibitor, pioglitazone, a sulfonylurea, or an SGLT2 inhibitor, · or we can consider starting insulin. In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, and dual therapy with two oral drugs still isn’t keeping HbA1c below the agreed threshold, then insulin should be considered. This essentially means that triple therapy is only recommended by NICE when one of those three drugs is metformin, not otherwise If triple therapy with metformin and two other oral drugs isn’t effective, isn’t tolerated, or is contraindicated, we may consider switching one of those drugs for a GLP-1 mimetic—but according to NICE, this is only for adults who:
GLP-1 mimetic therapy should only be continued if the patient shows a clear benefit, that is, a drop in HbA1c of at least 11 mmol/mol (or 1%) and a weight loss of at least 3% of their starting body weight within six months. Also, we need to be aware that combining a GLP-1 mimetic with insulin should only be done under specialist care and advice. So, as we’ve just seen, NICE recommends using GLP-1 mimetics mainly for people with type 2 diabetes who have a higher BMI or specific obesity-related problems. They also set clear criteria for continuing treatment, based on how well the patient responds metabolically and whether they lose enough weight. Now, we should also point out that other guidelines, like those from the ADA and EASD, take a fairly different approach. They suggest considering GLP-1 receptor agonists earlier in the treatment journey—especially for patients who already have cardiovascular disease or are at high risk of developing it, no matter their BMI. These guidelines focus more on the cardiovascular benefits of GLP-1 therapies, in addition to blood sugar control. So, while NICE tends to emphasize weight and BMI, the ADA and EASD put more weight on cardiovascular risk when they recommend GLP-1 receptor agonists. This is because research has shown that GLP-1 receptor agonists can reduce the risk of major cardiovascular events in people with type 2 diabetes who either have established cardiovascular disease or are at high risk. For example, the LEADER trial looked at liraglutide, and the SUSTAIN-6 trial studied semaglutide. Both showed significant reductions in cardiovascular events compared to placebo. Next, let’s move on to insulin-based treatments for adults with type 2 diabetes. When starting insulin therapy, we are likely to continue offering metformin—provided there are no contraindications or intolerance. At the same time, we should review whether other blood glucose-lowering medications are still needed. For insulin options, we have several choices. The first line option for NICE is NPH insulin, which can be given once or twice daily, depending on the person’s needs. A quick note about NPH insulin: it’s an intermediate-acting insulin with an onset of action around 1 to 2 hours after injection. Its peak effect usually occurs between 4 to 8 hours, and it lasts for about 12 to 16 hours. Because of this profile, it’s useful for covering blood sugar levels between meals and overnight. We should consider starting both NPH and short‑acting insulin particularly if the person's HbA1c is 75 mmol/mol [9.0%] or higher. This can be administered either:
However, NICE also suggests we can consider using insulin detemir or insulin glargine as alternatives to NPH insulin in certain situations. For example:
And now a quick note on insulin detemir and glargine: Insulin glargine is a long-acting basal insulin that provides a steady release over about 24 hours with no pronounced peak, which helps maintain more stable blood sugar levels throughout the day and night. Insulin detemir is also a long-acting insulin but usually has a slightly shorter duration, lasting around 16 to 20 hours. It tends to have a mild peak and may require twice-daily dosing in some people to maintain adequate coverage. Both glargine and detemir offer a more predictable action profile than NPH insulin, which can help reduce the risk of hypoglycaemia and improve blood glucose control. When it comes to pre-mixed, or biphasic, insulin preparations, NICE recommends considering short-acting insulin analogues rather than short-acting human insulin—particularly if:
This is because short-acting analogue insulins are rapid-acting insulins designed to manage the blood sugar spikes that happen around meal times. They start working fast—usually within 10 to 20 minutes—peak around 1 to 3 hours, and their effects last for about 3 to 5 hours. Because of this quick action and shorter duration, they can be injected right before or just after eating, offering more flexibility. Common examples include insulin lispro, insulin aspart, and insulin glulisine. One key advantage of these analogues over regular human insulin is a lower risk of hypoglycaemia, especially overnight or between meals. Their rapid onset and shorter duration mean insulin levels drop off sooner, reducing the chance of blood sugar dipping too low when it’s not needed. Finally, if someone is already on NPH insulin, we should also consider switching from NPH insulin to a long-acting analogue like insulin detemir or insulin glargine if:
We will need to monitor patients on a basal insulin regimen—whether that’s NPH, detemir, or glargine—for the possible need to add short-acting insulin before meals, or to switch to a pre-mixed, biphasic insulin preparation. Similarly, adults on pre-mixed insulin should be regularly assessed to see if they need an additional injection of short-acting insulin before meals or if their blood glucose control would benefit from moving to a basal-bolus regimen with NPH, detemir, or glargine. This ongoing review helps ensure insulin therapy is tailored to achieve the best possible blood sugar control for each patient. So that is it, a review of the treatment options in type 2 diabetes if further interventions are needed after first line treatment. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - T2DM guideline Part 1 -First Line, First Try: Metformin and Flozins’ Time to Shine | 03 Sep 2025 | 00:11:06 | |
The video version of this podcast can be found here: · https://youtu.be/32Lf5UlyTOA This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by them. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The links to the NICE guideline can be found below.
In today’s episode, we are focusing on the first line drug management. In the next episode, we will cover treatment options if further interventions are needed. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The NICE guideline on Type 2 diabetes in adults: management [NG28] can be found here: · https://www.nice.org.uk/guidance/ng28
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In this episode, we’ll go through the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The link to it is in the episode description.
In today’s episode, we are focusing on the first line glucose-lowering drugs. In the next episode, we will cover treatment options if further interventions are needed. Right, let’s jump into it. And before we look at regular glucose-lowering drugs, we first need to check whether rescue therapy is required, remembering that it can be necessary at any stage of treatment. If the patient has symptoms of hyperglycaemia, we’ll consider starting insulin or a sulfonylurea, then review the treatment once blood glucose control is achieved. In symptomatic patients, the priority is to bring glucose levels down quickly to prevent complications and improve wellbeing. Because insulin and sulfonylureas lower blood glucose faster than most other diabetes medications, we’ll use these first, and once control is restored, switch to more suitable long-term treatment. After that, we’ll move on to first-line regular drug treatment. The usual starting point is standard-release metformin. After starting a low dose, we will increase the dose gradually over several weeks to reduce the risk of gastrointestinal side effects, and if those occur, we can switch to a trial of modified-release metformin. Metformin is recommended first because it’s been shown in large clinical trials to lower blood glucose with a low risk of hypoglycaemia, and it doesn’t promote weight gain. The UK Prospective Diabetes Study — or UKPDS — found that in people with type 2 diabetes who were overweight, metformin not only improved blood glucose control, but also reduced the risk of diabetes-related complications. Importantly, it also lowered their cardiovascular risk and overall mortality. These benefits, together with its long track record of safety, make metformin the preferred first-line treatment for most patients. At the same time that we start metformin, we’ll assess the patient’s cardiovascular status and risk. The goal is to determine whether they have chronic heart failure, established atherosclerotic cardiovascular disease, or are at high risk of developing it. We need to remember that established atherosclerotic cardiovascular disease includes conditions such as coronary heart disease, acute coronary syndrome, previous myocardial infarction, stable angina, ischaemic stroke or TIA, and peripheral arterial disease. We also need to be aware that a high cardiovascular risk means a QRISK score above 10% in anyone aged 40 or over, or, for those under 40, having any one of these factors: hypertension, dyslipidaemia, smoking, obesity, or a family history in a first-degree relative of premature cardiovascular disease. If the patient has chronic heart failure, established atherosclerotic cardiovascular disease, or is at high risk of developing cardiovascular disease, we’ll offer an SGLT2 inhibitor in addition to metformin — and we’ll do this regardless of their HbA1c level. This approach is supported by strong evidence. Large randomised controlled trials, have shown that SGLT2 inhibitors not only improve blood glucose control but also reduce the risk of hospitalisation for heart failure, and in some cases lower cardiovascular mortality. These benefits are seen even in patients without diabetes, which highlights their role in protecting the cardiovascular system as well as the kidneys. Now, when starting dual therapy with metformin and an SGLT2 inhibitor as first-line treatment, we’ll introduce the drugs sequentially. We will start with metformin first, then check tolerability, and then add the SGLT2 inhibitor as soon as metformin is confirmed to be well tolerated. If metformin is contraindicated or not tolerated, our approach will also depend on the patient’s cardiovascular history and risk. If they have chronic heart failure, established atherosclerotic cardiovascular disease, or are at high risk of developing it, we’ll offer an SGLT2 inhibitor as monotherapy. We do this because of the SGLT2 inhibitors cardiovascular benefits. If the patient is not in any of these higher-risk groups, we can consider any other glucose-lowering treatments. Options include:
In order to make the right choice of drug, it may be a good idea here to give a comparative overview based on their effect on weight, hypoglycaemia risk etc. And let’s start with weight. Although metformin was once thought to cause weight loss, NICE now describes it as weight neutral. DPP-4 inhibitors, or gliptins, are also generally weight neutral, meaning they usually don’t cause significant weight gain or loss. In contrast, SGLT2 inhibitors—also called flozins—tend to promote weight loss, which can be especially helpful for patients who are overweight or need to lower their cardiovascular risk. On the other hand, both Pioglitazone and Sulfonylureas are linked with weight gain, something to watch out for, particularly in patients where added weight could worsen insulin resistance or raise cardiovascular risk. In terms of hypoglycaemia risk. Metformin, DPP-4 inhibitors, Pioglitazone, and SGLT2 inhibitors all carry a low risk of hypoglycaemia. However, Sulfonylureas stand out here with a much higher risk, especially in older adults or those with irregular meal patterns. All these oral medications are contraindicated in diabetic ketoacidosis but SGLT2 inhibitors, in particular, carry a significant risk of ketoacidosis, including the unusual euglycemic form, so patients on these drugs need careful monitoring. Pioglitazone is also contraindicated in patients with current or past heart failure, as well as those with a history of bladder cancer or unexplained haematuria. Renal function is another key factor. Most of these drugs need dose adjustments or close monitoring when kidney function is reduced. Metformin, for example, requires dose reduction or may need to be avoided depending on the patient’s eGFR. Most clinicians will reduce the dose of metformin to half if the eGFR is between 30 and 45 and metformin is stopped completely if eGFR falls below 30. Pioglitazone generally doesn’t require dose changes for kidney impairment, but it should still be used with caution. Finally, liver impairment can affect how we prescribe these medications. Many require caution or should be avoided depending on the severity of liver disease. I won’t cover every detail here, but we should always consult the BNF before prescribing. Because of what we said earlier about the increased risk of ketoacidosis, before starting someone on an SGLT2 inhibitor, we need to check if they might be at higher risk of diabetic ketoacidosis. This includes people who have had a previous episode of DKA, those who are currently unwell with an illness, or anyone following a very low carbohydrate or ketogenic diet. And because of the risk that SGLT2 inhibitors carry in this respect, we will want to address any modifiable risks before starting them. For example, if someone is on a very low carb or ketogenic diet, they may need to delay treatment until they’ve stopped it. We will also advise them not to restart that kind of diet without talking to their healthcare team first, as they might need to stop the SGLT2 inhibitor if they do. I will not go through all other possible side effects of SGLT2 inhibitors, but it’s important to know that SGLT2 inhibitors have been linked to a rare but serious infection called Fournier’s gangrene. This is a rapidly progressing infection of the genital and perineal area. It happens because SGLT2 inhibitors increase glucose in the urine, which can create an environment where bacteria grow more easily. Patients at higher risk include those who are immunocompromised, have poor hygiene, or have other infections. If Fournier’s gangrene develops, it can cause severe tissue damage and can quickly become life-threatening if not treated promptly. That’s why patients should be warned to look out for symptoms like redness, swelling, pain, or tenderness around the genital area, along with fever or feeling generally unwell. If any of these symptoms appear, they should seek urgent medical care immediately, because early treatment is critical to prevent serious complications or the need for surgery. And well, that brings us to the end of the first-line drug treatment section for type 2 diabetes. There’s a separate part of the diabetes guideline that focuses on people with type 2 diabetes and chronic kidney disease, because they have some specific recommendations when it comes to SGLT2 inhibitors. This section essentially says that, for patients with both CKD and type 2 diabetes, we start by giving an ACE inhibitor or an ARB, titrated up to the highest tolerated licensed dose if their albumin-to-creatinine ratio, or ACR, is 3 mg/mmol or higher. Once they’re on this medication, we then add an SGLT2 inhibitor—on top of the ACEI or ARB—if their ACR is above 3 mg/mmol, especially if it’s over 30, and if they meet the appropriate eGFR thresholds for each particular SGLT2 inhibitor. We also need to remember that not all SGLT2 inhibitors are licensed specifically for CKD. NICE has produced specific technology appraisals for dapagliflozin and empagliflozin for adults with chronic kidney disease. These two drugs can be given to CKD patients without type 2 diabetes specifically for their CKD management. So that is it, a review of the first line drug management in type 2 diabetes. In the next episode, we will cover treatment options if further interventions are needed. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - Sweet but Sticky: Making Sense of HbA1c | 27 Aug 2025 | 00:11:43 | |
The video version of this podcast can be found here: · https://youtu.be/t8U8-isTieM This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by them. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through recommendations on the diagnosis and monitoring of type 2 diabetes, which includes guidance by NICE. The links to the NICE guideline is in the episode description.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement. Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The NICE guideline on Type 2 diabetes in adults: management [NG28] can be found here: · https://www.nice.org.uk/guidance/ng28 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll go through recommendations on the diagnosis and monitoring of type 2 diabetes using HbA1c, focusing on what is relevant in primary care only. This information includes guidance by NICE contained in the NICE guideline on Type 2 diabetes. The link to it is in the episode description.
Right, let’s jump into it. Let’s start with the diabetic diagnostic thresholds. They could be:
Why have these thresholds been chosen? These thresholds are based on the evidence of glucose levels at which the risk of diabetes-related complications—particularly retinopathy—increases significantly. They have been agreed in order to strike a balance between diagnostic accuracy and early intervention, helping to catch diabetes at a point where treatment can prevent progression and complications. And let’s also remember that if the person has symptoms of diabetes, a single abnormal HbA1c or fasting plasma glucose level can be used, although repeat testing is always advisable to confirm the diagnosis. However, If the person is asymptomatic, we should not diagnose diabetes on the basis of a single abnormal HbA1c or plasma glucose result. Instead, we should arrange repeat testing, preferably with the same test, to confirm the diagnosis. If the repeat test result is normal, we will monitor the person for the development of diabetes, and the frequency of such monitoring will depend on our clinical judgement. This guidance to not diagnose diabetes in an asymptomatic person based on a single abnormal result is based on principles of biological variability, and the importance of avoiding misdiagnosis. This is because Glucose levels and HbA1c can fluctuate due to a variety of reasons and a single abnormal result may not reflect the person's usual glycaemic status. Repeating the test helps rule out false positives due to possible transient factors or a lab artefact or error. Can we use HbA1c and plasma glucose interchangeably to diagnose type 2 diabetes? Well, in general, yes, but there are times when HbA1c should not be used to diagnose diabetes. This is the case for:
Additionally, HbA1c should be interpreted with caution in people with abnormal red blood cell turnover or abnormal haemoglobin type, like:
Why do we need caution in these situations? Well, HbA1c reflects the percentage of haemoglobin that has glucose attached to it—essentially giving us an average of blood glucose over the past 2 to 3 months, which is the typical lifespan of a red blood cell. However, anything that alters red blood cell turnover or haemoglobin structure can affect the accuracy of this measurement. For example:
So, in these cases, HbA1c may not accurately reflect the patient’s glycaemic control, and alternative measures like fasting glucose or an oral glucose tolerance test may be more reliable. What about diabetic monitoring? NICE recommends that we should measure HbA1c levels in adults with type 2 diabetes:
If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, we will need to estimate trends in blood glucose control using one of the following:
What do these alternative forms of monitoring involve? Well:
Each of these methods has limitations, but they can give a more reliable picture than HbA1c when red cell-related interference is present. What about HbA1c targets? NICE advises that we should discuss and agree an individual HbA1c target with patients, encouraging them to reach and maintain it, unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target impair their quality of life. However, from a general perspective, for those managed either by lifestyle and diet alone, or combined with a single drug not associated with hypoglycaemia, we should aim for an HbA1c target of 48 mmol/mol (6.5%). For those on a drug associated with hypoglycaemia, we will aim for an HbA1c target of 53 mmol/mol (7.0%). In adults, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
These thresholds are heavily influenced by the results of clinical trials such as the UKPDS (or United Kingdom Prospective Diabetes Study), which is still one of the most influential long-term RCTs on glycaemic control in type 2 diabetes. It showed that intensive blood glucose control (targeting HbA1c around 53 or ~7.0%) significantly reduced:
What is exactly the legacy effect? Well, it describes the fact that participants in the UKPDS randomised controlled trial were followed for 10 years after the trial ended. Although the differences in HbA1c between intensive and conventional groups disappeared within a year, the intensive group still had significantly lower rates of both micro and macrovascular complications as well as all-cause mortality. In a way, this showed that early good control leaves a "metabolic imprint" that protects patients long term, even if later control becomes less strict. However, although tight control can be beneficial, we will consider relaxing the target HbA1c on a case-by-case, with particular consideration for people who are older or frailer, if:
This is because there is strong evidence that in older or frail adults, sometimes the risks of hypoglycaemia may outweigh the benefits of strict control. In particular, the ACCORD Trial found that intensive glucose lowering (with a target HbA1c of less than <6.0%) increased all-cause mortality in people with type 2 diabetes at high cardiovascular risk. In fact, the trial had to be stopped early due to this excess mortality. Our take home message is that tight control is not always safe, especially in older, comorbid populations. On the other hand, if the HbA1c level is lower than their target and they are not experiencing hypoglycaemia, we will encourage them to maintain it, being aware that there are other possible reasons for a low HbA1c level, for example deteriorating renal function or sudden weight loss. So that is it, a review of the diagnosis and monitoring of type 2 diabetes. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||
| Podcast - NICE News - July 2025 | 20 Aug 2025 | 00:10:13 | |
The video version of this podcast can be found here: · https://youtu.be/j5z0Qv35dWE This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in July 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
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:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for July 2025 can be found here:
The updated quality standard Cardiovascular risk assessment and lipid modification [QS100] can be found here: · https://www.nice.org.uk/guidance/qs100
The new technology appraisal Dapagliflozin for treating chronic kidney disease [TA1075] can be found here:
· https://www.nice.org.uk/guidance/ta1075
Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in July 2025, focusing on what is relevant in Primary Care only. Today we just have two clinical areas to discuss, the updated quality standard on cardiovascular risk assessment and a new technology appraisal on Dapagliflozin for CKD. Right, let’s jump into it. There are only 5 updated quality standard on cardiovascular risk assessment and lipid modification, so let’s have a look at them: Quality statement 1 refers to the identification of adults who are likely to be at high CV risk. What does the new statement say? It says that General practices should systematically search their patient records to identify people who are likely to be at high risk of CVD. Using routinely collected data, practices can estimate someone's 10-year risk of CVD ideally using the QRISK3 tool. What’s different from the old guideline? Previously, the guidance said that If a person between 25–84 was flagged as having an increased CVD risk, we would offer them a formal QRISK3 assessment. Now, the focus is to use a proactive, structured search of patient records to find those likely to be at risk. So instead of waiting for risk to be flagged, we now go looking for it. However, we have to be cautious and use clinical judgment, especially in groups which may have missing or incomplete data in their records, which can lead to their risk being underestimated. Let’s now look at Quality Statement 2, which covers Diet and lifestyle advice for primary prevention. What does the new guideline say? Someone with a CVD risk of 10% or more, should be given lifestyle advice and this should happen within 3 months of their risk score being recorded. What’s different from the older guidelines? The previous (now obsolete) standards said that:
So, this update simplifies and strengthens this advice. Everyone with a ≥10% CVD risk should get lifestyle advice within 3 months. It's no longer just a “before statins” step. It’s a core part of primary prevention. Let’s move on to Quality Statement 3, on Lipid-lowering treatment for primary prevention. What does the new guideline say? People with a 10-year CVD risk of 10% or more should be prescribed a high-intensity statin unless it's not suitable for them. If they can’t tolerate statins or have a medical reason not to take them, then an alternative lipid-lowering treatment should be offered. The recommended statin here is atorvastatin 20 mg, which is proven to be effective. What’s different? Under the obsolete standards we were first advised to try lifestyle changes, and only if those changes were ineffective or unsuitable, would a discussion about statin therapy take place Now, the emphasis is on timely treatment. If a person has a 10-year CVD risk of 10% or more, and they choose to start treatment, they should be prescribed a high-intensity statin straightaway, usually atorvastatin 20 mg. There is no longer a requirement to try lifestyle changes first. While lifestyle advice remains important, it’s not a prerequisite to offering statins. This change reflects stronger evidence that earlier intervention with statins in high-risk people can significantly reduce the risk of CVD events. But let’s remember other key considerations:
Quality statement 4 refers to Assessing response to lipid-lowering treatment. This one focuses on how we monitor people after starting or changing lipid-lowering treatment, such as statins. The obsolete guidance recommended that adults on a high-intensity statin should have a repeat lipid profile and liver transaminase levels measured after 2 to 3 months. What’s changed? The new quality statement broadens this. It now applies to all adults starting or changing any lipid-lowering treatment, not just those on high-intensity statins. This change recognises that monitoring response and safety is important for everyone, not just high-intensity statin users. And let’s remember that Fasting is not required for a full lipid profile, which should include
Let’s now look at the final quality statement, Quality statement 5 which focuses on Secondary prevention of cardiovascular disease The previous (now obsolete) guidance said that people newly diagnosed with CVD should be offered atorvastatin 80 mg and that, if someone developed side effects, they should be offered a lower dose or a different statin. What’s changed? The new guidance shifts the focus from prescribing a specific drug or dose to achieving a specific cholesterol target. It says that people with CVD should have either:
This is a move toward outcome-focused care, rather than just prescribing a medication and assuming it's effective. So, instead of asking: "Did we prescribe atorvastatin 80 mg?" We now ask: "Has this person’s cholesterol actually reached a level that protects them?" Besides, using non-HDL cholesterol as an alternative to LDL is helpful when LDL hasn't been specifically measured or calculated. Let’s remember that, for example, LDL may not be calculated in people with very high triglycerides. Let’s now take a few minutes to go through the updated NICE guidance on dapagliflozin for chronic kidney disease. This updated recommendation replaces earlier guidance and reflects both new evidence and a broader treatment scope for patients with CKD. So, what’s changed? Under the previous guidance dapagliflozin was only recommended for people with CKD, with or without type 2 diabetes, but only if their eGFR was between 25 and 75. This meant that certain patients were excluded — for example:
At the time, these restrictions were based mostly on the inclusion criteria of the DAPA-CKD trial, and also concerns that the size of the eligible population might have been overestimated. Now, with this update, things have shifted significantly. The new guidance states that dapagliflozin can be used more widely, in people with an eGFR between 20 and 90 as long as certain conditions are met. For people with an eGFR between 20 and 45, no additional criteria are required. But for those with an eGFR between 45 and 90, they must also either:
So, this new recommendation includes a much broader group of patients, especially those with early-stage CKD and diabetes, or those with elevated proteinuria but better preserved kidney function. Why has it changed? The change is due to new evidence, including meta-analyses and indirect treatment comparisons between dapagliflozin and empagliflozin. While the two haven’t been directly compared in a clinical trial, the available data suggest that they are similarly effective and safe for people with CKD. Also, the costs of dapagliflozin and empagliflozin are comparable, so there’s no financial reason to prefer one over the other. As a result, NICE has aligned the eligible population for dapagliflozin with that of empagliflozin creating a consistent and flexible approach to SGLT2 inhibitor use in CKD. It also reflects a more inclusive and practical approach, one that gives patients better access to effective treatment and gives clinicians greater flexibility when choosing between dapagliflozin and empagliflozin. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye. | |||