The video version of this podcast can be found here:

·      https://youtu.be/SA7pJQLlmvg

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.

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 2024 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.  

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: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for August 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-08-01&to=2024-08-31&ndt=Guidance&ndt=Quality+standard

The links to the current guidance can be found here:

Diabetic retinopathy: Management and monitoring:

·      https://www.nice.org.uk/guidance/ng242

Abaloparatide for treating osteoporosis after menopause:

·      https://www.nice.org.uk/guidance/ta991

National Osteoporosis Guideline Group (NOGG) clinical guideline for the prevention and treatment of osteoporosis:

·      https://www.nogg.org.uk/full-guideline

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

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 am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in August 2024, focusing on what is relevant to Primary Care only.

We are going to cover just two areas, the treatment of osteoporosis and the management of diabetic retinopathy, so it is a brief episode.

Let’s jump into it.

The first area is a technology appraisal on Abaloparatide for treating osteoporosis after the menopause.

And you may be thinking, Abaloparatide, is this really something that we need to know about in Primary Care?

And the answer is yes. And let’s see why.

And we will start by saying that treatments of osteoporosis can be broadly divided into 2 types:

·    antiresorptive treatments (which slow the rate of bone breakdown), such as our usual bisphosphonates and

·    anabolic (or bone-forming) treatments.

Treatment with anabolic skeletal agents result in rapid and greater fracture risk reductions than bisphosphonates. So, if we are used to prescribing bisphosphonates for the majority of our patients, who should be getting anabolic agents instead?

And the guidelines stipulate that people with a very high fracture risk should be referred for the consideration of these agents. According to the National Osteoporosis Guideline Group, 'very high risk' is defined as a FRAX-based fracture probability that exceeds the intervention threshold by 60%.

So, looking at this diagram based on FRAX, we can see how patients can fall into the different risk categories depending on their scores.

Apart from the patients already in the very high risk of fractures, we should also consider additional clinical risk factors for patients in the high-risk category, (e.g., frequent falls, or a very low spine Bone Mass Density) in case that they may move them from high to very high risk of fracture.

So, in summary, we need to be aware that these anabolic drugs exist and that they are recommended for people with a very high risk of fractures so that when we see such patients, we refer them appropriately to get these drugs.

Existing anabolic treatments are Romosozumab and Teriparatide and, following this technology appraisal, NICE recommends Abaloparatide too.

These anabolic agents can only be taken for a limited time between 12 and 24 months depending on the drug, and afterwards patients will continue to receive an antiresorptive treatment (such as an oral bisphosphonate).

Although abaloparatide is licensed for 'treatment of osteoporosis in postmenopausal women', we must also include trans men and non-binary people registered female at birth.

The next area is a brand-new NICE guideline on Diabetic retinopathy, its management and monitoring. It is mostly aimed at the diabetic retinal screening service and ophthalmologists but it also covers some areas of diabetic care that affects us in primary care. Let’s have a look at it.

1.   Firstly, we should always discuss with patients that good long-term diabetic control can have long-term benefits for their vision.

2.   Then the second recommendation refers to the effects on retinopathy of a rapid reduction in HbA1c.This is because there is some, although limited, evidence about the potential risk of worsening retinopathy from treatments that result in a rapid, substantial drop in HbA1c. Early worsening of diabetic retinopathy does not necessarily mean that the treatment is harmful in the long term but, instead, it highlights the need for close monitoring. NICE therefore recommended that an ophthalmologist should assess the patient before intensive glycaemic treatment is started, and then closely monitors for changes afterwards.

3.   We know that both HbA1c and blood pressure levels can be used to predict the likelihood of retinopathy progression. So, the third recommendation is that ophthalmologists should have access to a person's HbA1c and blood pressure records.

4.   Additionally, NICE has highlighted that the presence of renal disease can also influence retinopathy progression. The evidence for this is of low quality, but is supported by clinical experience.

5.   Also, we know that managing blood pressure in hypertensive patients can reduce retinopathy progression, so achieving good blood pressure control is important. However, we must also be aware that reducing blood pressure with antihypertensives in people who do not have hypertension has no such positive effect.

6.   There is some evidence that fenofibrate is beneficial for people with type 2 diabetes in respect of retinopathy progression. However, there is no evidence on other outcomes such as visual acuity or quality of life. NICE therefore recommends that it should be ophthalmologists who initiate fenofibrate for this indication. There is no evidence for people with type 1 diabetes, so they are not included in the recommendation.

7.   NICE has recommended further research about statins preventing retinopathy progression, because there is no strong evidence to this effect.

8.   The rest of the recommendations are entirely for secondary care and cover areas such as cataract surgery as well as recommendations of the treatment and frequency of monitoring for both proliferative and non-proliferative diabetic retinopathy and diabetic macular oedema.

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 and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/pxOeszuHRsI

This episode makes reference to guidelines produced for NHS Greater Glasgow and Clyde and Liverpool University Hospitals NHS Trust. 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 go through the management of hypocalcaemia, in particular, we will look at the guidance on the management of hypocalcaemia in NHS Greater Glasgow and Clyde and in Liverpool University Hospitals NHS Trust, always focusing on what is relevant in Primary Care only.  

I am not giving medical advice; this episode is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

●      Apple podcast: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

●      Spotify: https://open.spotify.com/show/2kmGZkt1ssZ9Ei8n8mMaE0?si=9d30d1993449494e

●      Amazon Music: https://music.amazon.co.uk/podcasts/0edb5fd8-affb-4c5a-9a6d-6962c1b7f0a1/primary-care-guidelines?ref=dm_sh_NnjF2h4UuQxyX0X3Lb3WQtR5P

●      Google Podcast: https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5yZWRjaXJjbGUuY29tLzI1ODdhZDc4LTc3MzAtNDhmNi04OTRlLWYxZjQxNzhlMzdjMw%3D%3D

●      Redcircle: https://redcircle.com/shows/2587ad78-7730-48f6-894e-f1f4178e37c3

There is a YouTube version of this and other videos that you can access here: 

●       The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk 

The resources consulted can be found here:

The guidance on the management of hypocalcaemia by Liverpool University Hospitals NHS Trust can be found here:

·      https://pathlabs.rlbuht.nhs.uk/Guideline%20for%20Treating%20and%20Monitoring%20Hypocalcaemia%20for%20non-critical%20areas%20of%20Trust.pdf

The guidance on the management of hypocalcaemia by the Adult Therapeutics Handbook for the NHS Greater Glasgow and Clyde can be found here:

·      https://handbook.ggcmedicines.org.uk/guidelines/electrolyte-disturbances/management-of-hypocalcaemia/

Calcium – The Lancet - Bushinksy DA, Monk RD. Calcium. Lancet 1998; 352 (9124): 306-311:

·      https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)12331-5/abstract 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

●       Music provided by Audio Library Plus 

●       Watch: https://youtu.be/aBGk6aJM3IU 

●       Free Download / Stream: https://alplus.io/halfway-through 

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 management of hypocalcaemia, in particular, we will look at the guidance on the management of hypocalcaemia in NHS Greater Glasgow and Clyde, and in Liverpool University Hospitals NHS Trust, always focusing on what is relevant in Primary Care only. The links to their guidelines and the other sources consulted are in the episode description. 

Right, without further ado, let’s jump into it. 

As a quick overview of calcium metabolism, I will simply say that it is tightly regulated by vitamin D and the parathyroid hormone or PTH. Active vitamin D or calcitriol enhances intestinal calcium absorption and PTH both enhances calcium reabsorption in the kidneys, and releases calcium from the bones by increasing osteoclast activity and bone resorption. 

Both phosphate and magnesium can also affect calcium levels. For example, a low magnesium can impair PTH secretion and action, resulting in hypocalcaemia.  

On the other hand, a high phosphate, like seen in CKD, can lead to the precipitation of calcium with phosphate and the consequent reduction in serum calcium and hypocalcaemia.

Right, now that we have done this review, let’s now look at hypocalcaemia itself.

The reference range for adjusted serum calcium is 2.2 - 2.6mmol/L.

Symptoms of hypocalcaemia, typically develop when serum adjusted calcium falls below 1.9mmol/L. However, this threshold varies and symptoms also depend on the rate of fall. 

So, we will talk of hypocalcaemia when we have an adjusted serum calcium less than 2.2 mmol/L, although you should always take into account your local path lab reference range.  

The cause of hypocalcaemia may be varied depending on whether we are talking about acute or chronic hypocalcaemia. And we must remember that hypocalcaemia is far less common than hypercalcaemia because of the role of the bones as a calcium reserve to maintain homeostasis. 

So, let’s look at causes of acute hypocalcaemia first. The most common cause is hyperventilation which induces transient hypocalcaemia with normal serum total calcium levels normal. Let’s quickly see why this is the case. 

• When a person hyperventilates, they breathe out excessive CO₂ which leads to a decrease of carbonic acid, and respiratory alkalosis.
• Alkalosis causes more calcium to bind to albumin, reducing the concentration of free (ionized) calcium. Given that the ionized form is the physiologically active form, this decrease leads to symptoms of hypocalcaemia.
• However, despite the decrease in ionized calcium, the total serum calcium remains normal because this value includes the calcium bound to albumin. 

Other less common causes are:

·      Other forms of alkalosis.

·      Medications, for example post IV bisphosphonate or denusomab treatment

·      A high phosphate. We have to remember that phosphate and calcium often behave like two parts of a seesaw, where changes in one can inversely affect the other. Therefore, hypocalcaemia can be seen in clinical situations where phosphate is high, like in:

• rapid tumour lysis – like e.g. during cytotoxic treatment of leukaemia or
• in excessive phosphate intake – like for example excessive phosphate containing enemas.
• And finally, another less common cause of hypocalcaemia is acute pancreatitis. 

Let’s now look at the causes of chronic hypocalcaemia. And the most common cause is a decrease in levels of active vitamin D. This could be because there is:

• An overall vitamin D deficiency, like in dietary causes, malabsorption, and lack of sunlight or
• A reduction in the active form of vitamin D or calcitriol, due to poor renal conversion as seen in CKD

Less common causes are:

• hypoparathyroidism which can be post-surgical, autoimmune, genetic, idiopathic etc.
• hypomagnesaemia, because low magnesium impair the secretion and function of PTH, giving rise to a functional hypoparathyroidism.
• Pseudohypoparathyroidism, which is a rare, genetic disorder characterized by the body’s resistance to PTH despite normal or elevated PTH levels and finally
• low plasma albumin caused by, for example, malnutrition, or liver disease. However, it is worth mentioning that a low plasma albumin can lead to low total calcium levels but it does not cause true hypocalcaemia (understood as a low ionized or free calcium). Instead, it leads to pseudohypocalcaemia, where only the bound calcium is reduced, so patients typically do not experience symptoms of low calcium unless their ionized calcium is also low.

It is also worth mentioning that dietary lack of calcium intake is a very rare cause of hypocalcaemia. 

What are the symptoms and signs of hypocalcaemia?

Well, the clinical features of hypocalcaemia are connected to its effects on the nerves and muscles. Typical features include: 

·      Effects on the nervous system like:

• Paraesthesia
• convulsions which may occur because hypocalcaemia lowers the seizure threshold, and
• psychiatric effects, from general malaise to overt psychosis in chronic hypocalcaemia
• Effects on the muscles like:
• painful cramps
• tetany, which may result in spontaneous muscular spasms largely precipitated by exercise
• laryngeal spasm causing stridor, and obstructive respiratory symptoms and
• latent tetany, which may be demonstrated by Trousseau's and Chvostek's signs. Let’s quickly have a look at them:

For Trousseau’s sign, a blood pressure cuff is inflated usually about 20 mm Hg above the systolic BP, and it is left inflated for about 3 minutes. A positive sign is indicated by involuntary contraction of the muscles in the hand and fingers, known as carpal spasm or "Trousseau’s phenomenon." 

On the other hand, Chvostek's sign is performed by tapping on the facial nerve just in front of the ear, at the angle of the jaw, which is the area where the facial nerve crosses the masseter muscle. A positive sign is indicated by twitching of the facial muscles on that same side.  

Both Trousseau's and Chvostek's signs are indicative of increased neuromuscular excitability, which is often associated with hypocalcemia, although not exclusively. 

Other features of chronic hypocalcaemia depend on the underlying cause. They can be very varied so I will mention only a few like:

• candidiasis
• nail dystrophy
• alopecia, and
• rickets or osteomalacia - from chronic vitamin D deficiency

What investigations should be carried out in primary care if we find hypocalcaemia? And we are obviously talking about mild asymptomatic hypocalcaemia because patients with severe or symptomatic hypocalcaemia should be referred to hospital. 

Initial investigations should include as a minimum: 

• A repeat serum adjusted calcium and phosphate
• Parathyroid hormone (PTH)
• Urea and electrolytes
• Magnesium
• Vitamin D and
• A 12-lead ECG as there is a significant likelihood of QT prolongation, in which case cardiac monitoring may be required.

We should monitor calcium concentrations regularly to judge response and review treatment. Serum bone profile should be checked regularly according to clinical judgement, perhaps weekly or fortnightly depending on the case until concentrations are stable. 

Let’s now have a look at the treatment of hypocalcaemia. 

The treatment depends on the severity of symptoms and underlying condition: 

• treatment generally invovles administration of calcium. How calcium is administered and the need for additional agents such as vitamin D depends on the acuity and severity of the hypocalcaemia as well as the underlying cause.
• Severe Hypocalcaemia, that it, a serum adjusted calcium <1.9mmol/L and/or symptomatic hypocalcaemia should be treated as a medical emergency because it can be life-threatening. So, these patients should be referred to hospital for the administration of IV calcium.
• Chronic, Asymptomatic Mild Hypocalcaemia, that is, serum adjusted calcium between 1.9 - 2.2mmol/L is treated with oral calcium and often vitamin D supplements.
• Because calcium binds with dietary phosphate and oxalate we should advise patients that calcium is better absorbed when taken between meals.
• oral calcium is given to increase its availability and, often, vitamin D to enhance absorption.
• calcium carbonate is widely available in tablet form and we should aim for a daily dose of 1-2.6 g and then adjust according to response.
• Examples of calcium carbonate supplements are adcal and calcichew.
• NHS Greater Glasgow and Clyde recommend starting Calcichew Forte Chewable, 2 tablets twice a day, which is an unlicensed dose, and adjust the dose according to the patient’s requirements. As soon as it is appropriate, we should prescribe the licensed dose of 1 tablet daily.
• Alternatively, Liverpool Hospitals recommend starting oral calcium and vitamin D supplements such as Adcal D3 (2 to 4 tab daily) with monitoring and adjustment.
• calcium citrate and calcium phosphate should be avoided because they may cause problems, especially in patients with renal failure.
• If the patient is vitamin D deficient, we will start oral vitamin D supplementation with loading doses of colecalciferol as per the NICE guideline on vitamin D deficiency.
• vitamin D2 or ergocalciferol and vitamin D3 or colecalciferol at doses of 400 units a day are adequate to avoid nutritional deficiency, although higher doses may be needed in malabsorption.
• However, they require conversion to the active form calcitriol and therefore they are not suitable if the alpha-hydroxylation process is impaired, like for example in renal failure. In these cases, we should be guided by the renal team.
• Other general principles that apply to the management of hypocalcaemia are:
• magnesium levels should be checked and corrected if low. If patient has hypomagnesaemia, we should stop any precipitating drug and admit the patient to hospital for the administration of IV magnesium.
• patients on digoxin should be monitored carefully because administration of calcium may lead to digoxin toxicity and death
• Patients with hypoparathyroidism have decreased renal calcium reabsorption and oral calcium supplementation, may lead to hypercalciuria with possible nephrocalcinosis or kidney stones. Therefore, in hypoparathyroidism, the treatment should be guided by endocrinology.
• If hypocalcaemia is secondary to post-thyroidectomy, we will also seek specialist advice.
• When calcium is given to patients with hyperphosphataemia, there is a risk of soft-tissue calcium phosphate precipitation, so we should get specialist advice on the use of phosphate binders. Calcium supplements may have to be delayed until phosphate levels come down.

Right, so that is it. We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.  

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/0cD2zityw9I

The interactive flowchart can be accessed here:

https://1drv.ms/b/s!AiVFJ_Uoigq0mRYQ2Yw67rtg00TM?e=2DpSYI

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.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the recently published NICE guideline on vitamin B12 deficiency in adults, 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.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Apple podcast: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

·      Spotify: https://open.spotify.com/show/2kmGZkt1ssZ9Ei8n8mMaE0?si=9d30d1993449494e

·      Amazon Music: https://music.amazon.co.uk/podcasts/0edb5fd8-affb-4c5a-9a6d-6962c1b7f0a1/primary-care-guidelines?ref=dm_sh_NnjF2h4UuQxyX0X3Lb3WQtR5P

·      Google Podcast: https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5yZWRjaXJjbGUuY29tLzI1ODdhZDc4LTc3MzAtNDhmNi04OTRlLWYxZjQxNzhlMzdjMw%3D%3D

·      Redcircle: https://redcircle.com/shows/2587ad78-7730-48f6-894e-f1f4178e37c3

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE guideline “Vitamin B12 deficiency in over 16s: diagnosis and management” (NICE guideline NG239 can be found here:

·      https://www.nice.org.uk/guidance/ng239

The links to the resource “Oral vitamin B12 replacement: ongoing care and follow up” can be found here:

·      https://www.nice.org.uk/guidance/ng239/resources/visual-summary-ongoing-care-and-followup-for-vitamin-b12-replacement-pdf-13315996909

The B12 pandemic guidance by the British Society of Haematology can be found here:

·       https://apps.nhslothian.scot/refhelp/guidelines/haematology/b12deficiency/

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

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 am Fernando, a GP in the UK. Today, we are looking at the NICE guideline on vitamin B12 deficiency in adults, published as recently as March 2024, focusing on what is relevant in Primary Care only.

Make sure to stay for the entire episode because, at the end, I will tell you how to access an interactive flowchart that I have created and that summarises the guidance.

Right, so let’s jump into it.

Let’s start by looking at common symptoms and signs of vitamin B12 deficiency, which are:

·      anaemia or macrocytosis on a FBC, but we should not rule out a diagnosis of vitamin B12 deficiency based solely on the absence of either anaemia or macrocytosis

·      difficulty concentrating or short-term memory loss, also sometimes described as 'brain fog'

·      glossitis and mouth ulcers

·      unexplained fatigue

·      eyesight problems related to optic nerve dysfunction like

o  blurred vision

o  a visual field loss or scotoma and

o  optic atrophy signs on fundoscopy

·      neurological or mobility problems including

o  balance issues and falls due to impaired proprioception or sensory ataxia

o  impaired gait and

o  paraesthesia, and finally

·      it can also be associated with mental health problems, including symptoms of depression, anxiety or psychosis.

There are also common risk factors for vitamin B12 deficiency. Before looking at them, let’s briefly look at the physiology of vit B12 in the human body.

In food, vitamin B-12 is generally bound to protein, so in the stomach, gastric enzymes such as pepsin separate the vitamin B12 from the protein using. Then, the freed vitamin B12 then combines with a protein produced by parietal cells in the stomach, called intrinsic factor. The vitamin B12-IF complex is taken to the cells in the terminal ileum, where the vitamin B12 is absorbed. So, in summary, for vit B12 to be absorbed effectively, we need a sufficient dietary intake and normal physiological processes in the stomach and terminal ileum.

So, with that in mind, the common risk factors for vitamin B12 deficiency are:

·      diet low in vitamin B12, for example, in people who:

o  follow a vegan diet or low in animal-source foods

o  people who do not consume items fortified with vitamin B12

o  people who have an allergy to some foods such as eggs, milk or fish

o  and people who have difficulties following a well-balanced diet, e.g.:

§ in dementia, frailty, and mental illness

§ in low-income situations and

§ in eating disorders

·      other risk factors include conditions such as:

o  atrophic gastritis

o  coeliac disease or another autoimmune condition and

o  previous gastrointestinal surgery like:

§ bariatric surgery and

§ gastrectomy or terminal ileal resection

·      some medicines like:

o  colchicine

o  H2-receptor antagonists and proton pump inhibitors

o  metformin and

o  some antiepileptics like phenobarbital, pregabalin, primidone and topiramate

·      a family history of vitamin B12 deficiency or an autoimmune condition and finally

·      recreational nitrous oxide use.

We should use our clinical judgement as to when to check for vitamin B12 levels, paying attention as to whether patients have symptoms, signs and risk factors.

In order to diagnose vitamin B12 deficiency, we will use either total B12 (or serum cobalamin) or active B12 (serum holotranscobalamin) unless:

·      the test needs to be done during pregnancy (when we should always use active B12 or serum holotranscobalamin), or if

·      recreational nitrous oxide is the suspected cause, when we will use plasma homocysteine or serum methylmalonic acid (or MMA)

We should not delay vitamin B12 replacement while waiting for the test results in:

·      suspected megaloblastic anaemia,

·      neurological symptoms or

·      suspected vitamin B12 secondary to medication.

We will use caution when interpreting test results if:

·      they are already using an over-the-counter preparation containing vitamin B12 because they may mask a deficiency but may not fully treat it or if

·      they are taking the combined oral contraceptive pill because this can lower total B12 concentrations without causing a true deficiency.

·      We also need to be aware that people of Black ethnicity may have a higher reference range for serum vitamin B12 concentrations.

The NICE guideline gives Vit B12 thresholds to decide whether the vitamin B12 deficiency is unlikely, confirmed or whether the value is indeterminate, but it also recommends using local validated thresholds if they exist. So, in the absence of local guidance we will follow these thresholds:

·      If total B12 is less than 180 nanograms per litre or active B12 is less than 25 pmol per litre, then the vit B12 deficiency is confirmed.

·      If total B12 is more than 350 nanograms per litre or active B12 is more than 70 pmol per litre, then the vit B12 deficiency is unlikely and we will investigate other causes of their symptoms and if they are still experiencing symptoms 3 to 6 months later, we will repeat the vit B12 test.

·      And finally, if total B12 is between 180 and 350 nanograms per litre or active B12 is between 25 and 70 pmol per litre, then the vit B12 levels are considered to be indeterminate, meaning that vit B12 deficiency is possible but not confirmed. In these cases, we will measure serum MMA concentrations if there are symptoms or signs of deficiency. While waiting for the results, we will start vit B12 replacement if

o  they could deteriorate rapidly, for example, neurological or haematological conditions such as ataxia or anaemia

o  if they have a suspected irreversible cause of vitamin B12 deficiency (for example, autoimmune gastritis, a gastrectomy, terminal ileal resection or some types of bariatric surgery or if

o  they are pregnant or breastfeeding.

If the vitamin B12 deficiency is confirmed, we will investigate further and we will:

·      Check for anti-intrinsic factor antibody if autoimmune gastritis is suspected bearing in mind that a negative test result does not rule out the presence of autoimmune gastritis.

·      If autoimmune gastritis is still suspected despite a negative anti-intrinsic factor antibody test, we will consider further investigations such as:

o  an anti-gastric parietal cell antibody test

o  a test to measure gastrin levels

o  a CobaSorb test to measure whether vitamin B12 can be absorbed and

o  gastroscopy with gastric body biopsy and

·      if the cause of the vitamin B12 deficiency is still unknown, we will test for coeliac disease

In terms of the management of the vitamin B12 deficiency, the management will vary depending on the cause.

In malabsorption due to:

·      autoimmune gastritis, 

·      a total gastrectomy, or a complete terminal ileal resection

we will offer lifelong intramuscular vitamin B12 replacement

In malabsorption for other reasons like coeliac disease, or bariatric surgery:

·      we will consider intramuscular instead of oral vitamin B12 replacement.

·      But if we offer an oral preparation, we will prescribe at least 1 mg a day.

In medicine- or nitrous oxide-induced vitamin B12 deficiency we will:

·      give either intramuscular or oral vitamin B12 replacement, based on clinical judgement and

·      we will advise to stop nitrous oxide and consider stopping the medication causing the deficiency if appropriate.

If the vitamin B12 deficiency is due to diet:

·      we will give dietary advice

·      we will consider oral vitamin B12 replacement, and, during pregnancy or breastfeeding, we will give at least 1 mg daily and

·      we will consider intramuscular vitamin B12 injections if the condition deteriorates rapidly or there are concerns about adherence to oral treatment

We will also explain that some over the counter supplements may not contain enough vitamin B12 or the right type to be effective and advise them to pick an oral supplement that contains cyanocobalamin, methylcobalamin or adenosylcobalamin.

In unknown causes of vitamin B12 deficiency we will consider oral instead of intramuscular vitamin B12 replacement and review the response to treatment.

Initial follow-up appointments after starting vitamin B12 replacement should be:

·      at 3 months or earlier depending on severity of symptoms, or

·      at 1 month if they are pregnant or breastfeeding.

In oral supplementation, we will ask about symptoms and if they have not sufficiently improved, got worse or are new we will:

·      increase the oral dosage to the maximum licensed dosage or

·      if they are already taking the maximum, switch to intramuscular injections and

·      consider further testing with serum MMA, or plasma homocysteine.

If the symptoms have resolved, we will continue with oral vitamin B12 replacement if the cause has not been addressed (for example, the person is still taking a medicine that could affect vitamin B12 absorption), or the cause of deficiency is unknown.

But we will consider stopping treatment if:

·      the symptoms have resolved and

·      the cause has been addressed (for example, the person has increased their dietary intake of the vitamin) although

·      we will advise to come back if symptoms develop.

For people receiving intramuscular replacement, we will not repeat the initial diagnostic test. If the symptoms have not improved enough, we will:

·      increase the frequency of injections if needed, in line with the summary of product characteristics and

·      think about alternative diagnoses and

·      agree a date for reassessment of the person's symptoms.

If a person has, or is suspected of having, an irreversible cause of vitamin B12 deficiency:

·      we will continue with lifelong intramuscular injections, even if their symptoms have resolved, and

·      we will advise them to come back if symptoms recur

If the person's symptoms have resolved, and they have either a reversible cause that has not been addressed (for example, continuing medication), or the cause is unknown:

·      we will continue with intramuscular injections and

·      we will continue to follow up.

But if the cause has been resolved and the symptoms have disappeared, we will:

·      think about stopping or reducing the frequency of injections and

·      advise them to come back if symptoms recur.

As we have seen, the guideline covers deficiency caused by autoimmune gastritis. But let’s pause for a minute. Is autoimmune gastritis the same as pernicious anaemia? Well, NICE does not use the term pernicious anaemia in this guideline. So, let’s see why:

Autoimmune gastritis can destroy the parietal cells in the stomach, which can prevent the absorption of vitamin B12, and also impair iron absorption.

Although pernicious anaemia can be a consequence of chronic, severe vitamin B12 deficiency caused by autoimmune gastritis, pernicious anaemia in its true sense (that is, life-threatening anaemia) is now extremely rare and for this reason, this term has not been used in the recommendations.

Also, although autoimmune gastritis is associated with the presence of auto-antibodies against gastric parietal cells and intrinsic factor, which can be detected blood tests, we should also bear in mind that they are not always present and, even when they are present, this is not always indicative of autoimmune gastritis.

We also need to take into account that people who have autoimmune gastritis:

·      are at higher risk of developing gastric neuroendocrine tumours and

·      may also be at higher risk of developing gastric adenocarcinoma.

So, we will refer them promptly for gastrointestinal endoscopy if they develop new, or worsening, upper gastrointestinal symptoms (for example, dyspepsia, nausea or vomiting)

To end the video, NICE has created a 2-page visual summary on ongoing care and follow-up options for oral and intramuscular vitamin B12 replacement. Let’s have a look at it.

So, for people on oral vitamin B12 replacement

At follow up

If the symptoms are not sufficiently improved

We will either increase the oral dose to the maximum licensed dose or, if they are on this already, we will switch to intramuscular administration, taking into account the patient’s preferences.

If there are new or worsening symptoms

We will see if the diagnosis was made using MMA or plasma homocysteine

If the answer is no, we will think about alternative diagnoses and consider testing serum MMA or, if not available, plasma homocysteine, continuing treatment until the results are received.

When the results are received …

if the deficiency is still present, we will either increase the oral dose to the maximum licensed dose or, if they are on this already, we will switch to intramuscular administration, taking into account the patient’s preferences.

However, if the results do not show a deficiency, we will explore alternative diagnoses to explain the symptoms.

If the answer to the question about MMA or plasma homocysteine testing is yes

Then we will consider alternative diagnoses and, taking into account the patient’s preference, we will either increase the oral dose of vit B12 to the maximum or, if the patient is already on the maximum oral dose, we will switch to intramuscular injections

Finally, if the symptoms have improved or resolved

If the cause has not been addressed or is unknown

We will continue with the oral replacement and continue follow up.

On the other hand, if the cause has been addressed,

We will consider stopping treatment, advising the patient to seek medical advice if the symptoms get worse, reappear or new ones emerge.

Now let’s have a look at the summary for patients on intramuscular vit B12 replacement

So, at follow up

If there are new symptoms, they are worsening or have not sufficiently improved

We will increase the frequency of injections, we will think about alternative diagnoses and we will continue reviewing the patient.

Conversely, if the symptoms have improved or resolved

If the cause is irreversible,

We will continue with lifelong injections, advising the patient to seek medical advice if the symptoms reappear, get worse or new ones appear.

However, if the cause is reversible but it has not been addressed or is unknown,

We will continue with the injection and regular reviews.

And finally, if the cause has been resolved,

We will think about stopping or reducing the frequency of the injections, advising the patient to seek medical advice if the symptoms get worse, reappear or new ones emerge.

I have created an interactive flowchart that incorporates these visual summaries as well as other NICE guidance and also advice given by the British Society of Haematology. You can access it in the episode description. I hope that you find it helpful.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/KjALe_M-tIw

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.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through new and updated guidelines published in May 2024 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.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The YouTube video on the management of headaches can be found here:

·      https://youtu.be/6AZttMzfFr0?si=yxPcoC4legE8zS_p

The Full NICE News bulletin for May 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-05-01&to=2024-05-31&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered can be found here:

Atogepant for preventing migraine - Technology appraisal guidance [TA973] can be found here:

·      https://www.nice.org.uk/guidance/ta973

Headaches in over 12s: diagnosis and management - Clinical guideline [CG150] can be found here:

·      https://www.nice.org.uk/guidance/cg150

The educational poster on the diagnosis of diagnosis of tension-type headache, migraine and cluster headache can be found here:

·      https://www.nice.org.uk/guidance/cg150/resources/diagnosis-poster-pdf-188219341

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

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 am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in May 2024, focusing on what is relevant in Primary Care only.

And again, in May we have had very little new guidance relevant to primary care, in fact, there was only one guideline containing relevant information for us, the published technology appraisal on atogepant for migraine prophylaxis. You may remember that we covered this to some degree last month, when we reviewed the final draft NICE guidance on the subject. To make up for the shortage of Primary Care updates, we will also go through the clinical signs and symptoms that differentiate between tension-type headache, migraine and cluster headache. We will do so by reviewing the NICE guideline on headaches. If you are interested in the full headache guideline, covering headaches other than migraine, please see the corresponding video on this channel. The link is in the episode description.

Right, we have a migraine heavy episode, so let’s jump into it.

And let’s start with an overview. Although we are covering atogepant, the guidance on Rimegepant is very similar. Both Rimegepant and atogepant, are a new class of drugs, also known as gepants, that have been developed specifically for the treatment of migraines. They are a calcitonin gene-related peptide (or CGRP) receptor antagonist which works by blocking this CGRP receptor. And although the mechanism of action is not fully understood, we know that CGRP is a protein found in the sensory nerves of the head and neck and causes blood vessels to dilate, which can lead to inflammation and migraine pain. 

Unlike triptans, gepants do not cause vasoconstriction so they do not have the same cardiovascular contraindications and cautions as triptans.

Gepants can be used as an acute treatment of migraine and also as prophylaxis, but only if there have been at least 4 migraine days per month and where at least 3 previous preventive treatments have failed. Rimegepant is only recommended as prophylaxis of episodic migraines, whereas NICE has recommended atogepant as prophylaxis for both chronic and episodic migraines.

What’s the difference between episodic and chronic migraine?

The definition of episodic migraine is when there are fewer than 15 headache days each month. On the other hand, chronic migraine is when for more than 3 months there are at least 15 headache days a month, with at least 8 of those having features of migraine.

And here it is a good time to look at the clinical features of migraine compared to other types of headaches such as tension-type headache and cluster headache.

NICE has produced a poster that classifies the signs and symptoms for all three types of headaches. Let’s have a look at it:

The first thing to look at are the features of the headache in terms of:

·      Location

·      Quality

·      Intensity and

·      Duration

So, the location of the pain is:

·      Bilateral in tension type headache,

·      Unilateral or bilateral in migraine and

·      Unilateral, generally around the eye, above the eye and along the side of the head/face in cluster headache.

The quality of the pain is:

·      Pressing or tightening and non-pulsating in tension headache,

·      Pulsating in migraine although it can be described as throbbing or banging in young people and

·      It can be variable in cluster headache, as it can be sharp, boring, burning, throbbing or tightening.

As for the intensity of the pain, it can be:

·      Mild or moderate in tension-type headache

·      Moderate or severe in migraine and

·      Severe or very severe in cluster headache.

And for the duration, we will say that it generallylasts:

·      From 30 minutes to continuous in tension-type headache,

·      4 to 72 hours in migraine in adults although it can be shorter in young people, from 1 to 72 hours and

·      From 15 minutes to 3 hours in cluster headaches, so usually a shorter headache but much more intense.

Other factors that can help us differentiate between them are the effects that the headaches have on daily activities and whether there are other associated symptoms.

When considering the effects of daily living, we will say that:

·      Tension-type headache is not usually aggravated by routine activities,

·      Migraines are aggravated by, or causes avoidance of, routine activities and

·      Cluster headache causes restlessness or agitation.

And when considering other symptoms, we must be aware that:

·      Tension headaches don’t normally have any 

·      Migraine can be associated to light and sound sensitivity or nausea and vomiting.

·      If there is migraine with aura, we need to remember that typical aura symptoms can occur with or without headache and include:

o  Visual symptoms such as flickering lights, spots or lines and partial loss of vision

o  Sensory symptoms such as numbness and pins and needles and

o  Speech disturbance.

o  But in order to diagnose migraine with aura the symptoms must be fully reversible, develop over at least 5 minutes and last generally between 5 minutes and 1 hour.

Finally, in cluster headache, we will find, usually on the same side as the headache, associated symptoms such as:

·      A red or watery eye

·      Nasal congestion or a runny nose

·      A swollen eyelid

·      Forehead and facial sweating and

·      A constricted pupil or drooping eyelid

This is the summary poster that NICE has produced in the headache guideline. The link to it is in the episode description. Now that we have had a look at the clinical features, let’s go back to the management.

Currently, the most effective prophylactic options for people with chronic migraines who have already tried 3 prophylactic treatments are drugs that need to be injected, such as for example:

·      Erenumab and galcanezumab and

·      botox

So, oral treatments such as atogepant or Rimegepant offer more choice for patients.

When should we stop atogepant? We should stop it after 12 weeks if the frequency of migraines does not reduce by:

·      at least 50% in episodic migraine (that is, fewer than 15 headache days per month)

·      at least 30% in chronic migraine (that is, 15 or more headache days per month, with at least 8 of those having features of migraine).

Clinical trial evidence shows that atogepant reduces monthly migraine days more than placebo, but there is no clinical trial evidence directly comparing it with other preventive medicines. The results from indirect comparisons are uncertain and it is unclear whether atogepant is better or worse than the other treatments. However, it has lower costs than injectables, so it is recommended for preventing episodic and chronic migraine after 3 or more preventive medicines have been tried.

So now, with that in mind, let’s quickly look at the preventative treatment pathway that NICE has produced.

First, for prophylaxis treatment to be considered, the patient needs to have 4 or more migraine days per month.

In that case, we will give 1st, 2nd and 3rd line prophylaxis with propranolol, amitriptyline and topiramate.

If there is inadequate response, then we move to 4th line treatment.

For episodic migraine we can give Rimegepant.

For both episodic and chronic migraines, we have a number of injectable medications and atogepant as the only oral medication.

Finally, if it is chronic migraine, then the recommended treatment will be with botox.

Rimegepant is an oral lyophilisate that should be placed on the tongue or under the tongue and it will disintegrate in the mouth and can therefore be taken without liquid. However, atogepant is a tablet to be taken orally.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/0yQ_Be-xU6o

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the NICE guideline [NG106] on Chronic Heart Failure 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.  

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: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Chronic Heart Failure in adults: diagnosis and management - NICE guideline [NG106]:

·      https://www.nice.org.uk/guidance/ng106

The visual summary for the diagnosis of chronic heart failure can be found here:

·      https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-diagnosis-visual-summary-pdf-6663137726

The visual summary for the management of chronic heart failure can be found here:

·      https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-management-visual-summary-pdf-6663137725

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

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 do a quick up-to-date review of the NICE guidelines on the diagnosis and management of chronic heart failure in adults, including the visual summary flowcharts, always focusing on what is relevant in Primary Care only.

Right, so let’s jump into it.

And we start with the diagnosis. We will take a detailed history and examination and, we will consider the following investigations to exclude other potential conditions:

·      an ECG

·      a chest X-ray

·      blood tests including FBC, renal, liver and thyroid function tests, a lipid profile and HbA1c

·      urinalysis and

·      peak flow or spirometry.

And, if we suspect heart failure, we will measure the N-terminal pro-B-type natriuretic peptide, which from now on we will refer to as NT‑proBNP

High levels of NT‑proBNP carry a poor prognosis. For this reason:

·      If the levels are very high, i.e. above 2,000 ng/litre or 236 pmol/litre, we will refer them urgently to have specialist assessment and a transthoracic echocardiogram within 2 weeks.

·      However, if the levels are only moderately high, that is, between 400 and 2,000 ng/litre or 47 to 236 pmol/litre, we will refer them also urgently but to be seen within 6 weeks.

We also need to be aware that:

·      an NT‑proBNP level less than 400 ng/litre or 47 pmol/litre in an untreated person makes heart failure less likely so we should consider alternative causes and refer if in doubt.

·      the NT‑proBNP level does not differentiate between heart failure with reduced ejection fraction and heart failure with preserved ejection fraction. Let’s remember that heart failure with preserved ejection fraction is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, so it has normal left ventricular ejection fraction and evidence of diastolic dysfunction, whereas the opposite is true for heart failure with reduced ejection fraction, when the ejection fraction is below 40%.

·      the NT‑proBNP level can be reduced in obesity, African or African–Caribbean family background, or drugs such as diuretics, ACE inhibitors, ARBs, beta‑blockers, and mineralocorticoid receptor antagonists or MRAs

·      conversely, the NT‑proBNP level can be high due to other reasons such as, for example, age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia, like in PE and COPD, eGFR less than 60, sepsis, diabetes, and liver cirrhosis.

The purpose of the initial transthoracic echocardiogram is to exclude valve disease, assess left ventricular function, and detect intracardiac shunts. However, alternative cardiac imaging can be considered if the transthoracic images are poor.

Finally, if a patient with a pre-existing diagnosis of heart failure has not been fully investigated in the past, then we should arrange the appropriate investigations in order to confirm the diagnosis.

NICE has produced a useful visual summary covering the diagnosis of chronic heart failure in the form of a flow chart. Let’s have a look at it.

If we suspect chronic heart failure

We will take a full history and examination

And then we will investigate by measuring the NT-proBNP level

And by performing alternative investigations such as an ECG, a CXR, blood tests, urinalysis and peak flow or spirometry.

If the NT-proBNP levels are very high, we will refer to specialist services urgently to be seen within 2 weeks.

If the NT-proBNP levels are only moderately high, we will refer to specialist services, also urgently but to be seen within 6 weeks

And this specialist assessment should also include a transthoracic echocardiogram.

If the NT-proBNP levels are not high

Then, we will consider alternative diagnoses and we will get specialist input if in doubt.

Finally, if heart failure is confirmed on an echocardiogram, then we will assess the severity and possible causes as well as correctable factors.

Let’s now have a look at the treatment.

I will start with the management that is applicable to all forms of heart failure, that is, both HFpEF and HFrEF,

but we need to be aware that there are specific recommendations for HFrEF that I will cover later.

So, for all types of heart failure, diuretics should be used for the relief of congestive symptoms and fluid retention, and titrated (up and down) according to need. A low to medium dose of loop diuretics (for example, no more than 80 mg furosemide per day) should be used in HFpEF.

As general recommendations, we will avoid verapamil, diltiazem and short-acting dihydropyridine agents like nifedipine in people who have heart failure with reduced ejection fraction.

Amiodarone should be initiated by a specialist only

And if a patient is in sinus rhythm, anticoagulation should be considered for those with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus.

In terms of non-pharmacological treatment:

·      Flu and pneumococcal vaccinations are recommended

·      In women of childbearing potential, contraception and pregnancy should be discussed and the patient referred if pregnancy is being considered or it occurs.

·      We will not routinely advise sodium or fluid restriction but we will restrict fluids is there is dilutional hyponatraemia and we will advise reducing salt intake if it is excessive. We should also advise against salt substitutes that contain potassium.

·      Air travel will be possible for most patients.

·      And we should follow the DVLA guidelines in terms of driving.

So, let’s now have a look at the specific treatment for HFrEF, that is, when the left ventricular function is below 40%

As first-line treatment, we will offer an ACE inhibitor and a beta‑blocker licensed for heart failure using clinical judgement when deciding which drug to start first. If an ACE inhibitor is not tolerated, we will substitute it with an ARB licensed for heart failure.

Currently, the betablockers licensed for heart failure in the UK are:

·      Bisoprolol

·      Carvedilol

·      Nebivolol

And currently, the ARBs licensed for heart failure in the UK are:

·      Candesartan

·      Losartan

·      Valsartan

But we will not offer ACE inhibitors if there is a clinical suspicion of haemodynamically significant valve disease, until seen by a specialist.

In terms of betablockers, we will not withhold them solely because of age or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease or chronic obstructive pulmonary disease. Also, if a patient develops heart failure, we will switch people who are already taking a beta-blocker for something else, for example, angina or hypertension, to a beta-blocker licensed for heart failure.

After this, we will offer a mineralocorticoid receptor antagonist (or MRA) such as spironolactone, in addition to an ACE inhibitor (or ARB) and beta-blocker, if they continue to have symptoms.

When prescribing ACE inhibitors, ARBs, betablockers and MRAs:  

·      We will start at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached.

·      We will measure sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor, ARB or MRA, and after each dose increment.

·      We will measure blood pressure before and after each dose increment and, in addition, we will assess the heart rate when giving betablockers.

·      Once the target or maximum tolerated dose is reached, we will monitor the treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell.

As well as ACE inhibitors, ARBs, betablockers and MRAs, there are a number of other drugs that can be given for heart failure by a heart failure specialist. These are:

·      Dapagliflozin and empagliflozin

·      Ivabradine

·      Sacubitril valsartan

·      Hydralazine in combination with nitrate and

·      Digoxin

We will give the same treatment to people who have heart failure with reduced ejection fraction and chronic kidney disease but:

·      If the eGFR is between 30 and 45, we will consider lower doses and/or slower titration of dose of ACE inhibitors, ARBs, MRAs and digoxin, monitoring closely and taking into account the increased risk of hyperkalaemia.

·      If the eGFR is below 30 we will liaise with a renal physician.

Monitoring treatment for all types of heart failure should include:

·      a clinical assessment

·      a review of medication

·      and an assessment of renal function. Monitoring potassium is particularly important if the patient is on digoxin or an MRA.

The frequency of monitoring depends on the clinical situation and stability of the person. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is needed at least 6-monthly for patients who are stable.

We will consider measuring NT-proBNP for monitoring purposes only in a specialist care setting.

A cardiac rehabilitation programme should be offered, unless their condition is unstable.

And in terms of palliative care, we will not offer long-term home oxygen therapy for heart failure alone.

And just like for the diagnosis, NICE has produced a useful visual summary covering the management of chronic heart failure in the form of a flow chart. Let’s have a look at it.

Once chronic heart failure has been diagnosed,

We can use diuretics for congestive symptoms and fluid retention, and then any further treatment will depend on the type of heart failure.

If it is heart failure with preserved ejection fraction, we will simply manage comorbidities such as hypertension, atrial fibrillation, ischaemic heart disease and diabetes

and we will offer a cardiac rehabilitation programme unless the condition is unstable.

On the other hand, if it is heart failure with reduced ejection fraction, we will offer and ACEI and a betablocker as first line, followed by an MRA if symptoms persist.

And we can give an ARB if the patient cannot tolerate an ACEI because of side effects.

And we will do this, as well as offering cardiac rehabilitation unless the condition is unstable.

If that is not enough, then we move to specialist referral for re-assessment and consideration of other forms of treatment.

So, if symptoms persist despite first-line treatment, specialist services may consider one or more of the following options:

Replacing the ACEI or ARB by sacubitril valsartan or

Adding ivabradine or

Adding hydralazine and a nitrate,

which can also be considered if ACEIs and ARBs are not tolerated at an earlier stage and

adding digoxin

and finally

Although it does not appear on this flowchart, SGLT2 inhibitors such as dapagliflozin and empagliflozin are now recommended for both HFpEF and HFrEF, so they could be another option here.

And that is it, a quick summary of the NICE guideline on chronic heart failure.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/Pi7cBcov2fI

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through a thorough review of the NICE guideline [NG136] on Hypertension in adults, with a series of multiple-choice questions. Each question is paired with quotation, aiming to clarify key concepts and enhance understanding. This informative segment is created to support continuous learning 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.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Hypertension in adults: diagnosis and management - NICE guideline [NG136]:

·      https://www.nice.org.uk/guidance/ng136

The NICE hypertension flowcharts can be found here:

·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

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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 do a revision of the NICE guidelines on hypertension, including the changes introduced in November 2023, always focusing on what is relevant in Primary Care only.

I have created a number of multiple-choice questions, many of them presented as clinical scenarios, which will help you revise, test your knowledge and also assist you in remembering the facts more effectively.

The range of questions varies from fairly easy and straightforward ones to others which are more complex and require more thinking. After each question and their four options, you will get the correct answer paired with a guiding quotation from the NICE guideline.

Please note that the correct answers only reflect the strict use of the guideline, not a flexible clinical judgement.

Finally, I am going to delegate the reading of this section to an automated voice. I hope that you find it useful.

Good luck with your self-test!

Sarah, a 50-year-old woman with type 2 diabetes and hypertension, is starting step 1 antihypertensive treatment. What should be offered to her?

 Calcium-channel blocker

 Thiazide-like diuretic

 ACE inhibitor or ARB

 Beta-blocker

The correct answer is: 

ACE inhibitor or ARB

NICE quote:

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

have type 2 diabetes and are of any age or family origin

What is recommended regarding lifestyle advice for people with suspected or diagnosed hypertension?

 Offer magnesium, and potassium supplements.

 Discourage excessive consumption of coffee and other caffeine-rich products.

 Avoid physical activity.

 Offer calcium supplements.

The correct answer is: 

Discourage excessive consumption of coffee and other caffeine-rich products.

NICE quote:

Discourage excessive consumption of coffee and other caffeine-rich products. 

Emma, a 54-year-old woman with hypertension, is taking an ACE inhibitor as step 1 treatment. Despite this, her blood pressure remains uncontrolled. What should be offered to her as step 2 treatment?

 Alpha-blocker

 Calcium-channel blocker

 ARB

 Beta-blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:

a Calcium-channel blocker or

a thiazide-like diuretic. 

James, a 40-year-old man, has severe hypertension of 188/123 with no symptoms indicating same-day referral. What should be considered for confirmation of diagnosis?

 Repeat clinic blood pressure measurement within 7 days

 Repeat clinic blood pressure measurement within 14 days

 Start antihypertensive drug treatment immediately

 HBPM after 7 days of lifestyle modifications

The correct answer is: 

Repeat clinic blood pressure measurement within 7 days.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days.

What action is recommended when there is a significant difference in blood pressure readings between both arms?

 Repeat the measurements with the same arm.

 Discard the measurements and measure blood pressure again after 24 hours.

 Repeat the measurements with the arm showing the higher reading.

 Ignore the difference and proceed with the diagnosis.

The correct answer is: 

Repeat the measurements with the arm showing the higher reading.

NICE quote:

If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.

Tom, a 65-year-old man with hypertension on step 1 treatment, develops oedema as a side effect of Calcium-channel blocker therapy. What alternative treatment should be offered to him?

 Thiazide-like diuretic

 ARB

 ACE inhibitor

 Beta-blocker

The correct answer is: 

Thiazide-like diuretic

NICE quote:

If a Calcium-channel blocker is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension.

If a person has severe hypertension with a clinic blood pressure of 180/120 mmHg or higher, but no symptoms indicating same-day referral, what action should be taken?

 Start antihypertensive drug treatment immediately

 Monitor using ABPM

 Repeat clinic blood pressure measurement within 30 days

 Carry out investigations for target organ damage

The correct answer is: 

Carry out investigations for target organ damage

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible.

Emma, a 55-year-old woman with hypertension, is considering combining ACE inhibitor with ARB for better blood pressure control. What should she be advised regarding this combination?

 Combination therapy is recommended for better control.

 Combination therapy should be avoided.

 Combination therapy is suitable only for resistant hypertension.

 Combination therapy is recommended only for people with diabetes.

The correct answer is: 

Combination therapy should be avoided.

NICE quote:

Do not combine an ACE inhibitor with an ARB to treat hypertension. 

For which group of patients is seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment recommended?

 Adults aged over 80.

 Adults aged under 40.

 Adults aged between 40 and 60.

 Adults aged between 60 and 80.

The correct answer is: 

Adults aged under 40.

NICE quote:

For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks.

When would you suspect phaeochromocytoma?

 If they have a history of hypertension.

 If they experience labile blood pressure.

 If they have mild headaches.

 If they have leg pain.

The correct answer is: 

If they experience labile blood pressure.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

What is the definition of stage 1 hypertension?

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema.

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg.

 Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg.

 Clinic systolic blood pressure of 180 mmHg or higher.

The correct answer is: 

Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg.

NICE quote:

Stage 1 hypertension

Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg.

Tom, a 65-year-old man with hypertension, has recently started a new exercise regimen and dietary changes to manage his blood pressure. How should his response to lifestyle changes be monitored?

 Immediately arrange ABPM.

 Monitor blood pressure every 6 months.

 Immediately organise HBPM.

 Use clinic blood pressure measurements.

The correct answer is: 

Use clinic blood pressure measurements.

NICE quote:

Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension. 

Emily, a 55-year-old asymptomatic woman, is found to have no target organ damage despite a blood pressure of 173/122 mmHg. What is an acceptable choice to confirm the diagnosis of hypertension?

 Repeat clinic blood pressure measurement within 7 days.

 Start antihypertensive drug treatment immediately.

 Monitor Emily's blood pressure using ABPM for two weeks.

 Check Emily's Blood pressure in the emergency Department.

The correct answer is: 

Repeat clinic blood pressure measurement within 7 days.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days.

John, a 60-year-old man with hypertension, experiences cough as a side effect of ACE inhibitor therapy. What alternative treatment should be offered to him?

 Thiazide diuretic

 Calcium-channel blocker

 Thiazide-like diuretic

 ARB

The correct answer is: 

ARB

NICE quote:

If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension. 

What action should be taken if a person with a blood pressure of 185/110 mmHg has signs of retinal haemorrhage or papilloedema?

 Monitor blood pressure using HBPM

 Start antihypertensive drug treatment immediately

 Refer to ophthalmology

 Refer for specialist assessment on the same day

The correct answer is: 

Refer for specialist assessment on the same day

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

Which term refers to a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements?

 Accelerated hypertension

 Masked hypertension

 White-coat effect

 Persistent hypertension

The correct answer is: 

White-coat effect.

NICE quote:

White-coat effect

A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

Sarah, a 75-year-old woman on antihypertensive medication and type 2 diabetes, experiences dizziness when standing up. How should her blood pressure be managed considering her symptoms?

 No treatment is necessary.

 Review medication and treat to a blood pressure target based on sitting blood pressure.

 Review medication and treat to a blood pressure target based on standing blood pressure.

 Review medication and treat to a blood pressure target based on lying down blood pressure.

The correct answer is: 

Review medication and treat to a blood pressure target based on standing blood pressure.

NICE quote:

In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure.

After checking the blood pressure twice, how should clinic blood pressure be recorded?

 Record the higher of the last 2 measurements.

 Record the average of all measurements taken during the consultation.

 Record the lower of the last 2 measurements.

 Record the first measurement only.

The correct answer is: 

Record the lower of the last 2 measurements.

NICE quote:

Record the lower of the last 2 measurements as the clinic blood pressure.

When should investigations for target organ damage be carried out in a person with severe hypertension (180/120 mmHg or higher)?

 Within 30 days

 As soon as possible

 After confirming the diagnosis with ABPM

 After starting antihypertensive drug treatment

The correct answer is: 

As soon as possible

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible.

James, a 60-year-old man with hypertension and type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him?

 Thiazide-like diuretic

 Beta-blocker

 ACE inhibitor

 Calcium-channel blocker

The correct answer is: 

ACE inhibitor

NICE quote:

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

have type 2 diabetes and are of any age or family origin 

John, a 50-year-old man, presents with a clinic blood pressure of 185/125 mmHg. He has no symptoms indicating same-day referral. What should be done next?

 Start antihypertensive drug treatment immediately.

 Monitor John's blood pressure using HBPM.

 Repeat clinic blood pressure measurement within 7 days.

 Perform investigations for target organ damage.

The correct answer is: 

Perform investigations for target organ damage.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible

Emma, a 45-year-old woman with hypertension, is of Black African origin and does not have type 2 diabetes. What drug should be offered to her as step 1 antihypertensive treatment?

 ARB

 ACE inhibitor

 Thiazide-like diuretic

 Calcium-channel blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

Offer a calcium-channel blocker (Calcium-channel blocker) to adults starting step 1 antihypertensive treatment who:

…

are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). 

Lisa, a 70-year-old woman, is experiencing new onset confusion along with a clinic blood pressure of 185/125 mmHg. What is the appropriate step?

 Start antihypertensive drug treatment immediately.

 Repeat clinic blood pressure measurement within 7 days.

 Monitor Lisa's blood pressure using ABPM with a review within 7 days.

 Refer Lisa for specialist assessment on the same day.

The correct answer is: 

Refer Lisa for specialist assessment on the same day.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

In what range of clinic blood pressure should ambulatory blood pressure monitoring (ABPM) be offered to confirm the diagnosis of hypertension?

 130/80 mmHg to 150/100 mmHg

 120/80 mmHg to 160/100 mmHg

 140/90 mmHg to 180/120 mmHg

 150/90 mmHg to 190/130 mmHg

The correct answer is: 

140/90 mmHg to 180/120 mmHg.

NICE quote:

If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. 

Which term describes clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher?

 Target organ damage

 Stage 3 or severe hypertension

 White-coat effect

 Persistent hypertension

The correct answer is: 

Stage 3 or severe hypertension.

NICE quote:

Stage 3 or severe hypertension

Clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.

How should blood pressure be measured if pulse irregularity is detected?

 Use automated devices

 Measure manually using direct auscultation over the brachial artery

 Ignore the irregularity and proceed with automated measurement

 Measure manually using direct auscultation over the radial artery

The correct answer is: 

Measure manually using direct auscultation over the brachial artery

NICE quote:

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. 

When should antihypertensive drug treatment be offered in addition to lifestyle advice to adults with persistent stage 2 hypertension (clinic BP 160/100 or higher)?

 Only in individuals aged under 60.

 Only in individuals aged over 80.

 Only in individuals aged between 60 and 80.

 To adults of any age.

The correct answer is: 

To adults of any age.

NICE quote:

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity

Mark, a 65-year-old man, presents with a clinic blood pressure of 180/120 mmHg but no symptoms indicating same-day referral. What action should be taken next?

 Start antihypertensive drug treatment immediately.

 Monitor Mark's blood pressure using HBPM.

 Repeat clinic blood pressure measurement within 7 days.

 Perform investigations for target organ damage.

The correct answer is: 

Perform investigations for target organ damage.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible

James, a 65-year-old man of Black African origin with hypertension, is already taking a Calcium-channel blocker as step 1 treatment. Despite this, his blood pressure remains uncontrolled. What should be offered to him as step 2 treatment?

 ACE inhibitor

 ARB

 Alpha-blocker

 Beta-blocker

The correct answer is: 

ARB

NICE quote:

If hypertension is not controlled in adults taking step 1 treatment of a Calcium-channel blocker, offer the choice of 1 of the following drugs in addition to step 1 treatment:

an ACE inhibitor or

an ARB or

a thiazide-like diuretic.

If hypertension is not controlled in adults of Black African or African–Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment.

What should be done while waiting for confirmation of a diagnosis of hypertension with ABMP?

 Immediate initiation of antihypertensive medication.

 Investigations for target organ damage followed by formal cardiovascular risk assessment.

 Minimise physical activity.

 Home blood pressure monitoring (HBPM) for at least 10 days.

The correct answer is: 

Investigations for target organ damage followed by formal cardiovascular risk assessment.

NICE quote:

While waiting for confirmation of a diagnosis of hypertension, carry out:

investigations for target organ damage …, followed by

formal assessment of cardiovascular risk using a cardiovascular risk assessment tool 

Emma, a 50-year-old woman with hypertension, has conflicting clinic and non-clinic blood pressure results. What additional method of blood pressure monitoring should be considered for her?

 Use only clinic blood pressure measurements by a doctor.

 Use only clinic blood pressure measurements by a nurse.

 Use only clinic blood pressure measurements in the community, e.g. pharmacy.

 Use ABPM or HBPM in addition to clinic blood pressure measurements.

The correct answer is: 

Use ABPM or HBPM in addition to clinic blood pressure measurements.

NICE quote:

Consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with hypertension identified as having a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting). Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements.

What is recommended when measuring the initial blood pressure in people with symptoms of postural hypotension?

 Measure blood pressure with the person standing

 Measure blood pressure after vigorous exercise

 Measure blood pressure in a crowded environment

 Measure blood pressure with the person lying on their back or consider a seated position if it's inconvenient to lie down

The correct answer is: 

Measure blood pressure with the person lying on their back or consider a seated position if it's inconvenient to lie down

NICE quote:

In people with symptoms of postural hypotension, including falls or postural dizziness:

measure blood pressure with the person lying on their back (or consider a seated position, if it is inconvenient to measure blood pressure with the person lying down)

Tom, a 65-year-old man without type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him?

 ACE inhibitor

 Thiazide-like diuretic

 ARB

 Calcium-channel blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

Offer a calcium-channel blocker to adults starting step 1 antihypertensive treatment who:

are aged 55 or over and do not have type 2 diabetes

What is the definition of masked hypertension?

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema

 High blood pressure at repeated clinical encounters

 Clinic blood pressure measurements are normal, but blood pressure measurements are higher when taken outside the clinic

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

The correct answer is: 

Clinic blood pressure measurements are normal, but blood pressure measurements are higher when taken outside the clinic.

NICE quote:

Masked hypertension

Clinic blood pressure measurements are normal (less than 140/90 mmHg), but blood pressure measurements are higher when taken outside the clinic using average daytime ambulatory blood pressure monitoring (ABPM) or average home blood pressure monitoring (HBPM) blood pressure measurements.

When should people with a clinic blood pressure of 180/120 mmHg and higher be referred for specialist assessment on the same day?

 If they experience hip pain

 If they have a cardiovascular risk >10%

 If they have signs of retinal haemorrhage or papilloedema

 If they have a history of hypertension

The correct answer is: 

If they have signs of retinal haemorrhage or papilloedema

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.

Sarah, a 70-year-old woman with hypertension, is already on treatment with a Calcium-channel blocker as step 1 therapy. Despite this, her blood pressure remains uncontrolled. What should be offered to her as step 2 treatment?

 ACE inhibitor

 Spironolactone

 Beta-blocker

 Alpha-blocker

The correct answer is: 

ACE inhibitor

NICE quote:

If hypertension is not controlled in adults taking step 1 treatment of a Calcium-channel blocker, offer the choice of 1 of the following drugs in addition to step 1 treatment:

an ACE inhibitor or

an ARB or

a thiazide-like diuretic. 

David, a 60-year-old man, experiences labile blood pressure along with headaches and palpitations. What should be considered for David?

 Start antihypertensive drug treatment immediately.

 Repeat clinic blood pressure measurement within 7 days.

 Monitor David's blood pressure using HBPM.

 Refer David for specialist assessment on the same day.

The correct answer is: 

Refer David for specialist assessment on the same day (suspected phaeochromocytoma).

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

When should subsequent blood pressures be measured in people with confirmed postural hypotension?

 After 5 minutes of standing

 Once, regardless of symptoms

 With the person lying down

 With the person standing for at least 1 minute

The correct answer is: 

With the person standing for at least 1 minute

NICE quote:

measure blood pressure again after the person has been standing for at least 1 minute.

If the person's systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute:

measure subsequent blood pressures with the person standing

Jack, a 45-year-old Asian man without type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him?

 ACE inhibitor

 Thiazide-like diuretic

 Beta-blocker

 Calcium-channel blocker

The correct answer is: 

ACE inhibitor

NICE quote:

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

…

are aged under 55 but not of Black African or African–Caribbean family origin.

How often should blood pressure be measured in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease?

 At least monthly

 At least quarterly

 At least six monthly

 At least annually

The correct answer is: 

At least annually

NICE quote:

Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice.

Sarah, a 60-year-old woman with hypertension is on amlodipine, ramipril and indapamide and she has been advised to reduce her dietary sodium intake. However, she asks if she can use salt substitutes containing potassium chloride instead. How should the healthcare provider respond to Sarah's inquiry?

 Encourage her to use salt substitutes containing potassium chloride.

 Discourage any changes in dietary sodium intake.

 Advise her to reduce sodium salt and avoid substitutes containing potassium chloride.

 Ignore her dietary sodium intake and manage with antihypertensive medication.

The correct answer is: 

Advise her to reduce sodium salt and avoid substitutes containing potassium chloride.

NICE quote:

Note that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin II receptor blockers. Encourage salt reduction in these groups.

Tom is a 55-year-old man with hypertension, chronic kidney disease and type 2 diabetes. What guideline should be consulted for guidance on choice of hypertensive agent?

 NICE guideline on type 2 diabetes.

 NICE guideline on chronic kidney disease.

 NICE guideline on hypertension.

 NICE guideline on type 1 diabetes.

The correct answer is: 

NICE guideline on chronic kidney disease.

NICE quote:

For guidance on choice of hypertensive agent in people with chronic kidney disease, see NICE's guideline on chronic kidney disease.

How many consecutive measurements should be taken for each blood pressure recording when using HBPM to confirm a diagnosis of hypertension?

 One measurement per recording.

 Three consecutive measurements per recording at least one minute apart.

 Two consecutive measurements per recording at least one minute apart.

 Four consecutive measurements per recording at least one minute apart.

The correct answer is: 

Two consecutive measurements per recording at least one minute apart.

NICE quote:

When using HBPM to confirm a diagnosis of hypertension, ensure that:

for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and

blood pressure is recorded twice daily, ideally in the morning and evening and

blood pressure recording continues for at least 4 days, ideally for 7 days.

Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. 

What action should be taken if target organ damage is identified in an asymptomatic person with severe hypertension?

 Repeat clinic blood pressure measurement within 7 days

 Consider monitoring using ABPM

 Start antihypertensive drug treatment immediately

 Refer for specialist assessment

The correct answer is: 

Start antihypertensive drug treatment immediately.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …:

If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

James, a 60-year-old man without type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him based on the guideline?

 ARB

 Thiazide-like diuretic

 ACE inhibitor

 Calcium-channel blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

Offer a calcium-channel blocker (Calcium-channel blocker) to adults starting step 1 antihypertensive treatment who:

are aged 55 or over and do not have type 2 diabetes

What should be encouraged regarding dietary sodium intake?

 Keeping a diary of sodium intake.

 Substituting sodium salt with salt substitutes containing potassium chloride.

 Reducing or substituting sodium salt.

 Discouraging any changes in dietary sodium intake.

The correct answer is: 

Reducing or substituting sodium salt.

NICE quote:

Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. 

What is the definition of accelerated hypertension?

 Clinic blood pressure of 160/100 mmHg or higher

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

 Clinic systolic blood pressure of 180 mmHg or higher

The correct answer is: 

Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema.

NICE quote:

Accelerated hypertension

A severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.

John, a 60-year-old man with hypertension, is already on treatment with bendroflumethiazide and has stable, well-controlled blood pressure. What should be done regarding his treatment?

 Continue with current treatment

 Switch to an ACE inhibitor

 Switch to indapamide immediately

 Switch to Calcium-channel blocker

The correct answer is: 

Continue with current treatment.

NICE quote:

For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment.

What is a recommended choice if no target organ damage is identified in a person with severe hypertension?

 Repeat clinic blood pressure measurement within 30 days

 Start antihypertensive drug treatment immediately

 Monitor using HBPM for two weeks

 Confirm diagnosis by repeating clinic blood pressure measurement within 7 days

The correct answer is: 

Confirm diagnosis by repeating clinic blood pressure measurement within 7 days

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days. 

When should specialist investigations be considered for possible secondary causes of hypertension?

 Only in severe cases of hypertension

 In all cases of hypertension

 When signs and symptoms suggest a secondary cause

 When there is a family history of hypertension

The correct answer is: 

When signs and symptoms suggest a secondary cause

NICE quote:

Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. 

Tom, a 70-year-old man with resistant hypertension, has uncontrolled blood pressure despite optimal tolerated doses of four drugs. What should be considered next?

 Adding a fifth antihypertensive drug

 Seeking specialist advice

 Discontinuing treatment

 Continuing current treatment without changes

The correct answer is: 

Seeking specialist advice

NICE quote:

For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice. 

Why is it advised to palpate the radial or brachial pulse before measuring blood pressure?

 To ensure the person is in a relaxed setting.

 To confirm the presence of atrial fibrillation.

 To check for pulse irregularity.

 To standardize the blood pressure measurement environment.

The correct answer is: 

To check for pulse irregularity.

NICE quote:

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. 

Emma is a 50-year-old woman with isolated systolic hypertension. How should she be treated?

 She should have the same blood pressure target but be treated with a calcium channel blocker by default.

 If the diastolic blood pressure is below 80 mmHg, she should be treated with lifestyle changes only.

 She should have the same treatment as people with both raised systolic and diastolic blood pressure.

 No treatment is necessary for isolated systolic hypertension, just close monitoring.

The correct answer is: 

She should have the same treatment as people with both raised systolic and diastolic blood pressure.

NICE quote:

Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure.

What is the definition of persistent hypertension?

 High blood pressure at repeated clinical encounters

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

 Clinic blood pressure of 160/100 mmHg or higher

 Clinic systolic blood pressure of 180 mmHg or higher

The correct answer is: 

High blood pressure at repeated clinical encounters.

NICE quote:

Persistent hypertension

High blood pressure at repeated clinical encounters.

James, a 75-year-old man with stage 1 hypertension, has a clinic blood pressure of 150/90 mmHg for several months. How should the healthcare provider manage James' hypertension?

 Monitor blood pressure for further 6 months.

 Ignore his hypertension.

 Start antihypertensive drug treatment straightaway.

 Consider treatment if has end organ damage, diabetes of a cardiovascular risk of 10% or higher.

The correct answer is: 

Consider treatment if has end organ damage, diabetes of a cardiovascular risk of 10% or higher.

NICE quote:

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

target organ damage

established cardiovascular disease

renal disease

diabetes

an estimated 10‑year risk of cardiovascular disease of 10% or more.

Use clinical judgement for people with frailty or multimorbidity

James, a 75-year-old man with hypertension, is using ABPM to monitor his blood pressure response to treatment. What should be his target blood pressure based on HBPM?

 Below 130/80 mmHg

 Below 135/85 mmHg

 Below 140/90 mmHg

 Below 145/85 mmHg

The correct answer is: 

Below 135/85 mmHg

NICE quote:

When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours ... Reduce blood pressure and ensure that it is maintained:

below 135/85 mmHg for adults aged under 80

below 145/85 mmHg for adults aged 80 and over.

How often should clinic blood pressure be measured subsequently if hypertension is not diagnosed initially?

 Every 2 years.

 Every 3 years.

 Every 5 years.

 Every year.

The correct answer is: 

Every 5 years.

NICE quote:

If hypertension is not diagnosed, measure the person's clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person's clinic blood pressure is close to 140/90 mmHg. 

James, a 50-year-old man with hypertension, is considering taking calcium, magnesium, or potassium supplements to help reduce his blood pressure. What should the healthcare provider tell James about the effectiveness of these supplements?

 Inform him that these supplements can decrease blood pressure but do not recommend them.

 Advise him to avoid these supplements as they have no effect on blood pressure.

 Encourage him to start taking these supplements.

 Suggest he consult with a specialist before starting these supplements.

The correct answer is: 

Advise him to avoid these supplements as they have no effect on blood pressure.

NICE quote:

Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. 

John, a 60-year-old man with hypertension, is interested in self-monitoring his blood pressure at home. Which method of blood pressure monitoring should he use?

 ABPM only.

 Clinic blood pressure measurements only.

 Blood pressure monitoring in local pharmacy.

 Use HBPM for self-monitoring.

The correct answer is: 

Use HBPM for self-monitoring.

NICE quote:

Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM.

What is the definition of stage 2 hypertension?

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema

 Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg

 Clinic blood pressure of 180/100 mmHg or higher

The correct answer is: 

Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg.

NICE quote:

Stage 2 hypertension

Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.

Sarah, a 45-year-old woman, visits the clinic with a clinic blood pressure of 190/130 mmHg. Upon examination, signs of retinal haemorrhage are noted. What is the appropriate action?

 Start antihypertensive drug treatment immediately.

 Repeat clinic blood pressure measurement within 7 days.

 Refer Sarah for specialist assessment on the same day.

 Refer Sarah to the Eye Clinic urgently.

The correct answer is: 

Refer Sarah for specialist assessment on the same day.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

Sarah, a 55-year-old woman with hypertension and no other medical history, is aiming to reduce her blood pressure. What should her clinic blood pressure target be?

 Below 130/80 mmHg

 Below 140/90 mmHg

 Below 150/90 mmHg

 Below 160/100 mmHg

The correct answer is: 

Below 140/90 mmHg

NICE quote:

For adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mmHg and ensure that it is maintained below that level. 

Emma, a 60-year-old woman with a blood pressure persistently just over 160/100 mmHg, has been following lifestyle advice but her blood pressure remains elevated. What treatment option should now be offered to Emma?

 Continue lifestyle advice periodically.

 No treatment, just more regular monitoring.

 Antihypertensive drug treatment.

 Immediate statin therapy.

The correct answer is: 

Antihypertensive drug treatment.

NICE quote:

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity

What action is recommended if hypertension is not diagnosed but there is evidence of target organ damage?

 Initiate antihypertensive medication immediately.

 Repeat clinic blood pressure measurements after 24 hours.

 Consider carrying out investigations for alternative causes of target organ damage.

 Discontinue further blood pressure monitoring.

The correct answer is: 

Consider carrying out investigations for alternative causes of target organ damage.

NICE quote:

If hypertension is not diagnosed but there is evidence of target organ damage, consider carrying out investigations for alternative causes of the target organ damage

Which term describes damage to organs such as the heart, brain, kidneys, and eyes?

 Masked hypertension

 White-coat effect

 Target organ damage

 Stage 3 or severe hypertension

The correct answer is: 

Target organ damage.

NICE quote:

Target organ damage

Damage to organs such as the heart, brain, kidneys and eyes. Examples are left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy or increased urine albumin:creatinine ratio.

Compared with the lying down blood pressure reading, when can postural hypotension be diagnosed?

 When the standing systolic blood pressure drops by 20mmHg and the standing diastolic blood pressure drops by 10 mmHg

 When both the standing systolic and diastolic blood pressure drops by 20mmHg

 When the standing systolic blood pressure drops by 10mmHg and the standing diastolic blood pressure drops by 20 mmHg

 When both the standing systolic and diastolic blood pressure drops by 10mmHg.

The correct answer is:

When the standing systolic blood pressure drops by 20mmHg and the standing diastolic blood pressure drops by 10 mmHg

NICE quote:

Postural hypotension: If the person's systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute

Which symptoms warrant same-day specialist assessment for a person with severe hypertension?

 Mild headache

 Diarrhoea

 Limb pain

 Signs of heart failure

The correct answer is: 

Signs of heart failure

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

What alternative is recommended if ambulatory blood pressure monitoring (ABPM) is unsuitable or the person cannot tolerate it?

 Repeat clinic blood pressure measurements.

 Offer home blood pressure monitoring (HBPM).

 Refer the person to specialist care.

 Disregard the diagnosis of hypertension.

The correct answer is: 

Offer home blood pressure monitoring (HBPM).

NICE quote:

If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension.

Emma, a 75-year-old woman with hypertension, experiences oedema as a side effect of Calcium-channel blocker therapy. What alternative treatment should be offered to her?

 ARB

 Beta-blocker

 ACE inhibitor

 Thiazide-like diuretic

The correct answer is: 

Thiazide-like diuretic

NICE quote:

If a Calcium-channel blocker is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension. 

How should cardiovascular risk be estimated in people with hypertension?

 Use ABPM measurements to calculate cardiovascular risk

 Estimate cardiovascular risk based on family history

 Use clinic blood pressure measurements to calculate cardiovascular risk

 Rely on symptoms reported by the patient to calculate cardiovascular risk

The correct answer is: 

Use clinic blood pressure measurements to calculate cardiovascular risk

NICE quote:

Use clinic blood pressure measurements to calculate cardiovascular risk. 

John, a 70-year-old man with stage 1 hypertension (clinic blood pressure between 140/90 and 160/100 mmHg), has established cardiovascular disease. He is unsure about starting antihypertensive drug treatment. How should the healthcare provider discuss treatment options with John?

 Discuss with him his individual cardiovascular disease risk and treatment preferences, then consider treatment.

 Start antihypertensive drug treatment without discussing options.

 Just offer lifestyle advice.

 Advise him to continue monitoring for now.

The correct answer is: 

Discuss with him his individual cardiovascular disease risk and treatment preferences, then consider treatment.

NICE quote:

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

target organ damage

established cardiovascular disease

renal disease

diabetes

an estimated 10‑year risk of cardiovascular disease of 10% or more.

Use clinical judgement for people with frailty or multimorbidity

John, an active and fit 85-year-old man with a medical history of hypertension and hyperlipidaemia only, is experiencing difficulty maintaining his blood pressure below the recommended target. What should his clinic blood pressure target be?

 Below 130/80 mmHg

 Below 140/90 mmHg

 Below 150/90 mmHg

 Below 160/100 mmHg

The correct answer is: 

Below 150/90 mmHg

NICE quote:

For adults with hypertension aged 80 and over, reduce clinic blood pressure to below 150/90 mmHg and ensure that it is maintained below that level. Use clinical judgement for people with frailty or multimorbidity.

What action should be taken if the person's blood pressure falls by specific thresholds after standing for at least 1 minute?

 Review the person's current medication.

 Immediately refer the person to specialist care.

 Measure subsequent blood pressures with the person lying down.

 Disregard the symptoms and continue with regular monitoring.

The correct answer is: 

Review the person's current medication.

NICE quote:

If the person's systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute:

consider likely causes, including reviewing their current medication

What is the term for a severe increase in blood pressure to 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema?

 Masked hypertension

 Stage 2 hypertension

 Accelerated hypertension

 Persistent hypertension

The correct answer is: 

Accelerated hypertension.

NICE quote:

Accelerated hypertension

A severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.

Sarah, a 55-year-old woman with stage 1 hypertension (clinic blood pressure between 140/90 and 160/100 mmHg) is considering starting antihypertensive drug treatment. How should the healthcare provider advise Sarah?

 Monitor blood pressure daily for six months

 Recommend against antihypertensive drug treatment at present.

 Consider antihypertensive drug treatment in addition to lifestyle advice regardless cardiovascular risk.

 Consider antihypertensive drug treatment in addition to lifestyle advice if cardiovascular risk is 10% or greater.

The correct answer is: 

Consider antihypertensive drug treatment in addition to lifestyle advice regardless cardiovascular risk.

NICE quote:

Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10‑year risk below 10%. Bear in mind that 10‑year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease. 

What should be done if a person has suspected phaeochromocytoma?

 Start antihypertensive drug treatment immediately

 Refer for specialist assessment within 30 days

 Monitor using ABPM

 Refer for same-day specialist assessment

The correct answer is: 

Refer for same-day specialist assessment.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

Tom, a 40-year-old man of Black African origin with hypertension and type 2 diabetes, is considering starting antihypertensive drug treatment. What should be considered when choosing his medication?

 Prescribe an ACE inhibitor in preference.

 Prescribe an ARB in preference.

 Avoid ACE inhibitors and ARBs.

 Prescribe a calcium channel blocker in preference.

The correct answer is: 

Prescribe an ARB in preference.

NICE quote:

When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor. 

Emma, a 60-year-old woman with hypertension, is using ABPM to monitor her blood pressure response to treatment. What should be her target blood pressure based on ABPM?

 Below 130/80 mmHg

 Below 135/85 mmHg

 Below 140/90 mmHg

 Below 145/85 mmHg

The correct answer is: 

Below 135/85 mmHg

NICE quote:

When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours … Reduce blood pressure and ensure that it is maintained:

below 135/85 mmHg for adults aged under 80

below 145/85 mmHg for adults aged 80 and over.

When should hypertension be confirmed in people with a clinic blood pressure of 140/90 mmHg or higher?

 ABPM daytime average or HBPM average of 130/80 mmHg or higher.

 ABPM daytime average or HBPM average of 135/85 mmHg or higher.

 ABPM daytime average or HBPM average of 140/90 mmHg or higher.

 ABPM daytime average or HBPM average of 145/95 mmHg or higher.

The correct answer is: 

ABPM daytime average or HBPM average of 135/85 mmHg or higher.

NICE quote:

Confirm diagnosis of hypertension in people with a:

clinic blood pressure of 140/90 mmHg or higher and

ABPM daytime average or HBPM average of 135/85 mmHg or higher. 

If a person with severe hypertension has no symptoms indicating same-day referral, what is an acceptable option for confirmation of diagnosis?

 ABPM with review within 7 days

 Repeat clinic blood pressure measurement within 30 days

 Start antihypertensive drug treatment immediately

 Lifestyle modifications

The correct answer is: 

ABPM with review within 7 days

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days. 

Sarah, a 65-year-old woman with hypertension, type 2 diabetes and chronic heart failure, is prescribed antihypertensive drug treatment. What guideline should be followed for her medication choice?

 NICE guideline on hypertension.

 NICE guideline on type 2 diabetes.

 NICE guideline on acute heart failure.

 NICE guideline on chronic heart failure.

The correct answer is: 

NICE guideline on chronic heart failure.

NICE quote:

For people with cardiovascular disease:

Follow the recommendations for disease-specific indications in the NICE guideline on their condition ... Relevant recommendations include:

… acute coronary syndromes

… acute heart failure

… chronic heart failure

… stable angina

… type 1 diabetes ...

What is an essential initial test for end organ damage that should be offered to all people with hypertension?

 Dipstick for leucocytes in the urine

 Blood test for calcium and vitamin D

 An echocardiogram

 A 12-lead ECG

The correct answer is: 

A 12-lead ECG

NICE quote:

For all people with hypertension offer to:

… a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip

… measure …HbA1C, electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol

examine the fundi for the presence of hypertensive retinopathy

arrange for a 12‑lead electrocardiograph to be performed. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/dVpfeUxt8K8

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.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through new and updated guidelines published in April 2024 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.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for April 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-04-01&to=2024-04-30&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered can be found here:

Endometriosis: diagnosis and management- NICE guideline [NG743] can be found here:

·      https://www.nice.org.uk/guidance/ng73

Final draft guidance on Atogepant for preventing migraine [ID5090] | can be found here:

·      https://www.nice.org.uk/guidance/indevelopment/gid-ta10992/documents

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

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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 am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in April 2024, focusing on what is relevant in Primary Care only.

And in April we have had very little new guidance relevant to primary care, in fact, there was only one guideline containing relevant information for us, the guideline on endometriosis. But, to make up for it, we also have the NICE final draft guidance on atogepant for migraine prophylaxis, which I will cover briefly after the endometriosis update.

Right, let’s jump into it.

So, let’s start with the guideline on Endometriosis. The management is normally guided by secondary care but this guideline also includes recommendations relevant to primary care such as the clinical presentation, diagnosis and referral recommendations.

And let’s start with the clinical presentation.

NICE says that we should suspect endometriosis in women (including those under 17) if they have at least 1 of the following:

·      chronic pelvic pain

·      dysmenorrhoea

·      deep pain during or after sexual intercourse and

·      either period-related or cyclical gastrointestinal and urinary symptoms, in particular, painful bowel movements, haematuria or dysuria

We will offer an abdominal examination to exclude masses and, if appropriate, a pelvic and vaginal examination too.

What investigations should we organise?

Well, we can do a transvaginal ultrasound, which can identify signs of endometriosis.

If a transvaginal scan is not appropriate, we will do a transabdominal pelvic ultrasound scan.

We will not use serum CA125 to diagnose endometriosis but if it is available we must be aware that:

·      a high level may be consistent with endometriosis but that

·      endometriosis may be present despite normal serum CA125 levels

Equally, pelvic MRI is not recommended as a primary investigation for endometriosis. However, this can be considered in secondary care to assess the extent of deep endometriosis involving the bowel, bladder or ureter.

But, and this is an important but, we must not exclude endometriosis just because the examination, ultrasound or MRI are normal. If there is a high clinical suspicion, we should refer for further assessment.

So, the question is, should we be initiating investigations in Primary Care if we know that we may end up referring to gynaecology anyway?

My view is that if there is a high clinical suspicion of endometriosis, then we are probably better off referring the patient straightaway, as this is likely to lead to an earlier diagnosis and management. However, if we are not certain or we wish to exclude other possible diagnoses, we could do some investigations first.

So, when do we need to refer?

And the answer is simple. We should refer if:

·      they have symptoms or signs of endometriosis or if

·      not responding to the initial management

There are updated management recommendations if fertility is a priority and these are obviously more relevant for secondary care. From a primary care perspective, we should know that, in general, surgical approaches are recommended because they are likely to improve the chance of spontaneous pregnancy.

However, the opposite is true for hormonal treatment, either alone or in combination with surgery, so it is not recommended because of its effect on fertility.

And that is it, this is the only published update for us.

But, as promised, let’s have a look at the NICE final draft on atogepant for migraine prophylaxis.

I will not say very much because we will be covering this fully when the final guidance is published, but I will give you just an overview.

Both Rimegepant and atogepant, are a new class of drugs, also known as gepants, that have been developed specifically for the treatment of migraines. They are a calcitonin gene-related peptide (or CGRP) receptor antagonist which works by blocking this CGRP receptor. And although the mechanism of action is not fully understood, we know that CGRP is a protein found in the sensory nerves of the head and neck and causes blood vessels to dilate, which can lead to inflammation and migraine pain. Unlike triptans, gepants do not cause vasoconstriction so they do not have the same cardiovascular contraindications and cautions as triptans. Gepants can be used as an acute treatment of migraine and, although rimegepant has a licence for migraine prophylaxis, NICE only recommends as prophylaxis of episodic migraines. However, NICE has recommended atogepant as an option for preventing both chronic and episodic migraines. But this is only if there have been at least 4 migraine days per month and where at least 3 previous preventive treatments have failed.

What’s the difference between episodic and chronic migraine?

The definition of Episodic migraine is when there are fewer than 15 headache days each month. On the other hand, chronic migraine is when there is at least 15 headache days a month, with at least 8 of those having features of migraine.

Currently, the most effective options for people with chronic migraines who have already tried 3 prophylactic treatments are drugs that need to be injected so an oral treatment such as Atogepant offers more choice for patients.

So, with that in mind, let’s quickly look at the preventative treatment pathway that NICE has produced in their new draft guidance.

First, for prophylaxis treatment to be considered, the patient needs to have 4 or more migraine days per month.

In that case, we will give 1st, 2nd and 3rd line prophylaxis with propranolol, amitriptyline and topiramate.

If there is inadequate response, then we move to 4th line treatment.

For episodic migraine we can give Rimegepant.

For both episodic and chronic migraines, we have a number of injectable medications and atogepant as the only oral medication.

Finally, if it is only chronic migraine, then the recommended treatment will be with botox.

Rimegepant is an oral lyophilisate that should be placed on the tongue or under the tongue and it will disintegrate in the mouth and can therefore be taken without liquid. However, atogepant is a tablet to be taken orally.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/8dYGalK25os

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the concept of Hypertensive Urgency as opposed to Hypertensive Emergency.

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.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Hypertension in adults: diagnosis and management - NICE guideline [NG136]:

·      https://www.nice.org.uk/guidance/ng136

The NICE hypertension flowcharts can be found here:

·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

Worcestershire Acute Hospitals NHS Trust guideline on the Management of Hypertensive crises:

·      https://www.bing.com/ck/a?!&&p=9b5fdeea73ebb791JmltdHM9MTcxMzU3MTIwMCZpZ3VpZD0xODRhNTBkMS0xZGExLTYzZWItMjMyYi00NGMwMWNhNzYyYjMmaW5zaWQ9NTIwOA&ptn=3&ver=2&hsh=3&fclid=184a50d1-1da1-63eb-232b-44c01ca762b3&psq=Worcestershire+Acute+Hospitals+NHS+Trust+guidelines+hypertensive+crises&u=a1aHR0cHM6Ly9hcHBzLndvcmNzYWN1dGUubmhzLnVrL0tleURvY3VtZW50UG9ydGFsL0hvbWUvRG93bmxvYWRGaWxlLzM3NDk&ntb=1

The Worcestershire Acute Hospitals NHS Trust Hypertensive crisis flowchart can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mRX6no6c5m3ddfEC?e=aPVQ67

NICBH PUBMED

·    https://www.ncbi.nlm.nih.gov/books/NBK513351/

Slides MRCP

·      https://www.bing.com/ck/a?!&&p=695818f027015fbaJmltdHM9MTcxMzU3MTIwMCZpZ3VpZD0xODRhNTBkMS0xZGExLTYzZWItMjMyYi00NGMwMWNhNzYyYjMmaW5zaWQ9NTIxMQ&ptn=3&ver=2&hsh=3&fclid=184a50d1-1da1-63eb-232b-44c01ca762b3&psq=adrian+stanley+hypertensive+urgency&u=a1aHR0cHM6Ly93d3cucmNwbG9uZG9uLmFjLnVrL2ZpbGUvMjk2Ny9kb3dubG9hZA&ntb=1

NEJM article: Acute severe hypertension:

·      https://www.nejm.org/doi/full/10.1056/NEJMcp1901117

Approach to HTN urgency in primary care setting

·      https://journals.lww.com/tnpj/Fulltext/2021/10000/Approach_to_a_patient_with_hypertensive_urgency_in.13.aspx

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Music provided by Audio Library Plus 

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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 I will touch on a subject which is not really covered by NICE, which is the concept of hypertensive urgency, as opposed to hypertensive emergency. It is an interesting subject which we are going to illustrate with a practical case, so make sure that you stick around till then. For this I have consulted a number of medical publications and guidelines and the links are in the episode description.

Right, so let’s jump into it.

So, let’s start with some definitions.

·      Severe hypertension is defined as SBP ≥180mmHg and/or DBP ≥120mmHg

·      Hypertensive emergency is defined as severe hypertension associated with evidence of target organ damage. 

·      Hypertensive urgency is defined as severe hypertension without evidence of ongoing target organ damage.  Studies have shown that Hypertensive urgency is two to three times more common than hypertensive emergencies.

We know from the hypertension NICE guideline that for people with a BP of 180/120 or higher we should investigate for target organ damage, that is, we have to differentiate between hypertensive urgency and emergency.

Starting with the history, we should look at possible causes, and non-compliance with antihypertensive drug treatment is the most common precipitating factor. Other possible factors include excess alcohol, anxiety or panic, drugs, either prescribed, over-the-counter, or illicit like cocaine, amphetamines, sympathomimetic agents, nonsteroidal anti-inflammatory drugs, and high-dose steroids.

We will need to consider the past medical history. Systematic reviews have concluded that hypertensive crises occur more often if there is a history of CKD, coronary heart disease, stroke and congestive heart failure and therefore checking whether the patient have these diagnoses is important because they represent both risk factors and consequences of severe hypertension.

In terms of examination, we will ensure that the BP reading is correct, that is, we will take the measurements in both arms making sure that the cuff is the correct size, and take at least two or three readings in the arm with the highest BP.

A study has shown that in up to a third of patients with severe hypertension, the blood pressure falls to less than 180/120 mm Hg after 30 minutes of quiet rest. So, if feasible, we could also try this.

And, in the history and examination we will look for signs and symptoms of possible end organ damage. So:

·      In the eye we will look for symptoms and signs of retinopathy such as blurring or loss of vision, dizziness, retinal haemorrhage, and papilloedema,

·      In the CNS we will look for symptoms and signs of hypertensive encephalopathy, intracerebral haemorrhage or ischaemic stroke such as headache, nausea, vomiting, confusion, seizures, visual disturbance, focal deficit, dysphagia, abnormal or loss of sensation, changes in mental status (like agitation or lethargy) and ataxia

·      In the aorta we will look for symptoms and signs of aortic dissection such as acute severe back pain or chest pain radiating to the back, unequal peripheral pulse or BP measurements, and diastolic murmur of aortic insufficiency

·      In the chest we will look for symptoms and signs of:

o  Acute coronary syndrome such as chest pain and shortness of breath and of

o  Acute pulmonary oedema such as shortness of breath, elevated JVP, decreased lung sounds, hypoxaemia, tachypnoea and bi-basal crackles and finally

·      In the kidneys will look for symptoms and signs of acute kidney injury such as oliguria, haematuria, and proteinuria

If there are any symptoms or signs of target organ damage, we will refer the patient to hospital as an emergency.

It is worth saying too that according to NICE, we should send the patient to hospital too if the patient has suspected phaeochromocytoma based on symptoms, for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis. 

Otherwise, without concerning symptoms or signs, as we know, we should carry out initial investigations such as:

·      UEs, FBC, HbA1c, Lipid profile, and TFTs

·      Urine dipstick for blood and protein as well as Albumin Creatinine ratio 

·      Fundoscopy – and, if unsure, we could consider an urgent optician retinal photography or an ophthalmological assessment

·      A Chest X-ray

·      An ECG and an

·      ECHO if there is evidence of LVH on ECG

Okay, so this is all very good in theory, but let’s put it into practice with a fictitious case:

A 54-year-old Caucasian woman without known hypertension comes to see you for an unrelated problem and you decide to check her BP. Her BP is 200/130 mm Hg. She is otherwise asymptomatic. On examination, funduscopy and the remainder of the examination is normal, including urinalysis.

What should we do next?

First of all, she has no symptoms of concern and no signs of end organ damage, so, assuming that the BP measurement is correct and that there are no other precipitating or risk factors, the next step will be to carry out investigations for end organ damage.

But, in practice, we do not have immediate access to chest x-rays and in some places, ECGs. Even if we can do blood tests and check ACR straightaway, the results wouldn’t be available immediately. Besides, our fundoscopy skills may not be perfect and getting an adequate fundoscopy assessment can also take time. Does this mean that we should always send the patient to the emergency department for a full assessment?

Most of us would probably find a BP of 200/130 quite scary. Our imagination may start thinking of all the possible things that could go wrong: neurological problems, cardiovascular events, retinal haemorrhages and acute kidney injury amongst many others.

In addition, we want to be good doctors, we want to do the best for our patients, we don’t want to get patients’ complaints and even less to be the subject of GMC investigations. But above all, we want to have peace of mind and sleep well at night.

So, what do we do?

And the first thing to say is that we have to do what feels right, it is our clinical judgement, and if it feels right to send the patient to the emergency department for a full screen, then so be it. This would be particularly relevant if we consider the patient to be at high risk because of, for example, other co-morbidities such as CKD, CHD or a previous stroke.

But there may be times when sending the patient to hospital may not be possible, or, perhaps, we will try but the medical team may refuse to accept the patient. What do we do then?

So, for then, let’s consider a few things.

As far as we know, this patient does not have any symptoms or signs of end organ damage.

NICE specifically says that when a patient does not have symptoms or signs indicating same day referral, we should carry out investigations for target organ damage “as soon as possible”. So NICE is asking us to use symptoms and signs, that is, history and examination as the basis for our assessment as to whether the patient needs to be seen in the emergency department or not. What carrying out investigations “as soon as possible” means exactly will be open to interpretation, but we should not take it as having to be done in hospital as an emergency.

Also, although repeated episodes of hypertensive urgency may have long-term complications, the immediate risk of hypertensive urgency is relatively low, and some studies have shown only 1 cardiovascular event per 1,000 patients in the week following the presentation. Therefore, the vast majority of these patients can be safely treated in Primary Care with oral antihypertensives.

Also, in the absence symptoms and signs of acute organ damage, there is limited evidence on benefits of immediate emergency blood and other diagnostic tests. A trial of patients presenting with hypertensive urgency in Primary Care showed that only 5% of ordered tests were abnormal, many of them being simply indicative of poorly controlled chronic hypertension. Consequently, although recommended, for most patients these tests are not needed as an emergency.

Also, most of these patients are likely to suffer from chronic hypertension. We know that many of these patients will have had very high blood-pressure readings for months or even years and we also know that for them the BP needs to be lowered slowly.

Why slowly? This is because perfusion of cardiac, renal, and brain tissue is tightly autoregulated in the body. And what does autoregulation mean?

Autoregulation of organ blood flow refers to physiological adaptations that allow organ perfusion to remain relatively constant across a wide blood-pressure range. For example, in chronic severe hypertension, cerebral blood flow is maintained at similar levels as in normotensive people, but its autoregulatory mechanism allows patients to tolerate higher blood-pressure levels without developing cerebral oedema. However, precisely because of this autoregulation, if the blood pressure is lowered too quickly, these patients are at risk of cerebral hypoperfusion, and this can happen even at higher-than-normal BP levels.

Therefore, although our wish may be to see a substantial drop in BP quickly, with no end organ damage, the BP should be lowered gradually, over a period of days to avoid hypotension, syncope, myocardial ischaemia and acute kidney injury which are commonly associated with, for example, the administration of sublingual nifedipine which is no longer widely advocated precisely for that reason.

Limited data suggest that hypertensive patients recover normal autoregulatory responses within weeks after treatment initiation.

Right, so, we have decided that this patient does not necessarily need to attend A&E so we will arrange investigations for end organ damage as soon as possible which, in Primary Care could be blood tests and ACR within 24 hours with available results generally within 48 hours. The availability of ECGs and CXRs may vary from practice to practice but, as long as there are no concerning symptoms, doing them within a few days may be acceptable. Equally, if we do not feel confident about our fundoscopy examination, we could arrange retinal photographs via an optometrist or arrange an alternative ophthalmological assessment, also within a number of days.

Now that we have arranged the investigations, and we have reassured ourselves that we do not need to send the patient to hospital, what do we actually do with the patient?

If the patient is known to have hypertension and the severe hypertension is secondary to, for example, non-compliance with medication, then it is easy. We will restart the medication counselling and monitoring the patient accordingly.

However, for those without a previous diagnosis of hypertension, NICE says that, as long as there are no symptoms or signs of end organ damage, we will confirm the diagnosis by either repeating the BP within 7 day or by reviewing the HBPM or ABPM results also within seven days, and then treat them if the diagnosis of hypertension is confirmed.

But I know that some of you will be thinking: really? Are we really going to let a patient go home for up to a week with a BP of 200/130 just like that?

Well, NICE says “review the BP within 7 days”, so this could mean reviewing the patient much more quickly, for example within 1 or 2 days. But I know that whilst this may be an appropriate management strategy for many patients, for others we, as doctors, would feel happier if we could do something sooner.

And this may also be a fair approach. In fact, although not advocated by NICE, there are other guidelines that recommend starting hypertensive medication straightaway in these situations, for example, the current guideline on the management of hypertensive crises by Worcestershire Acute Hospitals NHS Trust.

So, if you are worried enough to want to start medication straightaway, you could be justified doing just that, even if that means deviating from the NICE guideline.

And the next question is, how should this patient be treated?

Medical publications state that there is little evidence addressing directly what specific agent is best to use in the case of hypertensive urgency, that is a BP of 180/120 or higher without evidence of end organ damage.

This patient is Caucasian and she is under 55 years of age, so according to NICE, we should start her on an ACEI or an ARB.

But this is where some of the guidelines also differ. For example, some guidelines recommend starting what they call  “rapid” antihypertensive agents. For example, the Worcestershire guideline advocates starting a 10 to 20 mg daily dose of oral slow release nifedipine if the patient is not on a calcium channel blocker because it can be titrated up as required and it has a faster onset of action compared to amlodipine. When switching to amlodipine, they also recommend an overlap of 1-2 days, during which a patient can receive both Nifedipine and Amlodipine, to allow for the latter to reach adequate therapeutic levels before stopping nifedipine. To minimise the risk of cerebral hypoperfusion, an initial BP target of 160/100 within 6 to 24 hours is generally recommended.

After that, in general, once the hypertensive urgency has been addressed, the treatment options should be guided by NICE recommendations.

Worcestershire Acute Hospitals NHS Trust has created a simple flow chart which you will be able to find in the episode description.

Let’s have a look at it.

So, if the patient has severe hypertension, we will ask ourselves if there is evidence of end organ damage. If the answer is yes, then we will treat this as a hypertensive emergency, we will admit the patient and consider lowering the BP with IV medication.

If on the other hand, there is no evidence of end organ damage, then we will treat it as a hypertensive urgency that may not need admission and may be treated with oral medication. This could be nifedipine slow release orally or simply restarting usual antihypertensive medication in the case of non-compliance.

In summary, we must distinguish hypertensive emergency from hypertensive urgency. Short-term risk for serious cardiovascular events is minimal with hypertensive urgency and most of these patients can be safely treated in the Primary Care. Referral to the Emergency Department, aggressive BP reduction, and immediate diagnostic tests are generally unwarranted unless we have specific concerns. BP control is best achieved with the initiation or adjustment of long-acting oral antihypertensive medications although more rapid agents such as oral slow release nifedipine can be used if a faster onset of action is necessary. We should also consider and address any other possible precipitating factors.

Right, so this is it, a review of hypertensive urgencies.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here: https://youtu.be/wjIbwy9SdAQ?si=hBe18dtUf_rPtRc8 

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE. 

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the NICE guideline [NG136] 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.   

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Hypertension in adults: diagnosis and management - NICE guideline [NG136]: 

·      https://www.nice.org.uk/guidance/ng136

Chronic kidney disease: assessment and management - NICE guideline [NG203]:

·      https://www.nice.org.uk/guidance/ng203

The NICE hypertension flowcharts can be found here:

·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

The Full NICE guideline Hypertension in pregnancy: diagnosis and management [NG133] can be found at:

·      https://www.nice.org.uk/guidance/ng133/chapter/Recommendations

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

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 do an up-to-date review of the NICE guidelines on hypertension, including the changes introduced in November 2023, always focusing on what is relevant in Primary Care only. 

Right, so let’s jump into it.

First, this guideline does not cover specific recommendations in CKD, type 1 diabetes, or pregnancy. However, it does cover type 2 diabetes, given that the management of hypertension in type 2 diabetes is no different than in the general population.

Let’s just remind ourselves that, when checking the BP, we should always palpate the pulse first and, if there is pulse irregularity, we should measure the BP manually, because automated devices are not accurate when the pulse is irregular like in AF.

If there are symptoms of postural hypotension, like falls or dizziness:

·      We will measure their BP while lying on their back (although we can consider a seated position, if inconvenient)

·      And we will measure their BP again after standing for at least 1 minute. 

If the systolic BP falls by 20 or more, or their diastolic BP by 10 or more:

·      we will consider the causes, and review their medication

·      we will manage the risk of falls

·      we will check future BP readings with the patient standing and

·      we will refer if necessary

Also, in order to diagnose hypertension, we will measure the BP in both arms:

·      If the difference is more than 15 mmHg, more than once, we will measure subsequent BPs in the arm with the higher reading. 

If BP measured in the clinic is 140/90 mmHg or higher:

·      We will take a second measurement.

·      If it is substantially different, we will take a third measurement and we will record the lowest of them as the clinic BP. 

If clinic BP is between 140/90 mmHg and 180/120 mmHg, we will confirm hypertension by doing ambulatory BP monitoring (ABPM) or, if necessary, home BP monitoring (HBPM). While waiting, we will:

·      Estimate the cardiovascular risk using the clinic BP and we will

·      Carry out investigations for target organ damage by doing:

o  A urine test for a haematuria dipstick and an albumin-creatinine ratio or ACR

o  A blood test for HbA1C, renal function, total cholesterol and HDL cholesterol

o  A 12‑lead ECG

o  And examination of the fundi for the presence of hypertensive retinopathy

If a person has a clinic BP of 180/120 mmHg or higher, we will check for red flags symptoms or signs that would indicate the need for urgent same day assessment in hospital. These are:

·      signs of retinal haemorrhage or papilloedema or

·      life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury or 

·      Signs or symptoms suggestive of phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis or excessive sweating). 

If there are no symptoms or signs indicating same-day referral, we will carry out investigations for target organ damage as soon as possible and:

·      If target organ damage is identified, we will consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

·      If no target organ damage is identified, we will confirm diagnosis by:

o  Either repeating the BP within 7 days, or

o  using ABPM or HBPM, also reviewing the patient within 7 days. 

When using HBPM, we will ensure that:

·      the BP is checked twice, at least 1 minute apart and

·      the BP is recorded twice daily, ideally in the morning and evening and

·      the BP checked for at least 4 days, ideally for 7 days

·      we will then disregard the BP readings taken on the first day and use the average value of the rest to confirm the diagnosis. 

We will confirm the diagnosis of hypertension if:

·      the clinic BP is 140/90 mmHg or higher and

·      the ABPM daytime average or HBPM average is 135/85 mmHg or higher. As a rule of thumb, the ambulatory or home  readings are 5 mmHg lower than for clinic measurements

Obviously, if hypertension is not diagnosed but there is target organ damage, we will investigate further.

If hypertension is confirmed, we will offer lifestyle advice in respect of diet, exercise, smoking and alcohol and we will encourage low caffeine and salt consumption. Salt substitutes containing potassium should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking ACE inhibitors and ARBs.

When it comes to starting antihypertensive medication, we will always use clinical judgement for people with frailty or multimorbidity, but in general:

·      At any age, we will start antihypertensives if the clinic BP is 160/100 or higher or ABPM or HPBM is 150/95 or higher

·      If the patient is over 80, we will consider antihypertensives if the clinic BP is over 150/90 mmHg

·      If the patient is between 60 and 80, we will consider antihypertensives if the clinic BP is 140/90 or higher or ABPM or HBPM is 135/85 or higher but only if there is:

o  target organ damage

o  established CVD

o  renal disease

o  diabetes or

o  a CV risk of 10% or more

·      If the patient is under 60, we will consider antihypertensives if the clinic BP is 140/90 or higher or ABPM or HBPM is 135/85 regardless of the CV risk

·      And if the patient is under 40, we should consider referral for investigations of secondary causes.

In terms of monitoring, we will check for postural hypotension if:

·      There are symptoms for example falls and dizziness or if

·      There is type 2 diabetes or if

·      The patient is aged 80 and over.

And if there is postural hypotension or symptoms, we should base the BP target on the standing BP reading. 

In straightforward hypertension without any other consideration, the BP targets that we need to remember are:

·      If under 80, the target clinic BP is below 140/90 mmHg (or 135/85 if using ABPM or HBPM)

·      If aged 80 and over, the target clinic BP is below 150/90 mmHg (or 145/85 if using ABPM or HBPM), always using clinical judgement if there is frailty or multimorbidity.

These targets are for everyone, including type 2 diabetes, but not if the patient is pregnant or has CKD or type 1 diabetes.

NICE has created two tables with BP targets including patients with CKD and type 1 diabetes, so, let’s have a look at them:

·      If the person is aged under 80, we have two targets:

o  Below 140/90 for general hypertension, with or without type 2 diabetes, or Type 1 diabetes with ACR <70 or CKD with ACR <70; and the second target is

o  Below 130/80 in Type 1 diabetes with ACR of 70 or more or CKD with ACR of 70 or more

·      If the person is 80 or over, we have three targets:

o  Below 150/90 for people with hypertension, with or without type 2 diabetes and also for those with type 1 diabetes regardless of ACR levels, then

o  Below 140/90 in CKD with an ACR <70 and the third target is

o  Below 130/80 in CKD with an ACR of 70 or more

I have streamlined these two tables into a single flowchart which you will be able to access in the episode description.

Now, to achieve these targets, what antihypertensives should we choose?

And, again, let’s remember that if the patient has certain conditions, we will not follow the hypertension guidelines but the specific guideline for those conditions, such as the guideline on:

·      Type 1 diabetes

·      CKD

·      Cardiovascular disease like heart failure, stable angina and acute coronary syndromes and

·      Pregnancy and in particular we will note the MHRA advice to avoid ACEIs and ARBs during pregnancy or breastfeeding or for women planning pregnancy.

Otherwise, the following recommendations apply to everybody else regardless of whether they have type 2 diabetes or not, and treating isolated systolic hypertension (that is a systolic BP 160 mmHg or more) the same way as in both raised systolic and diastolic BP. 

Also, when treating patients of Black African or African–Caribbean family origin, we will go for an ARB, in preference to ACE inhibitor. This is because they have a low-renin state and therefore ACEIs and ARBs are less effective for them. However, when they are needed in this group of patients, ARBs are clinically more effective than ACEIs.

The treatment of hypertension comes in 4 steps. Step 1 treatment is with one drug, step 2 treatment with two drugs, step 3 with three and so on.

So, in Step 1 treatment, that is, when we initiate medication for the first time, we will offer an ACE inhibitor or an ARB if:

·      They have type 2 diabetes and are of any age or family origin or

·      They are aged under 55 but not of Black African or African–Caribbean family origin. 

Conversely, we will offer a CCB if:

·      They are aged 55 or over and do not have type 2 diabetes or

·      are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). 

If a CCB is not tolerated, for example because of oedema, we will offer a thiazide-like diuretic. And we should offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.

Step 2 treatment is treatment with two drugs. That is, if hypertension is not controlled with one drug, then, if the patient is taking an ACE inhibitor or ARB, we will offer either:

·      a CCB or

·      a thiazide-like diuretic

On the other hand, if hypertension is not controlled with a CCB, we will offer either:

·      an ACE inhibitor or an ARB or

·      a thiazide-like diuretic. 

Step 3 treatment is with three drugs so if hypertension is not controlled taking step 2 medication, we will offer a combination of them all, that is:

·      an ACE inhibitor or ARB and

·      a CCB and

·      a thiazide-like diuretic

But if hypertension is not controlled taking these three drugs, we will regard them as having resistant hypertension. 

And before considering further treatment:

·      We will discuss adherence 

·      We will confirm it with ABPM or HBPM

·      And we will assess for postural hypotension.

If resistant hypertension is confirmed, we may consider:

·      either seeking specialist advice

·      or adding a fourth antihypertensive drug as step 4 treatment

So, what is step 4 treatment with four drugs? Well, if we decide to give a fourth drug, we will need to look at the potassium level and:

·      If the potassium level of 4.5 mmol/l or less we will give further diuretic therapy with low-dose spironolactone, with particular caution if the eGFR is very low because of the risk of hyperkalaemia. When prescribing spironolactone, we will monitor electrolytes and eGFR within 1 month and repeat as needed thereafter. 

·      If the potassium level of more than 4.5 mmol/l we will give an alpha-blocker or a beta-blocker instead. 

If the BP remains uncontrolled with 4 drugs, then we will need to seek specialist advice. 

And that is it, a quick summary of the NICE guideline on hypertension.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here: https://youtu.be/41MH-Z-tcf8

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.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through new and updated guidelines published in March 2024 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.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for March 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-03-01&to=2024-03-31&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered can be found here:

Ovarian cancer: identifying and managing familial and genetic risk- NICE guideline [NG241] can be found here:

·      https://www.nice.org.uk/guidance/ng241

Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management- NICE guideline [NG240] can be found here:

·      https://www.nice.org.uk/guidance/ng240

Vitamin B12 deficiency in over 16s: diagnosis and management- NICE guideline [NG239] can be found here:

·      https://www.nice.org.uk/guidance/ng239

My summary of meningitis and meningococcal disease symptoms can be found here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mRE17SGM9XfnH-0n?e=lx7zVg

2-page visual summary on ongoing care and follow up options for oral and intramuscular vitamin B12 replacement:

·      https://www.nice.org.uk/guidance/ng239/resources/visual-summary-ongoing-care-and-followup-for-vitamin-b12-replacement-pdf-13315996909 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

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 am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in March 2024, focusing on what is relevant in Primary Care only. 

And in March we have had a feast of new guidance. Not because there have been many updates but because of three completely new guidelines that have been published for the very first time. We will be covering managing genetic risk of ovarian cancer, bacterial meningitis and meningococcal disease and the eagerly awaited vitamin B12 deficiency guideline. Right, let’s jump into it. 

So, let’s start with the guideline on identifying and managing genetic risk of ovarian cancer saying that these recommendations are for anyone who has a familial or genetic risk of ovarian cancer. This includes people with both female and male reproductive organs because although people with male reproductive organs cannot develop ovarian cancer, they can pass the risk on to their children, and may be at risk of developing other cancers.

So, the brief summary for us is that, in primary care, we should refer people for genetic testing if they have:

·      A first or second degree relative with a diagnosis of ovarian cancer

·      A diagnosis of ovarian cancer themselves

·      They have already been identified to be at high risk and if

·      they are from an at‑risk population, that is, those with at least 1 grandparent from the following populations:

o  Ashkenazi Jewish

o  Sephardi Jewish and

o  Greenlander

As we know, the combined oral contraceptive reduces the risk of ovarian cancer. However, we will only give it to reduce the risk of ovarian cancer if the reduction in the ovarian cancer risk outweighs the increased risk of breast cancer 

Equally, we can offer HRT until the average age of menopause (usually around 51 years) for people who:

·      have not had breast cancer and

·      have had bilateral salpingo-oophorectomy 

For those who have had breast cancer, HRT should be discussed with their breast cancer team.

Now let’s move to the guideline on bacterial meningitis and meningococcal disease, focusing on the recognition and diagnosis.

This guideline does not cover infection in babies under 28 days of age, or people with immunodeficiency, or any intracranial or spinal anomalies that increase the risk of meningitis.

The difficulty that we have with the diagnosis of meningitis or meningococcal disease, is that symptoms can be rapidly evolving and non-specific and they can be hard to distinguish from other infections and therefore we should always consider giving safety netting advice.

NICE has produced three long tables with signs and symptoms of when to suspect meningitis and meningococcal disease both in children and adults. We will not go through them here but I have created a summary that you can access in the episode description.

But we should strongly consider meningitis when encountering the following red flag combination:

·      fever

·      headache

·      neck stiffness and

·      altered level of consciousness (including confusion or delirium).

Also, we will really strongly suspect meningococcal disease if there is any of these red flag symptoms:

·      haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura)

·      rapidly progressive and/or spreading non-blanching petechial or purpuric rash and

·      any symptoms and signs of bacterial meningitis, when combined with a non-blanching petechial or purpuric rash.

But on the other hand, we will not rule out meningococcal disease just because there is no rash.

When looking for a rash we will check all over the body (including nappy areas), and check for petechiae in the conjunctivae, particularly if the person has brown, black or tanned skin.

There are a number of risk factors for bacterial meningitis and meningococcal disease like, to name but a few:

·      missed relevant immunisations

·      splenectomy

·      being a student in further or higher education, particularly if in large shared accommodation and

·      being in contact with someone with the disease, or having been in an area with an outbreak of meningococcal disease

We will obviously transfer people with suspected bacterial meningitis or meningococcal disease to hospital as an emergency, warning them that the patient is coming.

But, do we need to give antibiotics before sending the patient to hospital? Well, the things to consider in this respect are that:

·      First of all, we should not delay admission to hospital to give antibiotics

·      Second, we will give them in suspected meningitis only if there is likely to be a clinically significant delay in the transfer

·      But we will always give them in suspected meningococcal disease, unless this will cause a delay

·      And finally, if we give them, we will administer intravenous or intramuscular ceftriaxone or benzylpenicillin unless there is a known and severe allergy to these drugs.

Let’s now look at the guideline on vitamin B12 deficiency, which is probably one that is very relevant in our day-to-day practice. Because it’s so improtant, I think that the subject deserves its own dedicated episode, so I will only give a very quick overview here, just to give you a taste of what the guideline says.

And to start we will say that NICE does not use the term pernicious anaemia in this guideline but refers to autoimmune gastritis instead. And we also need to remember that people who have autoimmune gastritis:

·      are at higher risk of developing gastric neuroendocrine tumours and

·      may also be at higher risk of developing gastric adenocarcinoma.

So, we will refer them for gastrointestinal endoscopy if they develop upper gastrointestinal symptoms

The guideline explains that we should not rule out vitamin B12 deficiency just because there is no anaemia or macrocytosis.

We also need to be aware that vitamin B12 deficiency can be associated with mental health problems, including depression, anxiety or psychosis.

We will test vit B12 levels depending on symptoms and risk factors including gastrointestinal surgery, autoimmune medical conditions and medication taken.

To diagnosing vitamin B12 deficiency we can use total B12 levels, that is, serum cobalamin but in certain circumstances we will need to test for active B12 that is, serum holotranscobalamin, plasma homocysteine or serum methylmalonic acid or MMA.

In order to identify the cause of vitamin B12 deficiency, we will consider testing for anti-intrinsic factor antibodies if autoimmune gastritis is suspected, bearing in mind that a negative test result does not rule it out.

If it is still suspected despite a negative anti-intrinsic factor antibody test, we will consider further investigations including anti-gastric parietal cell antibodies or even a gastroscopy with biopsy

And we should consider testing for coeliac disease where the cause of deficiency remains unknown

In terms of managing vitamin B12 deficiency, we will give lifelong vitamin B12 injections if autoimmune gastritis is the cause, or they have had a total gastrectomy, or a complete terminal ileal resection.

For other causes of malabsorption, dietary problems, for medication related deficiencies and nitrous oxide use we can use either intramuscular or oral vitamin B12 replacement, based on clinical judgement

During follow up, we will not check vit B12 levels if we are giving vitamin B12 injections, but we will be guided by symptoms instead. If the symptoms have not improved enough, we will:

·      increase the frequency of injections if needed, and

·      think about alternative diagnoses 

If a person has an irreversible cause we will continue with lifelong injections, even if their symptoms have disappeared.

However, if the symptoms have disappeared and the reversible cause has been resolved we will think about stopping or reducing the vitamin B12 replacement, advising them to come back if symptoms recur.

NICE has produced a 2-page visual summary on ongoing care and follow up options for oral and intramuscular vitamin B12 replacement and the link to it is in the episode description.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here: https://youtu.be/SaizjWg7Fng?si=5067IvQ3Uf9yFVJX 

This episode reviews common abnormal urine tests based on published medical information as well as guidance by NICE and a number of NHS organisations in the UK. 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 go through the interpretation and initial management of invisible haematuria, sterile pyuria and proteinuria, 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 information consulted. You must always use your clinical judgement.   

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: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk 

My summary guide / flowchart can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mRCSWQ0Shpin4PS9?e=F5moTm 

The resources consulted can be found here:

Suspected cancer: recognition and referral -NICE guideline [NG12] – urological cancers:

·      https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer#urological-cancers

Chronic kidney disease: assessment and management - NICE guideline [NG203]:

·      https://www.nice.org.uk/guidance/ng203

Joint consensus statement on the initial assessment of haematuria prepared on behalf of the Renal Association and British Association of Urological Surgeons:

·      https://www.baus.org.uk/_userfiles/pages/files/Publications/haematuria_consensus_guidelines_July_2008.pdf

Assessment and management of non-visible haematuria in primary care BMJ article- BMJ 2009;338:a3021:

·      https://www.bmj.com/content/338/bmj.a3021

·      https://www.bmj.com/bmj/section-pdf/186116?path=/bmj/338/7688/Clinical_Review.full.pdf

North Central London Haematuria clinical pathway PDF:

·      https://gps.northcentrallondon.icb.nhs.uk/pathways/haematuria

Investigating painless haematuria BMJ article - BMJ 2008;337:a260:

·      https://www.bmj.com/content/337/bmj.a260

South East London Urology Adult Primary Care Guidelines:

·      https://www.bing.com/ck/a?!&&p=c2f49d786a34ebffJmltdHM9MTcxMDgwNjQwMCZpZ3VpZD0xZGNjZTJiMC05M2Y4LTYzZTUtMzhkYi1mNmY3OTJjNDYyYzYmaW5zaWQ9NTE4NQ&ptn=3&ver=2&hsh=3&fclid=1dcce2b0-93f8-63e5-38db-f6f792c462c6&u=a1aHR0cHM6Ly9zZWxvbmRvbmNjZy5uaHMudWsvd3AtY29udGVudC91cGxvYWRzL2RsbV91cGxvYWRzLzIwMjMvMTEvSEczMDM3LVNFTC1Vcm9sb2d5LUd1aWRlbGluZXMtRklOQUwtTm92LTIwMjMtMS5wZGY&ntb=1

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
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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 and initial management of non-visible haematuria, always focusing on what is relevant in Primary Care only. 

And for that I will summarise a variety of guidelines and medical publications including NICE guidance and advice provided by a number of NHS bodies in the UK. The links to them are in the episode description and I recommend having a look at them. There you will also be able to find the link to download my summary, which I hope that you will find useful 

Right, so let’s jump into it.

And the reason why this subject generates so many questions is because, when it comes to non-visible haematuria, we are often unsure if and when patients need to be referred and whether they should be referred, to urology, nephrology, or both.

Metanalysis have demonstrated that there is insufficient trial evidence from high quality studies to answer questions relevant to clinical care and therefore clinical pathways are based on consensus agreement and expert opinions. These have changed over the years and, although the oint Consensus Statement of the Renal Association and British Association of Urological Surgeons has been superseded since they were published in 2008, most of their recommendations remain valid and have been incorporated into Primary Care Pathways with only fairly minor changes. And these pathways are going to be the basis of our review today 

And before we start, let’s clarify some basic concepts:

As we probably know, We should no longer use the terms macroscopic and microscopic haematuria but visible and non-visible haematuria instead. In addition, Non-Visible Haematuria can be sub-divided into:

·      Symptomatic Non-Visible Haematuria, when there are some urinary symptoms and

·      Asymptomatic Non-Visible Haematuria which is just an incidental detection without symptoms. This should really be a rarity because we should only test for haematuria for clinical reasons and not opportunistically.

And why is this? Non-visible haematuria is present in about 2.5% of the general population, although it can be as high as 20%, depending on the study group but the overall incidence of serious conditions is <1.5%. This is why there is consensus that general screening for non-visible haematuria is not warranted.

The next question is, what is better? A dipstick or microscopy?

And the answer is that the test of choice is a urine dipstick or urinalysis. Microscopy, because it misses haemolysed haematuria and because of delays in the processing of the urine samples, has a significant false negative rate. Furthermore, the procedure is more labour intensive, and therefore it is not recommended.

What is a positive result? Scores of 1+ or more are considered positive and both non-haemolysed and haemolysed results are of equal significance. On the other hand, a trace of blood should be regarded as a negative result.

The next question is, what is significant haematuria?

Well, clinically significant haematuria is:

·      Either Any single episode of Visible haematuria.

·      Or Any single episode of symptomatic non visible haematuria, obviously not due to a UTI or another transient cause, or

·      Persistent asymptomatic non-visible haematuria and persistent is defined as 2 out of 3 positive dipsticks.

Transient and spurious causes that need to be excluded before establishing the presence of significant haematuria are, for example:

·      A UTI, and a repeat dipstick test after treatment of the infection will determine whether haematuria is persistent.

·      Exercise induced haematuria such as seen in long distance runners, and in these cases urine testing should be repeated at least three days after such activity

·      Myoglobinuria as seen in rhabdomyolysis when myoglobin is released from necrotic muscle cells and

·      Menstruation leading to urinary contamination and the urine test should be repeated after menstruation has stopped

So, what are the causes of persistent non-visible haematuria?

And, obviously, the main worry is cancer, so, first of all, let us deal with this issue

And according to NICE, non-visible haematuria is only a reason for an urgent cancer referral to exclude bladder cancer if the non-visible haematuria appears in a person aged 60 and over with either dysuria or a raised white cell count on a FBC. 

For all other cases, haematuria only features as a cancer sign if it is visible in the over 45s, like in renal and bladder cancers, or if it is visible and with a raised PSA in the case of prostate cancer.

Other possible non-cancer causes of non-visible haematuria can be urological or nephrological.

Examples of some relatively common urological causes of haematuria can be:

·      Benign prostatic hyperplasia

·      Calculus disease

·      Prostatitis or urethritis and

·      Urethral strictures

The most common nephrological causes are:

·      IgA nephropathy or Berger’s disease

·      Thin basement membrane disease

And finally, we will also bear in mind that haematuria should not be attributed to anti-coagulant therapy and these patients should be fully evaluated regardless of their anticoagulation.

Once a UTI has been excluded, the initial investigations for patients with non-visible haematuria, both symptomatic and asymptomatic are:

·      A blood test for FBC and renal function tests

·      A urine test for ACR

·      a BP check

·      and we will consider an INR if the patient is on anticoagulants and a PSA, a further MSU and an USS if clinically indicated

And then we will consider whether referral is necessary, But, Who should patients be referred to?

Well, a urological cause is more likely in patients with:

·      Visible haematuria

·      Symptomatic non-visible haematuria, whatever their age

·      And asymptomatic non visible haematuria if they are aged 40 or over, although the age threshold will vary depending on the guideline that you look at.

So, in all these cases, initial referral to urology is recommended.

Younger patients, generally under 40 or 45 years of age with asymptomatic non-visible haematuria are more likely to have a renal cause. Nephrology referral is not always necessary unless performing a renal biopsy is going to be justified. So, the risk factors that should definitely trigger a nephrology referral with a view to renal biopsy are:

·      Proteinuria with an ACR ≥30 mg/mmol or a PCR ≥50 mg/mmol

·      An eGFR <60 ml/min

·      Or Hypertension, i.e. BP >140/90

There are a few Primary Care guidelines governing non-visible haematuria and I have reviewed the South-East London haematuria guideline as well as the North and Central London haematuria pathway. They both cover this area very clearly and you can find the links to them in the episode description. These pathways cover both visible and non-visible haematuria but, here I have only summarised non- visible haematuria section of the pathway. I have combined them creating a streamlined pathway so that it is clear from a Primary perspective. You can also find a link to download this summary in the episode description.

So, let’s have a look at it:

Right, so we start with checking the urine dipstick. And we find that there is non-visible haematuria. Then we ask ourselves, has the patient got symptoms? and if they do, we will ask ourselves, do we suspect a UTI? And if the answer is yes, we will treat it and recheck the urine dipstick after the antibiotics. If there is no UTI, we will then investigate with a blood test for a full blood count and renal function tests, a urine test for ACR and we will check the blood pressure.  We will also consider an INR if the patient is on anticoagulants and a PSA, a repeat MSU and an ultrasound scan. if clinically indicated. And after that, we will ask ourselves, is the patient over 60, with dysuria or a raised white blood cell count on a full blood count? And if the answer is yes, then they would meet the cancer referral criteria so we would make an urgent Cancer referral to urology. If the answer is no, this is where some of the guidance varies. Some guidelines will say that we can just monitor these patients in primary care, but others will recommend referral. So, on this occasion, I have taken the conservative approach and recommend that we should refer the patient or at the very least, seek specialist advice. And then we will look at the patient’s age, and again, the age threshold can also vary depending on the guideline that you consult. But generally, if the patient is over 45, we will do a routine urology referral because urological causes would be more common in this age group And conversely, if the patient is under 45, it would be a routine nephrology referral and we will make this referral, especially if the investigations show abnormalities like, for example, an eGFR below 60, an ACR of 30 or more, a PCR of 50 or more or if the blood pressure is higher than 140/90.

Now, if we go back up to the beginning and we find that the patient has non-visible haematuria but does not have any symptoms. Then we will need to repeat the test to confirm it and we will do so for up to 3 occasions. We will then ask ourselves if at least two out of three dipstick tests have come back positive. And, if the answer is yes, then we will investigate and rejoin the pathway that we have just explored. If the answer is no, as precaution we will check for proteinuria and we will check the patient’s ACR. If the ACR is normal then we can reassure the patient and stop here. But if the ACR is high, then we will investigate the patient with the standard investigations already mentioned and, following a conservative approach, we would consider seeking specialist advice or refer the patient.

If you have any doubts, here at the bottom you have the links to the original pathways that I have consulted to create this one.  

Finally, Patients with persistent non visible haematuria not meeting criteria for referral, or who have been referred and have had normal investigations, will need long term monitoring, usually in Primary Care, due to the uncertainty of the underlying diagnosis. Patients should be monitored for the development of:

·      Symptoms

·      Visible haematuria

·      Significant or increasing proteinuria

·      Progressive renal impairment with a falling eGFR and

·      Hypertension

So, the NICE guideline on CKD says that annual follow-up of these patients should continue for as long as the non-visible haematuria persists and it should include:

·      repeat dipstick testing for haematuria

·      Review of symptoms

·      A blood test to check renal function and eGFR

·      A urine test for ACR and

·      A Blood pressure check

Referral or re-referral to urology will be needed if the patient develops at any stage either:

·      Visible haematuria or

·      Symptomatic non-visible haematuria

And nephrology referral will be needed if there is:

·      Deteriorating renal function (that is, a drop in eGFR >5 ml/min within previous year or >10 ml/min within past five years)

·      CKD stage 4 or 5 (that is, when the eGFR is <30 ml/min)

·      Or if there is Proteinuria with ACR ≥30 mg/mmol or PCR ≥50 mg/mmol

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

Podcast description 

The video version of this podcast can be found here:

https://youtu.be/IaId_nNbO-c?si=0FF7A5J7iPxocdBd

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. 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 go through the interpretation of an abnormal 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 information consulted. You must always use your clinical judgement.   

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: 

• The Practical GP YouTube Channel: 

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)

Southeast London pathway:

·      Microsoft Word - Abnormal liver function test pathway-explanatory.docx (selondonccg.nhs.uk)

North and East Devon pathway:

·      Management of Abnormal LFTs in Asymptomatic Adults - North & East (devonformularyguidance.nhs.uk)

North Bristol

·      https://www.nbt.nhs.uk/sites/default/files/Investigation%20of%20Adult%20Patients%20with%20Abnormal%20LFT%20in%20Primary%20Care.pdf

West Hampshire:

·      Liver Blood Test Pathway | GP Portal (westhampshireccg.nhs.uk)

Medscape:

·      Liver Blood Tests: How to Interpret Abnormal Results (medscape.co.uk)

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

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 of abnormal liver function tests or LFTs, including initial follow up management, always focusing on what is relevant in Primary Care only.

And for that I will summarise the British Society of Gastroenterology guidelines on LFTs. They were first published in the BMJ and the relevant links are in the episode description. Although the full guideline covers both adults and children, in today’s episode I will be focusing only on adults. 

At the end, I will also tell you how to access my summary of the recommendations, which will be based not only on the BSG but also on a number of NHS bodies in the UK. The links to them are in the episode description and it’s worth having a look as they have flowcharts and other information that you may find useful. 

Right, there is a lot of information to cover, so let’s jump into it.

The three the most common causes of liver disease are alcohol-related liver disease, non-alcoholic fatty liver disease and viral hepatitis, although autoimmune liver disease is also a significant cause.

Liver disease develops silently and at earlier stages liver enzymes may be normal. If they are high, the degree of abnormality is not necessarily related to the severity of the underlying condition and this is why many patients are not diagnosed until they have developed significant liver fibrosis.

In many cases if used in isolation, LFTs are neither very specific or sensitive and they are better at assessing liver fibrosis if incorporated into algorithms or ratios.

What constitute LFTs? Well, the LFTs standard panel can vary from hospital to hospital. Although we call them LFTs, not all the tests assess liver function. For example, high liver enzymes point towards liver injury; bilirubin, albumin and INR give information on liver function, while platelets can give information on the level of liver fibrosis.

So, let’s have a look at a number of these tests.

Bilirubin is the by-product of the breakdown of haemoglobin. It exists in two forms, unconjugated and conjugated. Bilirubin is transported to the liver as unconjugated bilirubin, where it is converted into conjugated bilirubin. A high unconjugated level is usually due to haemolysis or impaired conjugation whereas a high conjugated level is typically due to liver disease or biliary obstruction.

Many path labs will routinely report just total bilirubin, but they will give a breakdown if the level is abnormal or if specifically requested.

In normal circumstances, the majority of bilirubin should be conjugated. So, if the majority of the bilirubin is unconjugated, then, in the absence of haemolysis, the cause is almost always Gilbert’s syndrome where the enzyme that conjugates bilirubin has a reduced activity with a consequent rise in unconjugated bilirubin. it is not associated with liver disease or ill health, so patients should be fully reassured.

Albumin is a protein that is produced only in the liver and because of this, it is often considered as a marker of liver function. However, albumin can also be reduced in for example, sepsis, inflammatory disorders, and malabsorption.

Prothrombin time (PT) and INR can also be used to measure liver function, as the underlying clotting factors are made in the liver. Therefore, a high PT and INR can indicate liver dysfunction but it can also be caused by vitamin K deficiency as seen in fat malabsorption and chronic cholestasis.

A reduction in platelets, or thrombocytopenia, is an indicator of advanced liver disease. A low platelet count is caused by decreased production due to bone marrow suppression, splenic sequestration due to portal hypertension and increased platelet destruction due to shear stress, and fibrinolysis in liver cirrhosis or due to antiplatelet antibodies in autoimmune liver disease.

Alkaline phosphatase (ALP) is produced mainly in the liver but is also found in bone, intestines, kidneys and placenta. Levels are physiologically higher in childhood, because of bone growth, and in pregnancy due to placental production. High levels cab be due to bone disease (e.g., bone metastases and fractures) and cholestatic liver disease (like for example, in biliary obstruction).

γ-Glutamyltransferase (or GGT) is present in the liver but not in bone and therefore when the ALP s high, the measurement of GGT can indicate whether the ALP is of hepatic or non-hepatic origin. The most likely cause of a non-hepatic high ALP in someone asymptomatic is vitamin D deficiency. A high GGT can als be due to obesity, excess alcohol or drugs.

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 advanced fibrosis. Although AST and ALT can be normal even in liver disease, the high AST:ALT ratio generally persists even if both values are normal.

When should LFTs be checked? We should do so when there are:

·      Non-specific symptoms such as fatigue, nausea or anorexia.

·      Symptoms or signs of advanced liver disease, like ascites, peripheral oedema, spider naevi and hepatosplenomegaly. In these cases, checking the INR would also help assess the synthetic liver function.

·      Conditions which are associated with liver disease like autoimmune diseases, and inflammatory bowel disease.

·      Hepatotoxic drugs like for example carbamazepine, macrolide antibiotics, statins, terbinafine, and methotrexate. And although statins can lead to drug-induced liver injury, this is very rare, and they are generally safe in patients with raised liver transaminase levels if they are less than 3 times the upper limit of normal.

·      Family history of liver diseases such as haemochromatosis or Wilson’s disease.

·      Suspected alcohol-related liver disease. And

·      Suspected viral hepatitis.

So, what should we do when confronted by abnormal LFTs?

We often think that the extent of abnormality of the LFTs correlates with the severity, of the problem. However, this assumption is not supported by the evidence. Common conditions leading to chronic liver disease like NAFLD, and hepatitis C are frequently associated with only mild or moderate LFT abnormalities.

There is also the assumption that the duration of the abnormal LFTs is a reflection of clinical significance, so we often keep repeating the LFTs hoping that they will improve. And although LFTs can occasionally be high due to intercurrent illness, studies have shown that the vast majority still have abnormal LFTs after 2 years and therefore a strategy of simply repeating them can rarely be justified. Besides, 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.

This has led to the BSG to recommend that patients with abnormal LFTs should have a full liver screen irrespective of level and duration of the abnormality.

And before moving on, let’s remember that there are three common patterns of abnormal LFTs:

1.     An Isolated raised bilirubin with otherwise normal liver tests

2.     A Cholestatic pattern: Normally showing a high ALP and GGT And

3.     A Hepatitic pattern: with a raised ALT and AST indicating hepatocellular injury, like, for example, viral hepatitis, NAFLD, and ARLD.

The BSG has produced a flowchart to guide us through the process. You can access it in the episode description.

But, in summary, 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 there is an isolated raised bilirubin but no clinical concerns, then:

1.     We should request a FBC and repeat the LFTs on a fasting sample requesting the breakdown of conjugated and unconjugated bilirubin.

2.     Fasting causes the unconjugated bilirubin to rise further in Gilbert’s syndrome so this is the likely diagnosis when this happens and there is no evidence of haemolysis, like anaemia.

3.     If there is associated anaemia, we will have to consider haemolysis and we will request a reticulocyte count and LDH.

If the pattern is cholestatic or hepatitic we will do a 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.

If the patient has a cholestatic picture and the liver screen shows abnormalities or if the ALP and GGT remain high even in the context of normal investigations, we will refer the patient to secondary care.

If the patient has a hepatitic picture with a high ALT and AST, studies have shown that the majority will have NAFLD or ARLD and most will not need referral, but lifestyle advice and monitoring in primary care. The deciding factor is the level of liver fibrosis, which we can estimate using non-invasive fibrosis markers.

The BSG has also produced a specific flowchart for when NAFLD is suspected following a liver USS. You can also access it in the episode description.

In summary, it says that for patients with NAFLD or liver disease of unknown cause, the next step is to estimate the risk of fibrosis using the FIB4 or NAFLD fibrosis score.

Values <1.3 and ≤-1.455, respectively, represent a low risk of advanced fibrosis. Higher cut-off points, <2.0 and <0.12 respectively, should be used for patients over 65. In these cases, we will just manage the risk factors in Primary Care and reassess periodically, generally every 2 to 5 years.

FIB4 or NAFLD fibrosis score values >1.3 and >-1.455, respectively, should have second-line tests such as an enhanced liver fibrosis blood test, also known as an ELF tests or imaging such as a FibroScan or elastography.

However, patients with a very high FIB-4 score >3.25 or a NFS >0.675 should be referred without waiting to do an ELF test, Fibroscan or elastography.

Those with intermediate FIB-4 score (that is between 1.3 and 3.25) or NFS (that is, between -1.455 and 0.625), should have an ELF test or a Fibroscan. If the result is 9.5 or less or 7.8 or less respectively, we will manage them in primary care and we will refer if the result is above those limits

In primary care, the treatment for NAFLD is weight loss, alcohol advice, the reduction of cardiovascular risk and the management of co-morbidities.

Next, the BSG has also produced a specific flowchart to guide us if ARLD is suspected. I have also put a link to it in the episode description.

And in summary, those drinking ≥35 units/week for women and ≥50 units/week for men, will need referral to both alcohol services and hepatology for further assessment with a Fibroscan or elastography. For all other patients, the AUDIT C questionnaire alongside brief intervention is recommended initially. If the AUDIT C is 5 or more, we will need to give them the full AUDIT questionnaire.

For patients with an AUDIT score of >19, we will also need to refer them to both alcohol services and hepatology for further assessment with a Fibroscan or elastography. For those with an AUDIT score of between 8 and 19 we should check the GGT and if it is >100 we should refer them as for the higher-risk group. Otherwise, we could monitor them and refer to alcohol services if excessive drinking persists.

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 flowchart. As I mentioned earlier, we should follow it for patients with NAFLD or liver disease of unknown cause.

Well, this is the end of the BSG guideline itself. I have created a quick reference guide which contain the various BSG flowcharts as well as information found in the NHS pathways from Southeast London, North and East Devon, North Bristol, and West Hampshire. Links to their information and flowcharts are in the episode description. They all had similar advice to the BSG guideline but there were also some other elements which would be useful from a practical perspective. Where there was a discrepancy between their guidance, I have generally opted for the most conservative approach. If you are in any doubt, please consult the original guidance or seek local specialist advice. You will be able to find a link to download my summary in the episode description.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/2scjC_NoKfc

This episode makes reference to guidelines produced for the Maidstone and Tunbridge Wells NHS Trust, and NHS Greater Glasgow and Clyde. 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 go through the guidance on hypercalcaemia produced by the Maidstone and Tunbridge Wells NHS Trust, and the guidance in NHS Greater Glasgow and Clyde, always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this episode is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

●      Apple podcast: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

●      Spotify: https://open.spotify.com/show/2kmGZkt1ssZ9Ei8n8mMaE0?si=9d30d1993449494e

●      Amazon Music: https://music.amazon.co.uk/podcasts/0edb5fd8-affb-4c5a-9a6d-6962c1b7f0a1/primary-care-guidelines?ref=dm_sh_NnjF2h4UuQxyX0X3Lb3WQtR5P

●      Google Podcast: https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5yZWRjaXJjbGUuY29tLzI1ODdhZDc4LTc3MzAtNDhmNi04OTRlLWYxZjQxNzhlMzdjMw%3D%3D

●      Redcircle: https://redcircle.com/shows/2587ad78-7730-48f6-894e-f1f4178e37c3

There is a YouTube version of this and other videos that you can access here: 

●       The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

The guidance on the treatment of hypercalcaemia in adults by the Maidstone and Tunbridge Wells NHS Trust can be found here:

·      https://www.formularywkccgmtw.co.uk/media/1629/treatment-of-acute-hypercalcaemia-in-adults.pdf

The guidance on the management of hypercalcaemia by the Adult Therapeutics Handbook for the NHS Greater Glasgow and Clyde can be found here:

·      https://handbook.ggcmedicines.org.uk/guidelines/electrolyte-disturbances/management-of-hypercalcaemia/

Other guidance can be found here:

Joshi D, Center JR, Eisman JA. Investigation of incidental hypercalcaemia. BMJ. 2009;339:b4613

·       http://www.ncbi.nlm.nih.gov/pubmed/19933303

Carroll MF, Schade DS. A practical approach to hypercalcemia. Am Fam Physician. 2003;67(9):1959-66

·      http://www.ncbi.nlm.nih.gov/pubmed/12751658

Smellie WS et al. Best practice in primary care pathology: review 11. J Clin Pathol. 2008;61(4):410-8

·      http://www.ncbi.nlm.nih.gov/pubmed/17965216

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

●       Music provided by Audio Library Plus 

●       Watch: https://youtu.be/aBGk6aJM3IU 

●       Free Download / Stream: https://alplus.io/halfway-through 

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 guidance on hypercalcaemia produced by the Maidstone and Tunbridge Wells NHS Trust, as well as other general guidance on the subject, always focusing on what is relevant in Primary Care only. The links to the information consulted can be found in the episode description.

Right, let’s not waste any more time so let’s jump into it.

Before we start, let’s quickly have an overview of calcium metabolism.

Calcium is one of the most abundant electrolytes in the body, and levels are tightly controlled by parathyroid hormone and vitamin D. Serum calcium is bound to albumin, and measurements should be adjusted for it, so we should be primarily concerned about corrected calcium levels.

Calcium is mostly absorbed in the small intestine and active vitamin D (or calcitriol) enhances calcium absorption.

Parathyroid Hormone (or PTH) is also important. When blood calcium levels drop, PTH is secreted, which enhances calcium reabsorption in the kidneys, and also stimulates osteoclasts in the bones, breaking down bone tissue and releasing calcium into the blood stream. This is precisely the opposite effect of calcitonin, which inhibits osteoclast and reduces bone resorption and calcium levels.

So, from a pathophysiological perspective, a high calcium or hypercalcemia can be seen in, for example, hyperparathyroidism, malignancy, or excessive vitamin D intake.

There are also pathophysiological interactions between calcium and levels of phosphate and magnesium.

For example, a high calcium can suppress magnesium renal absorption, leading to hypomagnesaemia. Equally, a high calcium also often leads to a low phosphate due to its effect on PTH.

Right, having had this overview, let’s now have a look at hypercalcaemia itself. It is generally defined as a corrected calcium level greater than 2.6 on two occasions, although we will need to take into account our local path lab reference range.

About 90% of cases are due to either primary hyperparathyroidism or malignancy.

Other rarer causes of hypercalcaemia include:

·      Chronic granulomatous diseases like sarcoidosis or pulmonary Tb

·      Paget's disease with bed rest

·      Immobilisation

·      Vitamin A and/or vitamin D toxicity

·      Drugs like thiazide diuretics and lithium

·      Familial hypocalciuric hypercalcaemia

·      Non-parathyroid endocrine diseases (e.g. thyrotoxicosis, Addison's disease, and phaeochromocytoma) 

·      Milk-alkali syndrome 

·      Chronic kidney disease and

·      Tertiary hyperparathyroidism. By the way, if you want to know more about tertiary hyperparathyroidism, stay until the end because I will give you a brief pathophysiological explanation of it. 

The possible sign and symptoms of hypercalcaemia are often summarised by "stones, bones, thrones, abdominal groans and psychiatric overtones". Let’s see where these come from:

·      "Stones" refer to kidney stones.

·      "Bones" refer to skeletal symptoms such as bone pain, osteoporosis, and fractures associated with underlying bone disorders like in hyperparathyroidism or pathological fractures in malignancy. 

·      "Thrones" refers to polyuria and constipation

·      "Abdominal groans" refer to gastrointestinal symptoms such as nausea, vomiting, anorexia, weight loss, abdominal pain, pancreatitis and peptic ulcer. By the way, peptic ulcers can be an effect of increased gastric acid secretion caused by hypercalcemia.

·      "Psychiatric overtones" refer to effects on the central nervous system such as lethargy, fatigue, depression, confusion, irritability, memory loss, psychosis, ataxia, delirium, and coma.

·      Other: obviously this list of symptoms is not exhaustive. There are others not included, such as flushing, itching and cardiovascular complications, like hypertension, cardiac conduction abnormalities and arrhythmias. 

In general, hypercalcaemia can be classified as:

mild – if corrected calcium levels are between 2.6 – 3.00 mmol/l. It is often asymptomatic and does not usually require urgent correction.

moderate – if between 3.00 – 3.40 mmol/l and it may be well tolerated if it has risen slowly, but it may also be symptomatic and require prompt treatment and

severe – if it is more than 3.40 mmol/l, which requires urgent correction due to the risk of dysrhythmia and coma. The most common cause of severe hypercalcaemia is malignancy.

What initial investigations should we consider in Primary Care for a patient with a high corrected calcium? I am obviously referring to mild hypercalcaemia, given that the more severe cases we will be referring to secondary care for immediate management.

So, as investigations, we should organise Blood Tests in order to check:

·      An FBC

·      Renal function tests, as hypercalcemia can cause renal impairment.

·      Sodium and potassium to assess for electrolyte imbalances that may coexist.

·      To check a repeat corrected calcium to ensure it is not a lab error.

·      Also to check phosphate levels. and

·      Alkaline phosphatase which may suggest bone involvement, such as in malignancy or Paget’s disease.

·      Also to test for Vitamin D levels to assess for vitamin D intoxication or deficiency.

·      To check magnesium levels: As magnesium abnormalities, usually hypomagnesaemia can also be associated to hypercalcaemia.

·      To measure PTH to determine whether the hypercalcaemia is PTH-dependent or PTH-independent. For example,

o  A low PTH in the context of hypercalcaemia suggests a non-PTH-mediated cause, such as malignancy, excess vitamin D, granulomatous disease, or drug-induced causes. On the other hand,

o  A high or normal PTH in the context of hypercalcaemia suggests primary or tertiary hyperparathyroidism or familial hypocalciuric hypercalcemia (FHH). Please note that Familial hypocalciuric hypercalcemia has an inappropriately normal or elevated PTH because the calcium-sensing receptors in the parathyroids glands are less sensitive due to genetic reasons and this tricks the body into believing that the calcium levels are lower than they are.

·      The blood test is also to check thyroid function tests given that hyperthyroidism can also cause hypercalcaemia and we should also

·      Check serum protein electrophoresis if multiple myeloma is suspected.

We should consider additional tests depending on the clinical context such as:

·      A Chest X-ray to screen for granulomatous disease, TB or malignancy

·      An ECG to look for shortened QT intervals or other conduction abnormalities

·      A 24-hour urinary calcium excretion if we need to differentiate between primary hyperparathyroidism and familial hypocalciuric hypercalcemia, which has a low urinary calcium and a

·      Serum cortisol if Addison’s disease is suspected

In terms of treatment, we should get specialist advice and treat the underlying cause.

We should consider:

·      Immediate referral or same day hospital admission in cases of severe hypercalcaemia, that is, with a corrected calcium >3.4 mmol/L. We should also do so, regardless of the level of hypercalcaemia, for symptomatic patients, if there is a suspicion of a serious underlying condition, such as malignancy or a parathyroid crisis, or if there is worsening renal function.

·      Non-urgent outpatient referral would be reserved for patients with mild hypercalcaemia, that is, a corrected calcium less than 3, as long as they are asymptomatic and otherwise stable. We should carefully monitor calcium, renal function, and other relevant tests while awaiting secondary care input. And finally, what do we do with patients with moderate hypercalcaemia? Well,

·      From a primary care perspective, the management of patients with moderate hypercalcaemia, that is, levels between 3.00 and 3.40 mmol/L, is controversial but, in general, it may also be safer to err on the side of caution, and many guidelines recommend immediate hospital referral in these cases too.

Other obvious measures that we should instigate in Primary Care would be to stop drugs associated with hypercalcaemia, such as thiazide diuretics, encourage hydration and, if possible, avoid immobilisation.

I will not indulge in secondary care treatment as this is outside our hands, but one of the limitations is that there are no national guidelines for the management of hyerpcalcaemia, and practice varies widely across UK Hospitals. The acute management in secondary care generally involves:

·      Rehydration:

·      And then assess if IV bisphosphonates such as pamidronate or zolendronic acid are required, followed by the definitive treatment of the underlying cause, like, for example, parathyroidectomy in primary hyperparathyroidism.

Now, as promised, I am going to tell you more about tertiary hyperparathyroidism.

And before I can explain tertiary hyperparathyroidism, we probably need to go through the definitions of primary and secondary hyperparathyroidism first.

Primary hyperparathyroidism is when the parathyroid glands produce excessive amounts of parathyroid hormone (or PTH) without any external trigger, that is, it is an intrinsic problem within the parathyroid glands and the most common cause is a benign tumour or adenoma.

In Secondary hyperparathyroidism, the parathyroid glands overproduce PTH as a compensatory response to low calcium levels in the blood and it is the body's attempt to normalise calcium levels.  Possible causes of secondary hyperparathyroidism are chronic kidney disease and vitamin D deficiency.

And, finally, tertiary hyperparathyroidism involves the autonomous overproduction of PTH due to hyperplastic parathyroid glands that no longer respond to normal regulatory feedback, generally seen after prolonged secondary hyperparathyroidism in patients with CKD.

Let’s quickly examine the pathophysiology of tertiary hyperparathyroidism:

In CKD, the kidneys lose their ability to excrete phosphate, leading to hyperphosphatemia.

In CKD, the kidneys also produce less active vitamin D, resulting in decreased calcium absorption and hypocalcemia.

Both hypocalcemia and hyperphosphatemia stimulate the parathyroid glands to produce more PTH to maintain calcium levels. This is the secondary hyperparathyroidism stage.

However, over time, the continuous stimulation of the parathyroid glands leads to glandular hyperplasia and, as hyperplasia progresses, the parathyroid glands become less responsive to normal feedback mechanisms.

So, in some patients, particularly in those after prolonged and severe secondary hyperparathyroidism, the parathyroid glands can become autonomous, meaning they secrete PTH independently of blood calcium levels. At this stage, even when the initial cause of secondary hyperparathyroidism is corrected (e.g., after a kidney transplant), the overactive parathyroid glands continue to produce excessive PTH which will lead to hypercalcemia. This is when we talk about tertiary hyperparathyroidism.

So that is it, a quick review of the different types of hyperparathyroidism.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here: https://youtu.be/XZxllA7iSIk?si=2d9kxQLJOY6ER0iu

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.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through new and updated guidelines published during 2023 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.  

The Clinic BP targets flowchart can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFp2iUfq8rimJSmo?e=BnJaCD

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

The Full NICE News bulletin for January 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-02-01&to=2024-02-29&ndt=Guidance&ndt=Quality+standard

The links to the update guidance covered can be found here:

The guidance on chronic heart failure in adults can be found here:

·      https://www.nice.org.uk/guidance/qs9

The guidance on UTI in adults can be found here:

·      https://www.nice.org.uk/guidance/qs90

The guidance on Type 1 diabetes in adults can be found here:

·      https://www.nice.org.uk/guidance/qs208

The guidance on Type 2 diabetes in adults can be found here:

·      https://www.nice.org.uk/guidance/qs209

The full NICE guideline on “Hypertension in pregnancy: diagnosis and management” can be found here:

·      https://www.nice.org.uk/guidance/ng133

Dapagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction:

·      https://www.nice.org.uk/guidance/ta902

Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction:

·      https://www.nice.org.uk/guidance/ta929

Obesity in adults: identification, assessment and management

·      https://www.nice.org.uk/guidance/cg189

Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care

·      https://www.nice.org.uk/guidance/dg56

Joint guidelines from ACPGBI and BSG can be found at: 

·      https://www.acpgbi.org.uk/resources/1075/fit_in_patients_with_signs_or_symptoms_of_suspected_crc_a_joint_guideline_from_acpgbi_and_bsg 

Chronic obstructive pulmonary disease in adults: quality standard

·      https://www.nice.org.uk/guidance/qs10

Rimegepant for treating migraine: 

·      https://www.nice.org.uk/guidance/ta919

Transient loss of consciousness ('blackouts') in over 16s:

·      https://www.nice.org.uk/guidance/cg109

Bipolar disorder: assessment and management:

·      https://www.nice.org.uk/guidance/cg185

Cardiovascular disease: risk assessment and reduction, including lipid modification:

·      https://www.nice.org.uk/guidance/ng238 

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 am Fernando, a GP in the UK. Today, as usual, I intended to do the usual monthly review of the NICE updates published in February 2024, focusing on what is relevant in Primary Care only. But, surprisingly and for the first time since I started doing these monthly updates, I have not found any new information relevant to General Practice. 

So, instead, we are going to do an overview of what I think were some of the most relevant updates published in the whole of 2023.  

Right, so let’s jump into it. 

In January 2023 

There were updated quality statements on chronic heart failure in adults. They say that: 

1.   If we suspect HF, we will check the BNP levels.

2.   If the result if high, we will organise an echocardiogram

3.   If the echo confirms heart failure with reduced ejection fraction, we will give optimal doses of an ACE inhibitor or ARBs and a beta-blocker. If clinically indicated, we will also give a mineralocorticoid receptor antagonist like spironolactone, an SGLT2 inhibitor, like dapagliflozin or empagliflozin, and refer for other specialist drugs if necessary.

4.   And We will review patients with heart failure within 2 weeks of any medication change and at least every 6 months thereafter.  

In February 2023

There were new quality statements on UTI saying that

1.   We can diagnose women under 65 with a UTI without having to do a urine dipstick as long as they have at least 2 key urinary symptoms.

2.   Equally, we can also diagnose catheterised patients with a UTI based on symptoms without needing a urine dipstick.

3.   Three, We will give a 3-day course of antibiotics to non-pregnant women with an uncomplicated lower UTIs, but a 7-day course to men and pregnant women with the same. And

4.   Four, We will refer patients with recurrent symptoms.

In March 2023

There were changes in the diabetes quality statements saying that:

·      We should offer continuous glucose monitoring to patients with type 1 diabetes and also to those with insulin-treated type 2 diabetes if they cannot self-monitor independently

·      Also that Adults with type 1 diabetes aged 40 and over should be offered a statin and

·      That Adults with type 2 diabetes should have an SGLT2 inhibitor if they have chronic heart failure, CVD or CKD

In April 2023

There was an update in the guideline on Chronic Hypertension in Pregnancy, and we must make sure that:

·      We refer them appropriately

·      We stop ACE inhibitors, ARBs and thiazide or thiazide-like diuretics as soon as we know that they are pregnant or planning a pregnancy because of the teratogenic potential

·      We will start treatment if the BP> 140/90 mmHg, using a target BP of 135/85 mmHg.

·      As treatment, we will give labetalol first line, then nifedipine if labetalol is not suitable, and then methyldopa if both labetalol and nifedipine are not suitable.

·      And from 12 weeks’ gestation we will also offer aspirin between 75 and 150 mg daily.

This is for Chronic Hypertension in Pregnancy, that is, a hypertensive woman that gets pregnant. The management of Gestational Hypertension, that is, a woman that becomes hypertensive during pregnancy should be led by secondary care because of the risk of preeclampsia.

In the Postnatal Period if the woman is breastfeeding, we will give Enalapril unless the patient is of black African or Caribbean family origin when we will give Nifedipine or amlodipine.

If one drug is not enough, a combination of enalapril with nifedipine or amlodipine can be considered. And if this combination is not suitable, atenolol or labetalol can be added.

We will avoid diuretics and ARBs if the woman breastfeeding or expressing milk but, if not breastfeeding, there are no special considerations and we will just follow the normal hypertension guideline.

In May 2023

NICE started recommending QRISK3 instead of QRISK2 to estimate the CVD risk.

For primary prevention we will give atorvastatin 20 mg daily if the 10‑year CV risk is 10% or higher but we will also give it at lower levels based on our clinical judgement. For secondary prevention it is atorvastatin 80 mg daily.

If a statin is given, we will check lipids and LFTs at 2 to 3 months. After that, we will check LFTS at 12 months, but not again unless clinically indicated. An annual full lipid profile is recommended long term as part of a medication review.

Further CV recommendations were made in December 2023 in respect of lipid targets.

The target for primary prevention is a greater than 40% reduction in non-HDL cholesterol. 

For secondary prevention, the target is an LDL of 2.0 or less, or a non-HDL cholesterol of 2.6 or less. If the target is not met with the statin alone, we should consider additional lipid-lowering treatments with ezetimibe or the injectables alirocumab, evolocumab and inclisiran. We can also consider ezetimibe in addition to statins, even if the lipid target is met, because studies have shown that the combination reduces CV events regardless of cholesterol levels.

In June 2023

Dapagliflozin was recommended for heart failure with preserved ejection fraction. It was already recommended for heart failure with reduced ejection fraction because it reduces cardiovascular deaths and hospitalisations for heart failure.

Heart failure with preserved ejection fraction is managed by treating other comorbidities and giving loop diuretics, which help with symptoms, but do not reduce mortality or morbidity.

Assumptions were made between the two types of heart failure and dapagliflozin is now recommended in all types for heart failure.

Additionally, later in November 2023 the same approach was taken with empagliflozin so both dapagliflozin and empagliflozin are now recommended for all types of heart failure.

In July 2023

The guideline on obesity was updated.

We will refer for bariatric surgery if they:

·      have a BMI of 40 or more, or over 35 with a significant comorbidity

·      The BMI threshold is reduced by 2.5 for South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background because of their higher cardiovascular risk at a lower BMI.

There are three approved medicines for obesity. Liraglutide and semaglutide can only be prescribed for obesity by secondary care and orlistat, which can also be prescribed in primary care.

We can give Orlistat if the BMI is 30 or more or 28 or more with associated risk factors. It should be continued beyond 3 months only if the person has lost at least 5% of their initial body weight but we can be flexible, especially with people with type 2 diabetes.

In August 2023

The guideline on suspected colorectal cancer was updated and it now recommends FIT tests in some clinical situations where before a two-week rule cancer referral would have been recommended. FIT tests are now recommended in adults:

·      with an abdominal mass,

·      with a change in bowel habit,

·      with iron-deficiency anaemia,

·      aged 40 and over with unexplained weight loss and abdominal pain,

·      aged under 50 with rectal bleeding and one other symptom, either:

o  abdominal pain or

o  weight loss,

·      aged 50 and over with just one symptom, either:

o  rectal bleeding

o  abdominal pain or

o  weight loss,

·      and lastly, those aged 60 and over with anaemia even in the absence of iron deficiency

If we get a negative result, we will provide safety netting, which may include:

·      a “watch and wait” approach or

·      offering further tests, including another FIT test or referral, especially if we are concerned because of unexplained symptoms

In September 2023

NICE updated the COPD quality standards and we will now refer patients for pulmonary rehabilitation if they have a score of 3 or above on the MRC dyspnoea scale, which means that they 'walk slower than contemporaries on level ground because of breathlessness, or have to stop for breath when walking at own pace'

In October 2023

NICE recommended a new migraine medication, Rimegepant but only if:

·      at least 2 triptans have been tried before but were ineffective or

·      if triptans cannot be used, and Paracetamol and NSAIDs are not effective.

What is Rimegepant?

Well, gepants are a new class of drugs that have been developed specifically for the treatment of migraines. Although the mechanism of action is not fully understood, we know that it blocks a receptor involved in the development of migraines. 

Unlike triptans, gepants do not cause vasoconstriction so they do not have the same cardiovascular contraindications and cautions as triptans. Rimegepant is an oral lyophilisate that should be placed on the tongue or under the tongue and it will disintegrate in the mouth and can therefore be taken without liquid.

In November 2023

NICE changed the postural hypotension recommendations. In summary we will check the BP in the supine or lying down position and then we will recheck the standing BP after at least 1 minute of the patient standing. This is better than the sitting to standing measurements. 

If the systolic blood pressure falls by 20 mmHg or more, or diastolic blood pressure falls by 10 mmHg or more when standing, then we will diagnose postural hypotension.  

We should check for postural hypotension in people:

·      With symptoms such as falls or postural dizziness as well as people

·      With type 2 diabetes and those

·      Aged 80 or over

And if there is a significant postural drop, we will treat to a blood pressure target based on standing blood pressure. 

In November 2023  

NICE produced two tables to clarify the blood pressure targets. 

And there are 2 tables, one for the under 80s and one for those aged 80 and over. And these tables cover people with hypertension with or without type 2 diabetes as well as people with CKD or type 1 diabetes.  

In order to keep it simple, I created a flowchart which merges both tables into one document. 

So, in the under 80s we have two targets: 

·      The first target is Below 140/90:

o  for those with Hypertension, with or without type 2 diabetes

o  and for those with Type 1 diabetes or CKD and an ACR less than 70

·      The second target is Below 130/80 for those with

o  Type 1 diabetes or CKD and ACR of 70 or more  

And, in those aged 80 and over, we have three targets: 

·      The first target is Below 150/90 for those with:

o  Hypertension, with or without type 1 or 2 diabetes regardless of ACR levels.

·      Then the second target is Below 140/90 for those with:

o  CKD and ACR less than 70 and finally the third target

·      Of Below 130/80 for those with

o  CKD and ACR of 70 or more 

You can find links to this flowchart or the tables produced by NICE in the episode description  

And finally, In December 2023

NICE updated guidelines to incorporate new MHRA guidance on valproate. This new guidance states that valproate must not be started in people (either male or female) under 55 years of age, unless 2 specialists independently consider that there is no other treatment, or that the reproductive risks do not apply.

This is because of various reasons:

·      One, Valproate is a known teratogenic drug, and therefore it is never safe in pregnancy.

·      Two, There are risks of male infertility and testicular toxicity with it and

·      There are also concerns about possible transgenerational risks because animal studies have shown that some behavioural changes are transmitted by both males and females exposed to valproate in the second and third generations.  

Well, that is it, a nice summary of last year.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this episode can be found here:

• https://youtu.be/t-wXLOAr8ik?si=TR3eNXpNPlBP3NCs

My summary of the guidance consulted can be found here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84

This episode refers to guidelines produced by a number of organisations. Please note that the content 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 go through the interpretation of an abnormal full blood count, 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 information consulted. You must always use your clinical judgement.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

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

·      Medscape / Kevin Fernando- management of abnormal blood tests: https://1drv.ms/b/s!AiVFJ_Uoigq0mQPPwvFNZtsUSpIr?e=xYthDn

·      Oxford hospital referral pathway: https://nssg.oxford-haematology.org.uk/general-haematology/documents/general-haematology/raised-haematocrit.pdf

·      GP notebook: https://gpnotebook.com/en-GB/pages/general-information/abnormal-fbc-in-adults

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Music provided by Audio Library Plus 

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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 of full blood counts, including follow up management, always focusing on what is relevant in Primary Care only.

I will be covering several areas:

1.   Review of haematological indices

2.   Polycythaemia

3.   Anaemia

4.   Thrombocytosis

5.   Thrombocytopenia

6.   Neutrophilia

7.   Neutropenia

8.   Lymphocytosis

9.   Lymphopenia

10. Eosinophilia

11. Monocytosis

I have put time stamps throughout the video so that you can skip to the section that you are interested in.

I have based this episode on a variety of sources, primarily Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners, although other sources like Medscape and GP notebook were also reviewed. I have put links to them in the episode description. They are worth having a look as they have flowcharts and other information that you may find useful.

Make sure to stay for the entire episode because at the end, I will tell you how to access my summary of the recommendations, which I hope that you will find helpful. 

Right, there is a lot of information to cover, so let’s jump into it.

I will now go through the blood indices on the full blood count and I will also touch on iron investigations such as ferritin and total iron binding capacity. So, let’s look at them one at a time:

·      The Platelet Count gives us the absolute number of platelets

·      The Mean Platelet Volume or MPV gives us the average size of platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced, for example during infection or inflammation.

·      The White Blood Cell Count or WBC, gives the absolute number of white blood cells present. Leucocytosis is when the White Blood Cell Count is raised and leucopenia when it is low. In these situations, we need to look at the subtypes of the white blood cells, that is, we need to look at the:

·      WBC Differential, which looks at the number and proportion of the different types of WBC. We have five types: neutrophils, lymphocytes, monocytes, eosinophils, and basophils.

·      The Red Blood Cell Count or RBC is the absolute number of red cells. It is an important value but we often rely on other red blood cell indices to interpret the results correctly

·      Haemoglobin or Hb is crucial for the diagnosis of anaemia but, again, other indices are needed for the final interpretation.

·      The Haematocrit or HCT measures how much volume is taken up by red blood cells and it is expressed either as a percentage (that is from 0 to 100) or a proportion (that is, from 0 to 1). The haematocrit is therefore influenced not only by the number of red blood cells but also the amount of plasma present.

·      The Mean Corpuscular Volume or MCV refers to the average size of each RBC. An elevated MCV or macrocytosis is when the RBCs are larger than normal, for example in vitamin B12 or folic acid deficiency. A low MCV or microcytosis is when the RBCs are smaller than normal which may indicate, for example, iron deficiency anaemia.

·      The Mean Corpuscular Haemoglobin or MCH measures the average haemoglobin per red cell. Since macrocytic or larger RBCs tend to carry more haemoglobin that normal, they would normally have higher MCH values. 

·      The Mean Corpuscular Haemoglobin Concentration or MCHC is about concentration, that is, the amount of haemoglobin relative to the size of the cell. A decreased MCHC or hypochromia is seen in conditions such as in iron deficiency anaemia, chronic inflammation or thalassaemia. An increased MCHC or hyperchromia is seen when the haemoglobin is abnormally concentrated in the cells, such as in spherocytosis.

·      The Red Cell Distribution Width or RDW measures how uniform the red cells are in size. A high RDW indicates a mix of small and large cells, which can happen in some anaemias, such as iron deficiency or vitamin B12 deficiency. An increase in RDW happens when red blood cells have different sizes also called anisocytosis, or different shapes also called poikilocytosis.

·      Ferritin is the most useful indicator of iron deficiency, as it can drops before any decrease in levels of iron in the blood occurs. Ferritin is the main form of iron storage and is present mostly in the liver. Ferritin levels are low in long-term iron deficiency. Ferritin may also be decreased if protein levels are very low, like in malnutrition. Ferritin is high in states of iron overload, especially in haemochromatosis. However, ferritin can be high for a number of other reasons including inflammatory conditions, infection and liver disease. 

·      Total Iron Binding Capacity, or TIBC, measures the total capacity to bind iron in the blood. TIBC correlates with the amount of transferrin, and while both tests (TIBC and transferrin) are different, they measure essentially the same thing and most laboratories only measure one or the other. The amount of transferrin transporting iron is called transferrin saturation. Iron deficiency results in a low transferrin saturation, but an increased TIBC. In iron overload, such as in haemochromatosis, iron and transferrin saturation will be high and TIBC will be low or normal. Because transferrin is made in the liver, TIBC and transferrin will also be low in liver disease.

Now let’s start looking at the different haematological conditions. And the first section refers to polycythaemia.

Polycythaemia is judged on basis of HCT and it can be diagnosed if the HCT > 0.52 in men and > 0.48 in women.

Polycythaemia is also sometimes referred to as Erythrocytosis but this is not always correct. Why? Well, erythrocytosis indicates an excess number of erythrocytes or red blood cells and, as we have said, polycythaemia is judged on haematocrit, not red blood cells.

And this is because there are two types of polycythaemia, absolute polycythaemia, that is, when erythrocytosis is present, and relative or apparent polycythaemia, when this is not the case.  

For example, in apparent or relative polycythaemia, the HCT increases as a result of a reduced plasma volume rather than an increased red blood cell mass. It is common in obese men, and it is also associated with smoking, diuretics, alcohol, hypertension, stress, and dehydration. Despite the potentially reversible causes, these patients are also at risk of occlusive vascular episodes.

On the other hand, we have absolute polycythaemia, which can be primary or secondary. The primary cause is Polycythaemia Vera. Well over 90% of PV patients have an acquired mutation in a gene called JAK2 that regulates erythropoiesis. These patients do not need as much erythropoietin or EPO to drive red cell production. So, the features of PV are a positive test to the JAK2 mutation, and a low serum EPO level. It also has a low ferritin secondary to the excess production of red cells, which consumes a significant amount of iron. Being a myeloproliferative disorder, it can also sometimes be associated with raised WBC and / or platelets.

Secondary Polycythaemia is due to the physiological response to increased EPO levels. It can be an appropriate response to hypoxia like in COPD, heart disease and smoking or to an inappropriate response due to an EPO producing tumour like in some Renal & liver tumours or fibroids. Other possible causes are anabolic steroids and testosterone therapy, as androgens can also stimulate EPO production. In cases of secondary polycythaemia, the JAK2 mutation is negative, EPO levels are high and ferritin, WBC and platelets are normal.

Criteria for urgent referral are a HCT >0.60 in men or >0.56 in women or also if there is recent thrombosis, abnormal bleeding, or neurological or visual symptoms.

If the criteria for urgent referral are not met, we should confirm the results by repeating the blood test. In order to differentiate between apparent and absolute polycythaemia, the blood sample should be uncuffed and we should ensure that the patient has not fasted, is well hydrated, and has been advised about alcohol and smoking.  

In this blood test, we should request a:

·      Repeat FBC

·      A blood film and screen for diabetes, hyperlipidaemia and hypertension, checking

·      HbA1c

·      Lipids

·      Ferritin

·      Renal and liver function tests. Additionally, if we suspect absolute polycythaemia, we should also request

·      Genetic testing for the JAK2 mutation and do

·      EPO levels.

Criteria for routine referral are unexplained persistently elevated HCT >0.52 in men or >0.48 in women, taking into account that we should refer at lower limits if there is associated iron deficiency. “Persistently” means at least two readings above these levels 4 weeks apart.  

Alternatively, routine referral is also justified if the HCT >0.52 in men or >0.48 in women without waiting for a second test if there are associated symptoms of concern like pruritus, raised WBC and / or platelets or splenomegaly, or if there is a past (not recent) history of arterial or venous thrombosis. 

Right, let’s move on to the next chapter, which is a very important and common one, anaemia.  

Anaemia presents as a low haemoglobin and is not a disease in itself, but may reflect an underlying disease process. It may also result from an increase in plasma volume and a dilutional effect, like in pregnancy. There may be local variations in the thresholds for diagnosis but the WHO uses the following haemoglobin thresholds to define anaemia at sea level in adults:

·      women - 12 g/dl (reduced to 11 g/dl in pregnancy)

·      men - 13 g/dl 

So, I will be using these thresholds in this episode. 

Also, I will be focusing on what we normally see in Primary Care, that is, chronic anaemia rather than anaemia secondary to acute bleeding requiring admission. Hospital admission will also be required with very severe anaemias, for example when the Hb <50 or even at higher levels if the patient is very symptomatic 

The first thing to look after a low haemoglobin is the mean corpuscular volume or MCV. Depending on this value, the anaemia can be described as: 

·      Microcytic if the MCV is below 80

·      Macrocytic if it is over 100 and

·      Normocytic if it is between 80 and 100

·      Bearing in mind that there may be mixed deficiencies, so we should look at the whole picture. 

So, let’s look at the microcytic anaemias first. The most common cause of microcytosis is iron deficiency, so we will repeat the full blood count and check the patient’s iron status.  

As we said earlier, ferritin can be an acute phase reactant so it can be raised in cases like, for example, inflammation, malignancy, alcohol excess, liver or renal disease and infection. If we suspect any of this, we should check ferritin together with iron studies or transferrin saturation to get a clearer picture. If the ferritin is >50mcg/L and transferrin saturation is >20%, then iron deficiency can be excluded. In that situation, we will consider haemoglobinopathy screening in order to exclude thalassaemia or other haemoglobin variants and, if positive, we will refer to haematology as necessary. 

If the haemoglobinopathy screen is normal or if testing is not considered necessary , then we will think about the following conditions: 

·      One, Anaemia of chronic disease and we will look for causes of:

o  Chronic inflammation: for example, autoimmune diseases, malignancy or tuberculosis

o  Endocrine problems: for example, hypothyroidism, hypopituitarism or Addison’s and

o  Other conditions such as CKD, liver disease or malnutrition

·      Two, Myelodysplastic syndrome, usually presenting as lone unexplained and persistent anaemia and

·      Three, We will also consider haemochromatosis where ferritin is raised. 

And we will refer to the appropriate service if necessary. 

On the other hand, if ferritin is:

·      <30 mcg/L or

·      <100 mcg/L with transferrin saturation less than 20%  

We will regard it as iron deficiency anaemia. We will then enquire about upper and lower GI symptoms and we will consider an urgent cancer referral for upper and lower GI endoscopy after requesting a FIT test if:

·      There are red flag symptoms

·      There is an unexplained drop in Hb to below 110 in men and below 100 in non-menstruating women or if

·      There is a strong family history of colorectal cancer, that is, two first degree relatives with the diagnosis or one first degree relative with a diagnosis before the age of 50. 

If there are no criteria for urgent referral, and the cause of the iron deficiency is unknown, we will look for other possible causes, for example: 

·      Testing for coeliac serology and refer to gastroenterology if it is positive.

·      Enquire about Heavy menstrual bleeding

·      Consider Dietary causes

·      Do Urinalysis to test for haematuria (as 1% of IDA have a renal malignancy)

·      Do Stool testing for parasitology and we will also

·      Consider aspirin, NSAIDs and anticoagulants as an aggravating factor but we will still investigate these patients fully. 

When the cause of the iron deficiency anaemia is known, we will give iron therapy and treat the underlying cause accordingly and then recheck the Hb and ferritin within 3 months. If the deficiency has not resolved and it is not due to menstrual loss, we will refer to gastroenterology or other specialist services depending on the presentation and our clinical judgement.  

Let’s now look at macrocytic anaemias, that is, when the MCV is >100.

If there is macrocytosis, with or without anaemia we should consider some of the possible causes and: 

·      Check alcohol intake

·      Enquire about family history

·      Review medication that could cause it, for example methotrexate, metformin, and some anticonvulsants, amongst others and

·      remember that a high MCV can be a normal physiological finding in pregnancy. 

Initial investigations will include: 

·      A Repeat FBC

·      A Blood Film

·      Vitamin B12 and folate levels

·      Renal and liver function tests, including GGT

·      TFTs

·      Ferritin, iron studies

·      Myeloma screen, including bone profile, serum immunoglobulins, serum Free Light Chains and Urinary Bence Jones protein

·      And finally, we will also check the Reticulocyte count and LDH levels, looking for evidence of haemolysis, bearing in mind that markers of haemolysis include a raised reticulocyte count, a high bilirubin and a high LDH  

Criteria for urgent referral to haematology are: 

·      Leucoerythroblastic features or blasts seen on blood film

·      Unexplained symptomatic and progressive anaemia and if there is

·      Associated splenomegaly, lymphadenopathy or other significant cytopenias 

If the urgent criteria are not met, we will then act on the results and refer the patient accordingly. That is:

·      If the reticulocyte count is high: we will look for evidence of bleeding or haemolysis and refer to the appropriate department.

·      If there is CKD related anaemia: we will refer to the renal team

·      If the TFTs are abnormal, we will treat the dysfunction and repeat the FBC 4-6 weeks later

·      If vitamin B12 and / or folate levels are low: we treat the deficiencies and assess for the underlying cause. For example:

o  In vitamin B12 deficiency, we will check for intrinsic factor Antibodies and Parietal Cell Antibodies and treat as pernicious anaemia if positive and

o  In both vitamin B12 and folate deficiencies we will do a coeliac screen.  

Criteria for routine haematology referral are: 

·      If paraprotein is detected

·      If all results are normal, but there is persistent unexplained anaemia

·      If there is persistent unexplained macrocytosis with an MCV >100 as this can be a feature of myelodysplasia

·      If there is persistent unexplained vitamin B12 deficiency because persistent unexplained vitamin B12 deficiency can also occur in myelodysplastic syndromes

·      If there is anaemia with associated abnormalities in other blood cells

·      If the reticulocyte count is low or the picture is unclear and

·      If there is an abnormal blood film

Finally, let’s now look at normocytic anaemias, that is, when the MCV is between 80 and 100.  

Possible causes of normocytic anaemias are: 

·      A mixed haematinic deficiency

·      Myelodysplastic syndrome

·      Recent blood loss

·      Anaemia of chronic disease like in:

o  Chronic inflammation

o  Endocrine problems or

o  Other conditions such as CKD, liver disease or malnutrition

·      And haemochromatosis if ferritin is raised. 

In these cases, we will investigate similarly to macrocytic anaemias, that is, we will check the following: 

·      A repeat FBC with a Blood Film

·      Vitamin B12 and folate levels

·      Renal and liver function tests, including GGT

·      TFTs

·      Ferritin, iron studies

·      Myeloma screen

·      And finally, we will also check the Reticulocyte count and LDH levels, looking for evidence of haemolysis  

And we will act on the results and refer the patient accordingly.

The next section refers to thrombocytosis or a raised platelet count above 450 x 109/L.

Possible causes of thrombocytosis are:

·      Iron Deficiency Anaemia

·      Malignancies especially the LEGO cancers, that is:

o  Lung

o  Endometrium

o  Gastric

o  Oesophageal

·      Inflammation

·      Infection

·      Post-Splenectony and Hyposplenism like in Coeliac Disease

·      Post-Operatively situations and finally a

·      primary Myeloproliferative Disorder

But before moving on, let’s clarify a concept: should we call it thrombocytosis or thrombocythemia? Well, in fact, there is a difference. In summary, thrombocytosis is more common and arises as a secondary response, and therefore it is also referred to as reactive thrombocytosis. On the other hand, thrombocythemia, also referred to as primary or essential thrombocythemia, is less common and is a form of myeloproliferative disorder. Another key difference if that people with reactive thrombocytosis have normal platelets and therefore, also have a lower risk of blood clots and bleeding whereas those with thrombocythemia have abnormal platelets and also a higher risk of clots and bleeding. Thrombocythemia often presents with splenomegaly and a platelet count >1000.

Therefore, criteria for urgent haematology referral are if:

·      The PLT count exceeds 1000 x 109 / L

·      There is splenomegaly

·      There is a recent history of thromboembolism

·      The PLT count is >600 x109/L and the patient is at high risk of thromboembolism or CVD

·      There are neurological symptoms

·      There is abnormal bleeding

·      There are any signs of malignancy or

·      There are any other significant abnormal FBC indices 

If the urgent referral criteria are not present, we will then look for causes by doing the following initial investigations: 

·      A repeat FBC

·      A blood film

·      Inflammatory markers like ESR and CRP

·      Ferritin and iron studies and we will also

·      consider doing a coeliac screen as it can be associated with thrombocytosis 

If the patient is asymptomatic and there is no obvious cause, we will repeat the FBC 4-6 weeks later. If the thrombocytosis persists >450, we will refer to haematology routinely. 

The next section is thrombocytopenia, which is defined as a low platelet count below 150 x 109/L. We need to remember that thrombocytopenia can frequently be an artefact, stemming from platelet clumping, rather than reflecting an actual decrease in platelet count. We should always confirm it with a second FBC and a blood film report. 

We will enquire about travel, drugs and alcohol because possible causes of thrombocytopenia include:

·      Alcohol excess

·      Recreational drugs

·      Malaria

·      TB

·      Liver & Renal disease

·      Medications, for example, NSAIDs, Heparin, Digoxin, Quinine, anti-epileptics, antipsychotics, and PPIs

·      B12 and folate deficiency

·      Viral infection including:

o  EBV (it usually resolves within few weeks in this case)

o  HIV and

o  Hepatitis B and C

·      Malignancy

·      Bone marrow failure like in aplastic anaemias

·      Immune thrombocytopenic purpura or ITP and

·      Autoimmune diseases, like SLE 

Baseline investigations will include: 

·      Repeat FBC and blood film

·      Vit B12 and folate

·      Ferritin and iron studies

·      Inflammatory markers such as ESR and CRP

·      Autoimmune profile

·      Renal, liver and thyroid function tests

·      HIV, hepatitis B and C serology and

·      Any other test suggested by the clinical history or examination findings 

We should arrange a hospital urgent same day assessment if the platelet count is <20 with: 

·      Active Bleeding

·      An abnormal blood film like Blasts or Fragments on the blood film or an

·      Altered Conscious Level Or Confusion 

We should make an urgent referral to haematology if: 

·      The platelet count is 50-100 and there is splenomegaly, lymphadenopathy, other cytopenias, the patient is pregnant or there is upcoming surgery or if

·      The platelet count is <50. In this case, we will stop all antiplatelet agents and anticoagulants as it would be unsafe to continue. 

If the platelet count is over 50 and the urgent referral criteria are not present, we will repeat the FBC after 4-6 weeks and refer to haematology routinely if the thrombocytopenia persists and remains unexplained.

 Now, next, let’s have a look at neutrophilia, which is when the neutrophil count is raised, that is, over 7.5. 

Infection is the most common cause but other possible causes are: 

·      Infection

·      Inflammation

·      Steroids

·      Pregnancy

·      Smoking

·      Underlying Malignancy including Lymphoma and Leukaemia

·      Connective tissue disease like RA

·      Haemorrhage

·      Haemolysis

·      Hypoxia and

·      Tissue damage including infarction 

If the cause is unclear, we will investigate further by doing: 

·      A repeat FBC

·      A Blood Film

·      Inflammatory markers such as ESR and CRP

·      Renal and liver function tests

·      Autoimmune screen and

·      Any other tests led by history 

Criteria for urgent haematology referral will include a high suspicion of leukaemia because of: 

·      A leucoerythroblastic film or an

·      Absolute Neutrophil count, ANC > 50 x109/L  

We will make an early routine haematology referral, that is, without waiting for a repeat FBC, if the neutrophil count is >15 and: 

·      There is splenomegaly or

·      There are other FBC abnormalities.

Otherwise, we will repeat the FBC 6 weeks later and we will refer to haematology routinely if: 

·      The neutrophilia persists and remains unexplained 

Let’s now look at neutropenia, which is when the neutrophil count is low. A normal neutrophil count in adults is from 2.0 to 7.5. However, an isolated low neutrophil count is very common and a neutrophil count of between 1-5 -2.0 x 109/l, whilst below the normal range, is unlikely to be of any clinical significance. Also, people of Afro-Caribbean or Middle Eastern ethnicity have a lower normal range between 1 and 1.8 x 109/l, which is also referred to as constitutional or ethnic neutropenia. This is of no clinical consequence and we should only refer them if their neutrophils are <1.0 x 109/l on repeat testing. 

For everybody else and for the purpose of this episode, we will say that neutropenia is when the neutrophil count is below 1.5. 

Possible causes of neutropenia are: 

·      Drugs e.g. Phenytoin, Carbimazole, Antipsychotics and Clotrimoxazole

·      Malignancy, like myeloma, bone marrow infiltration and chemo or radiotherapy

·      Vitamin B12 and / or folate deficiency

·      Iron deficiency

·      Autoimmune diseases

·      Any viral infection including EBV, HIV and Hepatitis B and C

·      Excess alcohol

·      Liver disease and cirrhosis and, as already mentioned, the

·      Ethnic variation in people of Afro-Caribbean and Middle Eastern descent  

We should send the patient to hospital as an emergency if: 

·      There is any evidence of sepsis

·      The neutrophil count is <1 and:

o  The patient is on chemotherapy

o  There is lymphadenopathy

o  There is splenomegaly or

o  There is other cytopenia 

We should make an urgent haematological referral on a cancer pathway if: 

·      The neutrophil count is <0.5 and the patient is otherwise well

If the neutrophil count is >0.5 and the patient is well, we will repeat the blood test within 1 week and investigate the cause by doing:  

·      A repeat FBC

·      A blood film

·      Vitamin B12

·      Folate

·      Ferritin and iron studies

·      Autoimmune screen

·      HIV and

·      Hepatitis B and C serology 

If the patient is well and the cause remains unknown, we will:

·      Refer to haematology urgently if the neutrophil count remains <1 but

·      If the neutrophil count is between 1 and 1.5, we will monitor the FBC for 4-6 weeks and refer to haematology routinely if: 

o  The neutrophil count remains below 1.5 (or 1 in African-Caribbean patients)

o  There are other FBC abnormalities or

o  There is a history of infections or ulcers 

The next section refers to lymphocytosis, which is when the lymphocyte count is high that is, more than 3.5 x109 / L. 

Possible causes of lymphocytosis are: 

·      Viral infections especially

o  Glandular fever but also others such as:

o  Measles, mumps, rubella

o  EBV and

o  CMV

·      Bacterial infections, e.g. pertussis infection or whooping cough

·      Lymphoproliferative disorders (such as Acute or Chronic Lymphatic Leukaemia or non-Hodgkins lymphoma)

·      Post-splenectomy

·      Rheumatoid arthritis

·      Smoking

·      Stress and

·      Vigorous exercise

If there are features of acute or recent viral illness and the patient is otherwise well, we will repeat the FBC once resolved after 4-6wks.

We will refer to haematology urgently if: 

·      The Lymphocytosis is >20x109/L

·      There are other cytopenias

·      There is Lymphadenopathy

·      There is Splenomegaly or if

·      There are B symptoms, that is:

o  Unexplained fever >38

o  Drenching night sweats

o  Weight loss  

Otherwise, if the lymphocyte count is >5, we will repeat the blood in 4 to 6 weeks and investigate the cause by doing:

·      A repeat FBC

·      A Blood film

·      Inflammatory markers such as ESR and CRP

·      Glandular fever screen or other virology serology where indicated due to the clinical presentation and we will also request

·      Immunophenotyping screen 

And after this, we will refer to haematology routinely if the lymphocytosis persists and remains unexplained. 

The next section is lymphopenia, when the lymphocyte count is low, that is below 1 x 109/L.

Possible causes of lymphopenia are:

·      Elderly patients

·      Excess alcohol

·      Malnutrition

·      Medication, for example steroids and chemotherapy

·      Infection including legionella, HIV and hepatitis B and C and post viral lymphopenia is common

·      Malignancy for example, lymphoma, bone marrow infiltration, and myeloma and we should consider a myeloma screen if there are suggestive symptoms.

·      Renal or hepatic impairment

·      Autoimmune conditions like RA and SLE

·      Sarcoidosis

·      Anorexia Nervosa and

·      Primary immune deficiency 

We will refer to haematology urgently if the lymphocyte count is <1 and there are any red flags. Red Flag signs in lymphopenia are: 

·      Recurrent infections or

·      B symptoms, that is :

o  Unexplained fever >38

o  Drenching night sweats

o  Weight loss 

If there are no red flags, we will do a new blood test in 6 weeks and look for causes. So, we will do: 

·      A repeat FBC

·      A blood film

·      Renal and liver function tests

·      Inflammatory markers such as ESR and CRP

·      Autoimmune profile

·      Viral serology as appropriate depending on the clinical presentation and a

·      Myeloma screen if symptoms justify it 

If the cause is found, we will refer to the appropriate specialist department. However, if it persists and remains unexplained, we will refer routinely to haematology. 

There may be times when, if the lymphocyte count is >0.5x109/L and the patient is >70 years of age and otherwise well, we could consider just monitoring the FBC, but this will depend on our clinical judgement.

The next section refers to eosinophilia, when the eosinophil count is high. There may be local variations in the threshold but, in general, eosinophilia is defined as an eosinophil count over 0.5 x 109/L.

Examples of possible causes of eosinophilia are: 

·      Asthma

·      Skin disease like eczema, atopic dermatitis, urticaria, and psoriasis

·      Infections: especially those due to parasites (like hookworm, schistosomiasis and giardiasis), fungal infections as well as TB and malaria.

·      Drugs such as penicillin, allopurinol, amitriptyline, and carbamazepine but in fact any drug is a possible cause

·      Connective tissue disease like rheumatoid arthritis, and polyarteritis nodosa,

·      Solid malignancies, for example breast, renal, stomach and lung cancer

·      Myeloproliferative disorders like leukaemia and lymphoma

·      Respiratory diseases such as bronchiectasis, and cystic fibrosis

·      Endocrine conditions like Addison’s and

·      Post-splenectomy 

If the eosinophil count is >2.5, we will look for signs of organ damage and consider urgent admission if there are red Flags like: 

·      Severe symptoms secondary to organ involvement like:

o  difficulty breathing

o  chest pain

o  abdominal pain, or

o  neurological symptoms or

·      other Complications such as tissue damage, venous thromboembolism, or end-organ damage like AKI or heart failure. 

Criteria for urgent referral to haematology are:  

·      Leucoerythroblastic film or an

·      Absolute Eosinophil Count > 5 x109/L,  

If the eosinophil count is >0.5 and the patient is well, we will check the travel and drug history and check for any evidence of atopy. We will then repeat the blood test within 1 to 2 weeks and look for possible causes.

 Initial investigations will include: 

·      A repeat FBC

·      Blood film

·      Inflammatory markers like ESR and CRP

·      Immunoglobulin E

·      Autoimmune profile

·      Renal and liver function tests

·      Bone profile

·      LDH

·      Vitamin B12 and folate

·      Chest X-ray (e.g. if TB or pulmonary sarcoidosis are suspected)

·      Stool culture for ova, cysts and parasites

·      Serological antibodies for threadworm or other nematode infection and

·      Serological antibodies for Schistosomiasis depending on the travel history and after discussion with microbiology 

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 more than 1.5 for 3 months or longer or

·      if it is rising without an obvious cause. 

The final section refers to monocytosis when the monocyte count is raised, that is over 0.8 x 109/L. 

Possible causes of monocytosis include: 

·      CMML or Chronic Myelomonocytic Leukemia

·      Myelodysplasia

·      Hodgkins’s lymphoma and

·      Infections such as:

o  Malaria

o  Tuberculosis

o  Brucellosis

o  Infective endocarditis and

o  Rickettsial infections 

Criteria for urgent haematology referral would be: 

·      Evidence of CMML features on blood film

·      A persistently raised monocyte count >1.5 (which is typical of CMML)

·      Associated cytopenias, particularly if involving multiple blood cell lineages or of there is any

·      Clinical Suspicion of Hematologic Malignancy 

If the monocyte count is >0.8 and the patient is well, we will check the travel history and check for any evidence of malignancy. We will then repeat the blood test and look for possible causes.  

Initial investigations could include: 

·      A repeat FBC

·      A blood film

·      Inflammatory markers like ESR and CRP

·      Any investigation as appropriate based on clinical suspicion, for example:

o  A chest X-ray to screen for Tb

o  Malaria parasites, and

o  Serological tests for infectious diseases such as Brucella, Epstein-Barr virus, and cytomegalovirus 

If the monocytosis remains unexplained and over 0.8 we will refer to haematology. 

Well, this is the end of the clinical scenarios. I have created a quick reference guide based on the guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners which you are welcome to have a look at. Where there was a discrepancy between their guidance, I have generally opted for the most conservative approach, for example, if one neutropenia guideline recommends referral if the neutrophil count is <1 and another when it is <1.5, my summary will show <1.5. If you are in any doubt, please consult the original guidance or seek local specialist guidance. I have included links to sources consulted in the document itself, which you will be able to download in the episode description. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here: https://youtu.be/0r2kJQNzHME?si=hwG9mG3jNVaXRQEq

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through new and updated guidelines published in January 2024 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.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for January 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-01-01&to=2024-01-31&ndt=Guidance&ndt=Quality+standard

The links to the update guidance covered can be found here:

Suspected sepsis: recognition, diagnosis and early management:

·      https://www.nice.org.uk/guidance/ng51

National early warning score information:

·      National Early Warning Score (NEWS) 2 | RCP London website:

§ https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2

·      eLearning:

§ https://newslms.ocbmedia.com/login

·      The NEWS2 observation chart, score card and clinical responses can be downloaded from the main NEWS2 page at 

§ https://news.ocbmedia.com/resources

·       

COVID-19 rapid guideline: managing the long-term effects of COVID-19:

·      https://www.nice.org.uk/guidance/ng188

COVID-19 rapid guideline: managing COVID-19:

·      https://www.nice.org.uk/guidance/ng191

Skin cancer:

·      https://www.nice.org.uk/guidance/qs130

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
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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 am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in January 2024, focusing on what is relevant in Primary Care only.

And to be honest, there have not been any major changes, only minor tweaks in the guidelines on sepsis and COVID19.

Today’s episode is not very long so let’s jump into it.

The first clinical area is sepsis. We can’t really look at the whole sepsis guideline here so let’s just look at the update, which points out four aspects:

·      First, that temperature may not rise in cases of spinal cord injury. We know that some groups of people with sepsis may not develop a raised temperature. These include:

o  people who are older or very frail

o  young infants or children

o  people having cancer treatment

o  people severely ill with sepsis and after this update

o  people with a spinal cord injury

·      Second, we should suspect neutropenic sepsis also in immunosuppression which is not related to cancer.

o  That is, we should now suspect neutropenic sepsis and send them to hospital if they become unwell and:

§ Are having or have had systemic anticancer treatment within 30 days or

§ Are receiving or have received immunosuppressants for reasons unrelated to cancer, obviously using our clinical judgement

·      Third, we should give early antibiotics when the person is at high risk from sepsis.

o  This means that if the transfer time to the emergency department is likely to be more than 1 hour, we should give antibiotics if high risk criteria are present. And,

o  If meningococcal disease is specifically suspected, we will give appropriate doses of parenteral benzyl penicillin in the community.

·      And finally, we should use a national early warning score for sepsis. And this is the most interesting part of the update, so let’s have a look at it in a little more detail.

NICE says that the national early warning score should be done in ambulances and secondary care but it is not expected in primary care.

So, let’s have a look at what NICE says that we have to do in Primary Care.

Firstly, we should always ask ourselves 'could this be sepsis?' if there are infection symptoms, taking into account that these symptoms may be non-specific, like feeling very unwell. 

As part of the initial assessment in Primary Care, we will carry out a thorough examination, examining the skin for a mottled appearance, cyanosis and rashes and checking the temperature, heart rate, respiratory rate, oxygen saturation and level of consciousness for everyone. For those aged 12 and over, we will also check the blood pressure, and for the under 12s we will check the capillary refill and, if it is abnormal, we will check the BP if we have the equipment, including a correctly-sized blood pressure cuff. We will also enquire about urine output in the previous 18 hours. 

If we are worried about sepsis, we should send the patient to hospital. Like stated earlier, if, in addition, there are high risk features, we should also consider early antibiotics if there is going to be more than one hour’s delay.

So, what are these high-risk features? Well, for those aged 12 and over they are as follows:

·      New altered mental state

·      Respiratory rate: 25 breaths per minute or more

·      New need for 40% oxygen or more to maintain saturation more than 92% (or more than 88% in known COPD), being aware that pulse oximeters can underestimate or overestimate oxygen levels, and that overestimation has been reported in people with dark skin.

·      Systolic BP < 90 mmHg or more than 40mmHg below their normal

·      Heart rate: more than 130 beats per minute

·      Not passed urine in previous 18 hours.

·      Mottled or ashen appearance of skin

·      Cyanosis and a

·      Non-blanching petechial or purpuric rash- when we will consider meningococcal disease.

Now, let’s go back to the national early warning score or NEWS2 that we were talking about earlier.

The National Early Warning Score or NEWS 2 tool was designed by the Royal College of Physicians to be used in adults in addition to clinical judgement to assess a person's risk of deterioration. It is not advised in children or pregnant women or in cases of spinal cord injury.

The NEWS2 tool scores the same things that we already measure in Primary care, that is, temperature, heart rate, respiratory rate, oxygen saturation, blood pressure and level of consciousness. A score is given to each value where the high-risk criteria that we have just mentioned, score 3 points and other abnormal but less severe criteria only 2 points. I will not go through the score chart today but, if you want to look at it in more detail, I have put relevant links in the episode description.

 And when interpreting the risk from sepsis using the NEWS2 score we will recognise that:

·      a score of 7 or more suggests high risk from sepsis and we should arrange immediate admission.

·      a score of 5 or 6 suggests a moderate risk from sepsis and we should arrange an urgent hospital assessment

·      a single parameter scoring 3 points, is a red flag and we should discuss it with the hospital medical team.

·      a score of 1 to 4 suggests a low risk from sepsis but we should still use our clinical judgement

A score of 0 should not be interpreted as indicating that there is no risk from sepsis and the patient will still need to be monitored.

In summary, while a formal NEWS2 assessment is not mandatory in Primary Care, in practice, by measuring all relevant parameters and recognising high-risk values, we are effectively applying the NEWS2 system. That is why it is a good idea for us to have a good understanding of it.

Let’s now move to the second clinical area, which refers to the COVID-19 rapid guideline, both in managing COVID-19 itself and also managing the long-term effects of COVID.

The update is presentational only and the recommendations are largely unchanged. But since we are here, I will give you a very brief summary.

In respect of the acute COVID-19 guideline, I will keep it extremely brief. We will assess the severity of COVID checking what we have just discussed in the sepsis guideline, that is temperature, heart rate, respiratory rate, oxygen saturation, blood pressure and level of consciousness and we will consider using the NEWS2 tool here too, sending the patient to hospital when necessary.

In terms of managing cough in the community, we will encourage people to avoid lying on their backs, because this makes coughing less effective. And to manage fever, we will advise paracetamol or ibuprofen explaining that there is insufficient evidence to link non-steroidal anti-inflammatory drugs and worsening COVID-19.

Now let’s address the long-term effects of COVID.

And let’s remember that:

·      Acute COVID19 refers to the first 4 weeks.

·      Ongoing symptomatic COVID19 to between 4 and 12 weeks

·      And post-COVID-19 syndrome to more than 12 weeks

·      The term 'long COVID' is commonly used and it includes both ongoing symptomatic COVID‑19 and post‑COVID‑19 syndrome, that is, anything that is longer than 4 weeks

Examples of the most commonly reported symptoms in long COVID are:

·      Respiratory symptoms like Breathlessness and a Cough

·      Cardiovascular symptoms like Chest tightness, chest pain or Palpitations

·      General symptoms like Fatigue, Fever and Pain

·      Neurological symptoms like 'brain fog', loss of concentration or memory issues, Headache, and Dizziness

·      Gastrointestinal symptoms like Abdominal pain, Nausea and vomiting and Diarrhoea

·      ENT symptoms like Tinnitus, Sore throat, Loss of taste and/or smell and Nasal congestion

·      Dermatological symptoms like Skin rashes and Hair loss

·      Mental health symptoms like depression, anxiety and PTSD Symptoms and

·      In addition, absence or reduced performance in education, work or training.

In terms of investigations, we will offer tests and investigations tailored to the symptoms. If clinically indicated, we will offer blood tests, which may include a full blood count, kidney, liver and thyroid function tests, HbA1c, CRP, ferritin, and BNP. 

For people with postural symptoms, for example, palpitations or dizziness on standing, we will check lying and standing blood pressure and heart rate and we will offer a chest X-ray for continuing respiratory symptoms. 

After ruling out severe complications and alternative diagnoses, we will refer to a long COVID clinic.

Their management includes a personalised rehabilitation plan with fatigue management being a key component of this. Breathlessness, fatigue and 'brain fog' are among the most commonly reported long‑term symptoms, so support for these symptoms is also essential.

We will explain that it is not known if over-the-counter vitamins and supplements are helpful, harmful or have no effect in long COVID situations.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this episode can be found here:

·      https://youtu.be/2gDK6E85diU

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In the first part of this episode, I go through the NICE guideline [NG28] on Type 2 diabetes in adults, always focusing on what is relevant in Primary Care only. In the second part I go through a thorough review of the guideline with a series of multiple-choice questions. Each question is paired with quotation, aiming to clarify key concepts and enhance understanding. This informative segment is created to support continuous learning in Primary Care.

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.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The full NICE guideline can be found here:

·      https://www.nice.org.uk/guidance/ng28

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

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 do an up to date revision of the NICE guideline on type 2 diabetes. This episode is longer because it has two parts. In the first part, which lasts or about 20 minutes, I go through the NICE guideline itself, always focusing on what is relevant in Primary Care only. In the second part, I will present you with a series of multiple-choice questions so that you can test yourself. After each question, you are given the right answer, which is paired with a guiding quotation. This pairing is designed to clarify key concepts and enhance your continuous learning and retention.

I have created time stamps throughout the video so that you can skip to the section that you wish whenever you want.

Right, let’s jump into it.

Firstly, I will just state that this episode does not cover the management of pregnant women with type 2 diabetes. 

We will offer structured education to patients at the time of diagnosis, with annual reinforcement and, if possible, this should be in the form of group education programmes.

The dietary advice should be the same healthy eating advice as the general population, which includes:

·      high-fibre, low-glycaemic-index sources of carbohydrates

·      low-fat foods and

·      oily fish

And we will discourage foods marketed specifically for people with diabetes. 

If the person is overweight, we should aim for an initial body weight loss target of 5% to 10%, remembering that even a small amount of weight loss may still be beneficial. 

The guideline on type 2 diabetes makes reference to the bariatric surgery guideline which says that we should refer people with type 2 diabetes for consideration of bariatric surgery if they have a BMI of 35 or more. If they have Asian or African-Caribbean family background, we will do so if the BMI is 32.5 or more.

The recommendations on hypertension are broadly the same as for other people so we will simply follow the NICE guideline on hypertension because, when a different approach is needed for people with type 2 diabetes, this is specified in the hypertension guideline.

Additionally, we will not offer antiplatelet therapy (aspirin or clopidogrel) without cardiovascular disease. 

In respect of blood glucose management, broadly speaking we will measure HbA1c:

·      every 3 to 6 months until HbA1c is stable or

·      every 6 months once both HbA1c and therapy are stable. 

If HbA1c is not valid because of disturbed erythrocyte turnover or abnormal haemoglobin type, we will use:

·      plasma glucose levels

·      fructosamine or

·      in cases of abnormal haemoglobins, we will use total glycated haemoglobin

In terms of HbA1c targets, if the diabetes is managed either by diet, or a single drug not associated with hypoglycaemia, we will aim for an HbA1c of 48 mmol/mol or 6.5%. If it’s treated with a drug associated with hypoglycaemia, we will aim for an HbA1c level of 53 mmol/mol or 7.0%. 

If HbA1c on a single drug rises to 58 mmol/mol or 7.5% or higher, we will intensify drug treatment. aiming for an HbA1c of 53 mmol/mol or 7.0%. 

However, we will consider relaxing the HbA1c target, particularly for older or frailer people if:

·      they are unlikely to achieve benefits, for example, because of a reduced life expectancy or if

·      intensive treatment would not be appropriate, for example because of comorbidities or risks of hypoglycaemia. 

If the HbA1c drops below the target, we should consider other possibilities, for example deteriorating renal function or sudden weight loss. 

When considering self-monitoring of blood glucose, we will take into account the DVLA recommendations. But otherwise, we will not routinely offer self-monitoring of capillary blood glucose levels unless:

·      the person is on insulin or oral medication that may increase their risk of hypoglycaemia or

·      there is evidence of hypoglycaemia or

·      they are pregnant or planning to become pregnant

We will consider short-term self-monitoring of blood glucose:

·      when starting oral or intravenous corticosteroids 

·      to confirm suspected hypoglycaemia or

·      if concerned during acute intercurrent illness to help manage their treatment as necessary. 

What about the new technology of continuous glucose monitoring?

Well, we should offer intermittently scanned continuous glucose monitoring (isCGM), commonly referred to as 'flash' if they are on multiple insulin injections and:

·      they have recurrent or severe hypoglycaemia or impaired hypoglycaemia awareness or

·      they are unable to self-test or

·      they have to self-test at least 8 times a day.

We can consider real-time continuous glucose monitoring as an alternative to isCGM if it is available for the same or lower cost.

However, we should advise patients using CGM that they will still need to take capillary blood glucose measurements (although they can do this less often). This is because:

·      they need it to check the accuracy of their CGM device and also because

·      they need it as a back-up

Now let’s have a look at the drug treatment.

In terms of rescue therapy at any stage of treatment, if someone is symptomatically hyperglycaemic, we should consider insulin or a sulfonylurea, and review the treatment when blood glucose control has been achieved. 

Then, as first line drug treatment we will offer standard-release metformin. We will gradually increase the dose over several weeks to minimise the risk of gastrointestinal side effects and, if they appear, we will consider a trial of modified‑release metformin. 

After metformin, we should assess the cardiovascular risk to determine whether they have chronic heart failure or established atherosclerotic cardiovascular disease or are at high risk of it. And then, if they have chronic heart failure or established cardiovascular disease, or are at high risk of it, we will go for an SGLT2 inhibitor. 

When starting dual therapy with metformin and an SGLT2 inhibitor, we will start them sequentially, commencing with metformin and adding the SGLT2 inhibitor as soon as we confirm that metformin is well tolerated.

Now, if metformin is contraindicated or not tolerated, we will do the same. That is, we will assess the cardiovascular risk to determine whether they have chronic heart failure or established atherosclerotic cardiovascular disease or are at high risk of it. And then, if the patient is in any of these categories, we will also go for an SGLT2 inhibitor as monotherapy.

However, if they don’t have chronic heart failure or established atherosclerotic cardiovascular disease, and they are not at high risk of it, we have a lot of flexibility because we can consider:

·      a DPP‑4 inhibitor or

·      pioglitazone or

·      a sulfonylurea or, also,

·      an SGLT2 inhibitor. 

SGLT2 inhibitors have been associated to an increased risk of diabetic ketoacidosis and therefore, before starting them, we need to check whether the person may be at increased risk of DKA, for example if:

·      they have had a previous episode of DKA

·      they are unwell with intercurrent illness or

·      they are following a very low carbohydrate or ketogenic diet

If the patient is following a very low carbohydrate or ketogenic diet, they may need to delay the SGLT2 inhibitor until they have changed their diet, and, once they are on an SGLT2 inhibitor, we will advise them against following this type of diet in the future. 

If a patient’s first line treatment does not include an SGLT2 inhibitor because they do not have chronic heart failure or established atherosclerotic cardiovascular disease, and they are not at high risk of it, but later they fall into one of these categories, we will start an SGLT2 inhibitor either by adding it to their current treatment or by replacing an existing drug with the SGLT2 inhibitor depending on our clinical judgement.

Now, in general, if we need to intensify the drug treatment because monotherapy with metformin is not enough, we also have a lot of flexibility and we will consider adding:

·      a DPP‑4 inhibitor or

·      pioglitazone or

·      a sulfonylurea or

·      an SGLT2 inhibitor. 

Then, if we need to intensify the drug treatment again because dual therapy with metformin and another oral drug is not enough, we will either:

·      start triple therapy by adding a further oral agent, that is, a DPP‑4 inhibitor, pioglitazone, a sulfonylurea or an SGLT2 inhibitor or

·      consider starting insulin

However, if metformin is contraindicated or not tolerated and dual therapy with 2 oral drugs is not enough, we should go straight for insulin. That is, NICE only recommends triple oral therapy if one or the drugs is metformin.

Now, so far, we have not mentioned GLP-1 receptor agonists at all. When does NICE recommend them? Well, if triple therapy with metformin and 2 other oral drugs is not enough, we can consider triple therapy by switching one oral drug for a GLP‑1 receptor agonist if:

·      The BMI is 35 or higher and there are problems associated with obesity, although for people from Black, Asian and other minority ethnic groups we will reduce the BMI to 32.5  or

·      The BMI lower than 35 and:

o  insulin would have occupational implications or

o  weight loss would benefit other comorbidities. 

We will only continue the GLP‑1 receptor agonist if there has been a beneficial metabolic response, which is a reduction of at least 11 mmol/mol or 1.0% in HbA1c and a weight loss of at least 3% of the initial body weight in 6 months. 

NICE also says that a GLP‑1 receptor agonist and insulin should only be combined with specialist advice and ongoing support. 

Now, let’s have a look at the drug management specifically for people with both type 2 diabetes and CKD.

And the guideline on type 2 diabetes says that people with both type 2 diabetes and CKD should have standard CKD treatment with an ACEI or ARB, titrated to the highest licensed dose that the person can tolerate if the ACR is 3 or more.

And once they are on a fully titrated dose of the ACEI or ARB, we will add an SGLT2 inhibitor if:

·      ACR is over 3 (and particularly if it is over 30) and

·      they meet the eGFR thresholds to prescribe the SGLT2 inhibitor.

However, this area is a little confusing because this is the advice on the NICE guideline on type 2 diabetes NG28. However, more recently published NICE guidance in the form of technology appraisals, NICE says that Dapagliflozin is recommended as an add-on to ACEIs or ARBs, if their eGFR is between 25 and 75 and they have type 2 diabetes, without mentioning any ACR thresholds.

And a similar approach appears in the technology appraisal on empagliflozin which says that empagliflozin is recommended as an add-on to ACEIs or ARBs if the patient has type 2 diabetes and their eGFR is between 20 and 90, again without mentioning any ACR levels.

In summary, the technology appraisals recommend the SGLT2 inhibitors dapagliflozin and empagliflozin for people with type 2 diabetes and CKD if eGFR thresholds are met but without ACR thresholds at all. This is in contradiction to the guideline NG28 on type 2 diabetes where ACR thresholds of 3 and 30 are stipulated. Until the situation has been clarified, my personal view would be to follow the most recent guidance, that is, the technology appraisals on dapagliflozin and empagliflozin and offer these drugs to people with type 2 diabetes and CKD if the eGFR thresholds are met without taking into consideration ACR levels.

Now let’s have a look at what NICE says in respect of insulin therapy.

Firstly, when starting insulin, an insulin-specific structured educational programme should be offered to the patient.

If there are no issues, on starting insulin, we will continue to offer metformin and we will review the continued need for other diabetic agents. 

NICE recommends starting insulin following one of these regimens:

·      NPH insulin injected once or twice daily according to need.

·      NPH and short‑acting insulin, administered either:

o  separately or

o  as a pre-mixed or biphasic human insulin preparation.

·      Insulin detemir or insulin glargine can be used, as an alternative to NPH insulin, if:

o  the person needs help to inject insulin, or

o  there is recurrent hypoglycaemia or

o  the person would otherwise need twice‑daily NPH insulin injections as well as oral medication.

·      Pre-mixed or biphasic preparations including short‑acting insulin analogues, rather than short‑acting human insulin preparations, can be used if:

o  injecting immediately before a meal is preferred or

o  hypoglycaemia is a problem or

o  blood glucose levels rise markedly after meals. 

We will switch to insulin detemir or glargine from NPH insulin if:

·      there is hypoglycaemia on NPH insulin or

·      the HbA1c target is not met or

·      they have issues with the device or

·      they need help to inject insulin. 

We will monitor patients on a basal insulin regime, that is, NPH insulin, insulin detemir or glargine for the need for short‑acting insulin. Equally, we will monitor patients on pre‑mixed or biphasic insulin for the need for a further injection of short‑acting insulin before meals or for a change to a basal-bolus regimen, if control remains inadequate. 

Now let’s have a look at the complications and how we would manage them.

We will advise patients at their annual review that:

·      they are at higher risk of periodontitis and that

·      if they get it, managing it can improve their diabetic control and that

·      they should have regular oral health reviews, as advised by their dental team. 

We will suspect gastroparesis if there is erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses and referring if the diagnosis is in doubt or there are persistent or severe symptoms. 

We need to explain to patients with vomiting caused by gastroparesis that:

·      there is no strong evidence that antiemetic therapy is effective

·      some people have had benefit with domperidone, erythromycin or metoclopramide and that

·      the strongest evidence for effectiveness is for domperidone, but its prescribing is limited by its safety profile, in particular its cardiac risk and potential interactions. 

To treat vomiting caused by gastroparesis:

·      we will consider alternating the use of erythromycin and metoclopramide first line and

·      we will consider domperidone only in exceptional circumstances and in accordance with MHRA advice.

For guidance on managing painful diabetic peripheral neuropathy, we are advised to consult the specific guideline on neuropathic pain.

My summary of this guideline is this:

If the neuropathic pain is localised and they wish to avoid oral treatments, we will consider topical treatment in the form of capsaicin cream. 

Otherwise, if oral therapy is preferred, we will offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as the initial treatment. Gabapentin and pregabalin are controlled drugs so it would make sense to start with either amitriptyline or duloxetine first.

If the initial treatment is not effective or tolerated, we will offer one of the remaining 3 drugs, and consider switching again if the second and third drugs are also not effective or tolerated.

And, as a general rule, when withdrawing or switching treatment, we will taper the dose to minimise any withdrawal symptoms.

So, for me, considering the cost of drugs and controlled drug status, I would consider:

1.   Amitriptyline first

2.   Then duloxetine,

3.   Then gabapentin and

4.   Lastly pregabalin

We will obviously refer if despite treatment the pain is severe, disabling or affecting their sleep or if their underlying condition has deteriorated.

As acute rescue therapy for neuropathic pain, we could consider tramadol, but only for short term use, as this is counterproductive in the long term.

When it comes to autonomic neuropathy, we will suspect it if there is a loss of hypoglycaemia awareness. 

After excluding other diagnoses, we will also consider the possibility of autonomic neuropathy affecting the gut or the bladder if there is unexplained diarrhoea or unexplained bladder‑emptying problems respectively. 

In addition, we will bear in mind that patients with autonomic neuropathy who are taking tricyclic drugs and antihypertensive drug treatments, have an increased risk of side effects such as orthostatic hypotension.

For men with erectile dysfunction, also after excluding other diagnoses, we will consider a phosphodiesterase‑5 inhibitor taking into account their cardiovascular state and any contraindications and we will refer them to specialist services if this treatment is unsuccessful. 

I will not go into the management of diabetic foot problems because this is covered in a separate guideline, and in terms of eye disease, I will only say that they need to be referred immediately to the local eye screening service as soon as they are diagnosed with type 2 diabetes.

Right, so this is it, this is the summary of the actual guideline. We will now have a look at some MCQs which will hopefully help you to test your knowledge and also assist you in remembering the facts more effectively.

The range of questions varies from fairly easy and straightforward ones to others which are more complex and require more thinking. After each question and their four options, there will be a pause of a few seconds only.

I also want to stress that the MCQs are intended only to revise concepts in the guideline from a general point of view. We know that diabetes management can be very flexible and it is perfectly fine to deviate from the guideline using our clinical judgement.

Finally, I am going to delegate the reading of the questions to an automated voice. I hope that you find it useful.

Right, so good luck with your self-test!

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/W0LL-1BwV3w?si=OT-GNCXaHoA7dcbs

This podcast makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through a National Patient Safety Alert released on 3.1.2024 by the Department of Health and NHS England on the shortage of GLP1 receptor agonists, touching on sections of the NICE guideline on type 2 diabetes as well as relevant pharmaceutical information, 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.   

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: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk 

The PDF document related to the safety alert on GLP- RA shortage can be found here:

·      https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAttachment.aspx?Attachment_id=104161

The safety alert on GLP- RA shortage can be found here:

·      https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103245

The Central Alerting System Homepage can be found here:

·      https://www.cas.mhra.gov.uk/Home.aspx

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• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
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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 am Fernando, a GP in the UK. In this episode I will go through a National Patient Safety Alert released on 3.1.2023 by the Department of Health and NHS England on the shortage of GLP1 receptor agonists, touching on sections of the NICE guideline on type 2 diabetes as well as relevant pharmaceutical information, always focusing on what is relevant in Primary Care only.

If you want to access the safety alert website or the associated PDF document, the link is in the episode description.

Right, let’s jump into it.

You are probably aware that the supply of GLP-1 receptor agonists continues to be limited, with supplies not expected to return to normal until at least the end of 2024. The supply issues have been caused by an increase in demand for these products for licensed and off-label indications.

The situation at the moment is that exenatide as Byetta® will be discontinued in March 2024. In addition, liraglutide as Victoza® continues to be out of stock and further stock is not expected until end of 2024. The supply of other agents such as injectable semaglutide as Ozempic® and Dulaglutide as Trulicity® may be unreliable and the shortages may cause significant issues.

So, what is the solution?

Well, oral semaglutide has come to the rescue. Semaglutide as Rybelsus® tablets are now available in sufficient quantities to support initiation of GLP-1 RA for type 2 diabetes in line with NICE guidance. 

So let’s remind ourselves of what NICE recommends for type 2 diabetes. 

NICE says that if triple therapy with metformin and 2 other oral drugs is not effective, not tolerated or contraindicated, we can consider triple therapy by switching one drug for a GLP‑1 receptor agonist if:

·      The BMI is 35 or higher and there are psychological or medical problems associated with obesity. We will adjust the BMI to 32.5 for people from Black, Asian and other minority ethnic groups or

·      For lower BMIs if:

o  insulin would have occupational implications or

o  weight loss would benefit other significant comorbidities.  

NICE also says that we should only continue GLP‑1 receptor agonists if there is a reduction in HbA1c of at least 1.0% or 11 mmol/mol and weight loss of at least 3% of the initial body weight in 6 months.  

And NICE also states that starting GLP1 RAs in combination with insulin should only happen following specialist advice and with ongoing support from a consultant-led service.  

So, what do we need to do until supply issues have resolved?

1. First, we must only prescribe GLP-1 RAs for licensed indications.

2. Second, we will prescribe Rybelsus® tablets for new initiations

3. Third, we should identify patients prescribed Byetta® and Victoza® and switch to Rybelsus® tablets, counselling patients accordingly and referring to structured education and weight management programmes where available

4. Fourth, we will discuss stopping GLP1-RA if patients have not achieved a beneficial metabolic response as per the NICE guideline, that is, again, a reduction in HbA1c of at least 1% or 11 mmol/mol and weight loss of at least 3% of initial body weight in 6 months. 

5. And finally, we should not double up a lower dose preparation or switch between strengths solely based on availability. 

So, if oral semaglutide is going to be prescribed a lot more, let’s familiarise ourselves with it and let’s have a look at the summary of product characteristics.

How do we initiate oral semaglutide or Rybelsus tablets?

The starting dose of oral semaglutide is 3 mg once daily for one month. After one month, the dose should be increased to a maintenance dose of 7 mg once daily. After at least one month on 7 mg, if necessary, the dose can be increased to a maintenance dose of 14 mg once daily to further improve glycaemic control.

The maximum recommended dose of oral semaglutide is 14 mg once daily but this should be achieved by prescribing one 14mg tablet, not two 7mg tablets.

What about if the patient is already on subcutaneous semaglutide? Well, switching between oral and subcutaneous semaglutide cannot be easily predicted because of the high pharmacokinetic variability of oral semaglutide. However, we can say that oral semaglutide 14 mg once daily is comparable to s.c. semaglutide 0.5 mg once weekly. An oral dose equivalent to 1.0 mg of s.c. semaglutide has not been established.

How should it be taken? It should be taken on an empty stomach, swallowed whole with a sip of water (up to a maximum of half a glass of water equivalent to 120 ml). Splitting, crushing or chewing the tablets may decrease the absorption.

Patients should wait at least 30 minutes before eating, drinking or taking other drugs. Waiting less than 30 minutes also decreases the absorption.

When oral semaglutide is used in combination with metformin, an SGLT2i or pioglitazone, the current dose of those drugs can be continued.

However, when used in combination with a sulfonylurea or with insulin, a reduction in the dose of sulfonylurea or insulin may be considered to reduce the risk of hypoglycaemia. Blood glucose self-monitoring is necessary for this reduction but otherwise, self-monitoring of blood glucose is not needed to adjust the dose of semaglutide.

No dose adjustment is required for patients with hepatic or renal impairment but semaglutide is not recommended in patients with end-stage renal disease.

When should we use it with caution?

Semaglutide should not be used in patients with bariatric surgery, severe congestive heart failure, type 1 diabetes mellitus or for the treatment of DKA. Diabetic ketoacidosis has been reported in insulin-dependent patients who had a rapid dose reduction of insulin following the start of oral semaglutide.

The use of GLP-1 receptor agonists may be associated with gastrointestinal adverse reactions that can cause dehydration, which in rare cases can lead to a deterioration of renal function. Nausea, diarrhoea, and vomiting tend to be mild to moderate in severity and of short duration normally during the first months on treatment.

Patients should be informed of the risk of acute pancreatitis and if it is suspected, semaglutide should be discontinued and, if confirmed, it should not be restarted. Caution should be exercised in patients with a history of pancreatitis.

In patients with diabetic retinopathy treated with insulin and s.c. semaglutide, an increased risk of developing diabetic retinopathy complications has been observed, and this risk cannot be excluded for oral semaglutide.

Because of a drug interaction, patient on levothyroxine should have their thyroid function tests monitored closely.

So, we have an oral medication that is simple to take and has few interactions. Why has it not been more widely recommended instead of the seemingly more problematic injections?

And the answer is because of its pharmacokinetic properties.

Oral semaglutide has a variable absorption and a low bioavailability, approximately 1% following oral administration. As we have mentioned, the absorption of semaglutide is decreased if taken with food or large volumes of water and a longer post-dose fasting period results in higher absorption.

The variability in absorption between patients is also high and if the treatment response is lower than expected, we need to be aware that it may be due to a low absorption and that 2-4% of patients will not have any exposure to it after oral administration.

On the other hand, with an elimination half-life of approximately 1 week, semaglutide will be present in the circulation for about 5 weeks after the last dose. The primary excretion routes are via the urine and faeces. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This podcast makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through new and updated guidelines published in December 2023 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.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for December 2023 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2023-12-01&to=2023-12-30&ndt=Guidance&ndt=Quality+standard 

The links to the update guidance covered can be found here:

Bipolar disorder: assessment and management:

·      https://www.nice.org.uk/guidance/cg185

Empagliflozin for treating chronic kidney disease:

·      https://www.nice.org.uk/guidance/ta942

Cardiovascular disease: risk assessment and reduction, including lipid modification:

·      https://www.nice.org.uk/guidance/ng238

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in December 2023, focusing on what is relevant in Primary Care only. We will be covering: valproate toxicity, empagliflozin for CKD, and cardiovascular risk reduction.  

The episode is fairly short so let’s jump into it.

The first clinical area refers to the use of valproate in the bipolar disorder guideline, in line with new MHRA guidance published in November 2023.

And perhaps we should remember that the previous MHRA advice stated that valproate must not be used in women and girls of childbearing potential unless other options are unsuitable and a pregnancy prevention programme is in place.

But the new safety advice is much stricter and states that valproate must not be started in people (either male or female) younger than 55 years, unless 2 specialists independently consider that there is no other treatment, or that the reproductive risks do not apply.

So, let’s have a look at this in a bit more detail.

We know that valproate must not be used in pregnancy as well as in any female of child bearing age unless there is a Pregnancy Prevention Programme in place, which involves an annual review and the requirement for highly effective methods of contraception (such as a hormonal intrauterine device). This is because of the risks of malformations and developmental problems.

Valproate is a known teratogenic drug, resulting in both physical birth defects and neurodevelopmental harm including lower intellectual abilities, poor language skills and memory problems.

Although the risk of structural malformations is greatest in the first trimester, the risk of neurodevelopmental harm is thought to be present throughout, and therefore valproate is never safe in pregnancy.

But the new guidance also includes males. Why is this?

Well, although less information is available regarding reproductive risk in male patients; these risks remain an area of concern. The risks of impaired fertility or male infertility with valproate have been known for some years. Additionally, there is suspected testicular toxicity in younger males and further studies are being carried out in this respect.

Furthermore, it is thought that there is an unknown risk to the foetus from paternal exposure to valproate in respect of both congenital abnormalities and neurodevelopmental disorders, including autism spectrum disorders, and further studies are underway to evaluate this.

Finally, there is also a concern about possible transgenerational risk. Whilst we know about harm in the first-generation offspring, animal studies have shown that some behavioural changes are transmitted by both males and females in the second and third generations. The underlying mechanisms of these findings are unknown, although we know that valproate can induce DNA changes which could lead to this transmission.

At present, we still await more studies focusing on transgenerational risk as well as possible epigenetic effects of valproate.

The next area refers to empagliflozin for treating chronic kidney disease.

And we know that the management of CKD aims to slow its progression. Standard care is lifestyle changes, and usually ACE inhibitors or ARBs. In addition, dapagliflozin is also recommended as an add-on to optimised standard care if eGFR is between 25 and 75 and the patient has type 2 diabetes or an ACR of 22.6 or more.

Clinical trial evidence suggests that empagliflozin plus standard care is also beneficial. There are no clinical trials directly comparing empagliflozin with dapagliflozin in CKD but an indirect comparison suggests that empagliflozin has a similar effectiveness and safety to dapagliflozin. The main empagliflozin clinical trial did not include anyone with eGFR levels less than 20 and patients with eGFR between 45 and 90 were only included if they also had an ACR of 22.6 or more. Therefore, empagliflozin can also be recommended, but only:

·      as an add-on to optimised standard care with an ACEi or ARB, unless contraindicated, and

·      if eGFR is:

o  more than 20 and but less than 45 or

o  between 45 and 90 and either the patient has:

§ an ACR of > 22.6

§ or type 2 diabetes

And the third and final area refers to the risk reduction of cardiovascular disease. The main update affects the lipid targets in the secondary prevention of CVD. But there are also some other changes in the recommendations for primary prevention.

So, let’s look at the statin recommendations for primary prevention first:

People with and without type 2 diabetes should have atorvastatin 20 mg daily if they have a 10‑year QRISK3 score of 10% or more. But, and this is slightly different now, we should not exclude patients just because the 10‑year QRISK3 score is less than 10% if either the patient would like to take a statin or if we feel that the risk may be underestimated. 

The lipid target for primary prevention is a greater than 40% reduction in non-HDL cholesterol. 

For people with type 1 diabetes, the recommendations are slightly different. We will offer atorvastatin 20 mg if they:

·      are over 40 or

·      have had diabetes for > 10 years or

·      have nephropathy or other CVD risk factors. 

But equally, we should now consider statin treatment for those aged 18 to 40 with type 1 diabetes, including those who have had diabetes for 10 years or less. 

NICE has changed the recommendations because evidence shows that statins are cost effective for people with 10‑year CVD risk scores of less than 10% because of the greater reduction in CV events. However, the recommendation to consider atorvastatin 20 mg for people with QRISK3 scores less than 10% is a change in practice and will have practical consequences in Primary Care in terms of both cost and workload.

Let’s now have a look at the recommendations for statin therapy for secondary prevention, which apply to people both with and without type 1 and 2 diabetes.

And the main change relates to a change in the lipid target. So, now, for secondary prevention, we need to aim for LDL cholesterol levels of 2.0 or less, or non-HDL cholesterol levels of 2.6 or less.

The initial treatment for secondary prevention is with atorvastatin 80 mg, whatever their cholesterol level, although we can consider a lower dose if:

·      there are drug interactions

·      there is a high risk of side effects or

·      the person would prefer a lower dose. 

In terms of escalating treatment for people on statins, there are also new recommendations.

First, if the person is on the maximum dose of a statin but the lipid target for secondary prevention is not met, we should consider additional lipid-lowering treatments with ezetimibe or the injectables alirocumab, evolocumab and inclisiran

This is because studies have shown that the combination of a statin and one of those other 4 lipid-lowering drugs produces reductions in both cholesterol and major CV events. The use of these drugs is also cost effective in people with an LDL of 2 or more or a non HDL cholesterol of 2.6 or more.

Second, we can also consider ezetimibe in addition to statins, even if the lipid target is met. This is because studies have shown that the combination is effective in reducing CV events and ezetimibe is cost effective regardless of cholesterol levels.

It is expected that the new recommendations will lead to an increased use of lipid-lowering treatments. This will result in higher costs to the NHS and also an increased workload in primary care. However, the extra cost of lipid-lowering treatment would be partly offset by savings due to a reduction in CVD events

There are also some new minor changes as to when to repeat blood tests. The guidance says that we should measure liver transaminase and full a lipid profile at 2 to 3 months after starting or changing the lipid-lowering treatment. A timeframe of 2 to 3 months offers more flexibility and is reflective of actual clinical practice, rather than at 3 months of treatment as recommended in the 2014 guideline. The requirement to check a full lipid profile instead of a random cholesterol level, will result in higher monitoring costs too.

After that, we will measure liver transaminase at 12 months, but not again unless clinically indicated. However, an annual medication review offering an annual full lipid profile is recommended for both primary and secondary prevention.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the “National Institute for Health and Care Excellence” in the UK, also referred to as “NICE”. 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the NICE guidance on the management of lower urinary tract symptoms in men.

I will summarise the guidance from a Primary Care perspective only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

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: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The full clinical guideline CG97 on lower urinary tract symptoms in men: management can be found here:

·      https://www.nice.org.uk/guidance/cg97

The International Prostatism Symptom Score calculator can be found here:

·       https://www.uptodate.com/contents/calculator-international-prostatism-symptom-score-ipss

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

• Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE guidance on the management of lower urinary tract symptoms in men, which I have summarised from a Primary Care perspective.

So, let’s jump into it.

And to appreciate fully the importance of this subject, let’s have a look at this anonymous poem:

“As man draws near the common goal

Can anything be sadder

Than he who, master of his soul

Is servant to his bladder‟

And, of course, we know that the prevalence and severity of male lower urinary tract symptoms, also known as LUTS, increase with age and although transurethral resection of the prostate is often effective, about a quarter of men have poor post-surgical outcomes and some failures can be attributed to an incorrect initial diagnosis.

So, let’s start by talking about the conditions that can cause LUTS in men.

And in order to get the correct diagnosis, we should remember the ancient Chinese proverb that says that the “bladder is the mirror of the soul‟ and therefore LUTS can result from not only bladder dysfunction or prostatic pathology but also from a number of other causes, e.g., metabolic, hormonal, cardiac, respiratory, etc. And therefore, effective therapy depends on the accurate diagnosis of the underlying problem.

Although, the most common cause is benign prostate enlargement (BPE), which obstructs the bladder outlet, the term LUTS is an umbrella term introduced to dispel the perception that male urinary symptoms are simply caused by prostate problems.

Because other conditions, for example, detrusor muscle problems, prostatitis, UTIs, prostate cancer and neurological disease, can also cause LUTS.

We also need to be aware of the 3 stages of the bladder cycle, which are:

·      Storage - during which filling of the bladder occurs

·      Voiding - during which the bladder actively expels its contents and

·      Post micturition - immediately after voiding when the bladder returns to storage function.

And as a result, LUTS comprise three different types of symptoms:

·      First, storage symptoms normally causing daytime urinary frequency, nocturia, urgency and urinary incontinence

·      voiding symptoms, causing slow stream, spraying, intermittency, hesitancy, straining, and terminal dribbling and

·      post micturition symptoms, for example, sensation of incomplete emptying, and post micturition dribbling

In the management of male LUTS we need to understand that we are dealing with a complex functional unit comprising the bladder, bladder neck/prostate and urethra. LUTS may result from a combination of factors and, to avoid confusion, we should use the correct clinical terms. So let’s have a look at them:

·      “Benign prostatic hyperplasia” or BPH should be reserved for histopathological prostate hyperplastic changes (i.e. abnormality at the cell level). The prevalence of BPH increases with age and whilst it is often associated with LUTS, only 25% to 50% of men with BPH have symptoms.

·      “Benign prostatic enlargement” or BPE refers to an increase in size of prostate gland due to BPH. But only about half of men with hyperplasia will develop clinical enalrgement.

·      “Bladder outlet obstruction” (BOO) is an urodynamically diagnosed condition characterised by increased detrusor pressure and reduced urine flow rate.

·      “Overactive bladder” presents with urinary urgency, with or without incontinence, usually with frequency and nocturia. OAB does not include stress incontinence due to a weak sphincter or overflow incontinence due to chronic retention.

·      And finally, Detrusor overactivity (DO) is urodynamically characterised by involuntary detrusor contractions during the bladder filling phase and occurs in about two thirds of OAB cases and 50% of those with BOO.

There is also a clear association between LUTS and sexual dysfunction, including erectile dysfunction, ejaculatory dysfunction, decreased sexual activity and decreased sexual desire. However, we will not cover this area in today’s episode.

At initial assessment in General Practice, we will review their current medication and take a history and examination including an examination of the abdomen, genitalia, a digital rectal examination as well as a urine dipstick. 

We will check creatinine and eGFR if concerned about renal impairment and we will give information about PSA testing if:

·      their LUTS are suggestive of bladder outlet obstruction secondary to benign prostate enlargement (BPE) or

·      their prostate feels abnormal on digital rectal examination or

·      they are concerned about prostate cancer

If there are bothersome LUTS we could ask the patient to complete a urinary frequency volume chart and we will refer if the patient has not responded to the initial management or have complications such as UTIs, retention, renal impairment or suspected urological cancer. 

For uncomplicated LUTS, we will not routinely offer:

·      Cystoscopy

·      Imaging of the upper urinary tract

·      Flow-rate measurement

·      a post-void residual volume measurement

Although these investigations as well as other ones may be carried out following specialist referral.

To assess response to treatment, we should use a validated symptom score (for example, the International Prostatism Symptom Score or IPSS) before and after the intervention. There are online calculators that can facilitate this and I have included a link in the episode description.

As conservative management, we should offer advice on fluid intake and lifestyle measures, for example:

• cut down on fizzy drinks, and/or drinks that contain alcohol or caffeine

• avoid excessive drinking, aiming for between 1.5 and 2 litres of fluid a day and

• avoid constipation

If there is post-micturition dribble, we will advise how to perform urethral milking. 

If LUTS are suggestive of overactive bladder, we should refer to local community continence services for supervised bladder training

We should refer to urology if there is stress urinary incontinence but

If stress urinary incontinence is caused by prostatectomy, we should offer supervised pelvic floor muscle training for at least 3 months, again via local community continence services.

For urinary incontinence:

·      We will give temporary products, for example, pads or collecting devices, while waiting for a definitive management.

·      External collecting devices, for example, sheath appliances, pubic pressure urinals should be used before indwelling catheterisation

·      Intermittent bladder catheterisation should be considered before indwelling catheterisation.

·      Long-term indwelling urethral catheterisation maybe suitable when:

• medical management has failed and surgery is not appropriate and
• the patient is unable to manage intermittent self-catheterisation or
• there are skin problems aggravated by contact with urine or
• the patient is distressed by bed and clothing changes and

We will refer patients with symptoms of urinary retention and ensure that:

·      Men with acute retention are catheterised urgently and that

·      An alpha blocker should be given before removal of the catheter

·      Checking creatinine and imaging of the upper urinary tract is recommended for chronic urinary retention and

·      Surgery or permanent catheterisation will be guided by urology services

Drug treatment will be offered only when conservative management has been unsuccessful, after taking into account comorbidities and current medication.

Drug treatment may be guided by Urology but, in summary, we should be aware of the following:

·      An alpha blocker (like alfuzosin, doxazosin, tamsulosin or terazosin) can be offered to men with moderate to severe LUTS

·      An anticholinergic can be given if there are symptoms of an overactive bladder

·      A 5‑alpha reductase inhibitor such as finasteride can be given if LUTS are present with a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml

·      A combination of an alpha blocker and a 5‑alpha reductase inhibitor can be given if they have both moderate to severe LUTS and a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml.

·      An anticholinergic as well as an alpha blocker can be given if there are storage symptoms such as daytime urinary frequency, nocturia, urgency and urinary incontinence after treatment with an alpha blocker alone. 

·      A late afternoon loop diuretic may be offered if there is nocturnal polyuria although this is an unlicensed indication

·      Oral desmopressin may be offered to men with nocturnal polyuria if other medical causes have been excluded and they have not benefited from other treatments. This is an unlicensed indication and sodium should be measured 3 days after the first dose and desmopressin should be stopped if sodium is below the normal range.

We need to be aware that medical conditions that can cause nocturnal polyuria symptoms include diabetes mellitus, diabetes insipidus, adrenal insufficiency, hypercalcaemia, liver failure, polyuric renal failure, chronic heart failure, obstructive apnoea, dependent oedema, pyelonephritis, chronic venous stasis, and sickle cell anaemia.

Equally, medications that can cause nocturnal polyuria symptoms include calcium channel blockers, diuretics, and SSRIs.

We will review patients regularly to monitor symptoms and medication:

·      We will review men taking alpha blockers at 4 to 6 weeks and then every 6 to 12 months. 

·      We will review men taking 5‑alpha reductase inhibitors at 3 to 6 months and then every 6 to 12 months. 

·      We will review men taking anticholinergics every 4 to 6 weeks until symptoms are stable, and then every 6 to 12 months. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guideline. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through a number of NICE products on insomnia, including guidance on the medical technology sleepio, and the prescribing of z-drugs, daridodexant and melatonin.

I will summarise the guidance from a Primary Care perspective only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

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:  

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Medical technologies guidance [MTG70] on “Sleepio to treat insomnia and insomnia symptoms” can be found here:

·      https://www.nice.org.uk/guidance/mtg70

The Technology appraisal guidance [TA77] “Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia” can be found here:

·      https://www.nice.org.uk/guidance/ta77

The Technology appraisal guidance [TA922] “Daridorexant for treating long-term insomnia” can be found here:

·      https://www.nice.org.uk/guidance/ta922

The Evidence summary [ES38] “Melatonin for treating sleep disorders in adults who are blind” can be found here:

·      https://www.nice.org.uk/advice/es38/chapter/Product-overview

Thumbnail photo: from Freepik: https://www.freepik.com/

·      Image by Freepik

·      Image by a href="https://www.freepik.com/free-photo/flat-lay-woman-laying-bed_28694061.htm#query=insomnia&position=21&from_view=search&track=sph&uuid=65539da6-4c29-453b-9d22-c39df5176601"Freepik/a

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

Music provided by Audio Library Plus   

Watch: https://youtu.be/aBGk6aJM3IU  

Free Download / Stream: https://alplus.io/halfway-through  

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through a number of NICE publications on insomnia, including guidance on digital cognitive behavioural therapy for insomnia (CBT-I), and the prescribing of hypnotics, daridodexant and melatonin, all of them from a Primary Care perspective.

By the way, make sure that you stay for the entire episode because, at the end, I will go through some audit ideas backed by NICE which you could use as a Quality Improvement Project in your practice.

So, let’s jump into it.

Let’s talk a little about the condition first.

Insomnia is a disturbance of sleep characterised by difficulty in initiating and/or maintaining sleep. However, insomnia is highly subjective and although most healthy adults typically sleep between 7 and 9 hours per night, patterns vary between people, and in any given person there are also variations from night to night.

Estimates of the prevalence of insomnia vary and while up to 48% of people have reported sleeping issues, only 6% met the criteria for a diagnosis of insomnia. So, in general practice, differentiating between simple sleeping problems and significant insomnia is important before considering treatment.

The prevalence of insomnia is higher in women and increases with age and, although the majority do not seek medical advice, the treatment depends on the duration and nature of the symptoms. Appropriate management of co-morbidities may help and sleep hygiene advice is fundamental, for example, avoiding stimulants and maintaining regular sleeping hours with a suitable environment for sleep. Other non-pharmacological interventions, for example, cognitive behavioural therapies, are also effective.

Insomnia can have a number of different causes: primary insomnia can be differentiated from insomnia associated with factors such as personal circumstances, physical or psychiatric co-morbidities, concomitant drug treatments or substance abuse. Epidemiology surveys have shown that over half of people with sleep problems have either a mental or a physical health disorder.

And in this video, we will not be talking about specific issues caused by physical conditions such as sleep apnoea or narcolepsy or sleep disturbances associated to severe mental illness.

For the management, it is crucial to differentiate between short-term insomnia and long-term insomnia.

For short-term insomnia, sleep hygiene advice is offered. After this, medicines such as zopiclone, zolpidem and melatonin can be used for a short time, that is, less than 4 weeks or less than 13 weeks for melatonin. In addition, up to 40% of people with insomnia self-medicate with over-the-counter drugs, for example, sedative antihistamines.

However, long-term insomnia, also known as chronic insomnia, is different and it’s defined as dissatisfaction with quantity or quality of sleep for 3 nights or more per week for at least 3 months with an effect on daytime functioning. Therefore, long-term insomnia has both night-time and daytime symptoms. Furthermore, once insomnia has lasted for more than 6 months, it may last for years and be difficult to resolve.

For long term insomnia, sleep hygiene advice is given first and then, CBT-I is the recommended first-line treatment. But there are access difficulties to CBT-I across the country and in many areas access is poor. And this is a real pity because CBT-I has a 70% to 80% response rate and roughly 50% experience long-term remission.

NICE has published 17 products on insomnia but the majority are for sleep apnoea and narcolepsy. Only 4 would be relevant for this video and these are:

·      The Medical Technology Sleepio

·      Advice on hypnotics like benzodiazepines and Z-drugs such as zolpidem and zopiclone

·      Recommendations on Daridorexant

·      And finally, we will also briefly touch on melatonin

Sleepio is a digital self-help programme that includes CBT‑I and that reduces symptoms compared with sleep hygiene and sleeping tablets. The gold standard treatment for insomnia is face-to-face CBT-I, but its availability is very limited and therefore Sleepio is recommended as an alternative to sleeping tablets. Unfortunately, Sleepio is not available on the NHS in all regions of the UK either.

Let’s have a look at the recommendations on hypnotics like benzodiazepines and Z-drugs such as zolpidem and zopiclone. They can be considered after sleep hygiene but for a short time only and bearing in mind that they do not treat any underlying cause.

A number of hypnotic agents are licensed for the treatment of insomnia, including benzodiazepines and Z-drugs.

Benzodiazepines enhance the effects of GABA, which is the major inhibitory neurotransmitter in the central nervous system. Examples licensed for insomnia are, amongst others, nitrazepam, temazepam and lorazepam.

The effects of benzodiazepines are dependent upon the dose administered and the pharmacokinetic profile. The BNF refers to temazepam and lorazepam, as having a shorter duration of action. Benzodiazepines with a longer half-life like diazepam and nitrazepam tend to have prolonged effects the next day.

The main concern with benzodiazepines is that many people develop tolerance to their effects, gain little benefit from chronic use, become both physically and psychologically dependent on them, and suffer withdrawal symptoms when stopping them. 'Rebound insomnia' also occurs and is characterised by worsening insomnia symptoms.

The use of benzodiazepines for the treatment of insomnia should be restricted to severe insomnia and treatment should not be continued beyond 4 weeks.

Zolpidem and zopiclone (the Z-drugs) are non-benzodiazepine hypnotics. Although the Z-drugs differ structurally from the benzodiazepines, they are also agonists of the GABA receptor complex and therefore enhance GABA-mediated neuronal inhibition.

Zolpidem has a half-life of 2.5 hours and Zopiclone of between 3.5 and 6.5 hours. They are licensed for "the short-term treatment of insomnia in situations where the insomnia is debilitating or is causing severe distress for the patient". The duration of treatment is a maximum of 4 weeks, including tapering off where appropriate.

Although the Z-drugs were developed to overcome the disadvantages of benzodiazepines, the sedative effects of the Z-drugs may also persist into the next day and they can cause tolerance, dependence and withdrawal symptoms.

It may be worth mentioning that, a review of the trial evidence comparing the Z-drugs with benzodiazepines licensed for insomnia showed, in summary, that there were no clinically useful differences between the drugs.

Because of the lack of evidence to distinguish between zolpidem and zopiclone, the drug with the lowest purchase cost should be prescribed and switching from one to another should only occur if a patient experiences adverse effects considered to be directly related to a specific agent.

Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others.

So, we have now seen that short term insomnia can be treated with sleep hygiene and short-term use of hypnotics and long-term insomnia with sleep hygiene and either face to face CBT-I or digital CBT-I like Sleepio.

But what does NICE recommend for long term insomnia if CBT-I or Sleepio have not worked or are not available?

And here is where we find the latest NICE guidance on this issue, published in October 2023. It refers to a new type of drug, Daridorexant.

And NICE says that Daridorexant is both clinically and cost effective and it is recommended for insomnia lasting for 3 nights or more per week for at least 3 months, with affected daytime functioning but only if:

·      cognitive behavioural therapy for insomnia (CBT-I) is ineffective or

·      it is not available or is unsuitable.

What is daridorexant? Well, Daridorexant is now available on the BNF and unlike benzodiazepines and Z-drugs, which work by increasing sedation, daridorexant is a new type of drug, an orexin antagonist, which works in a different way. It inhibits arousal mechanisms. To understand this, we need to know that orexins are neuropeptides produced by the hypothalamus which promote a state of wakefulness. Therefore, daridorexant, by blocking the orexin receptors, reduces wakefulness and helps sleep.

Because of the different mechanism of action, if necessary, daridorexant could be used at the same time as other medicines or non-medicine treatments available for insomnia.

And the good news is that, in clinical studies, there has been no evidence of abuse or withdrawal symptoms indicative of physical dependence.

NICE recommends that the length of treatment should be as short as possible and the treatment should be reviewed within 3 months of starting and at regular intervals thereafter. But it can be used as maintenance treatment for managing longer-term symptoms if necessary.

Now let’s touch on the prescribing of Melatonin for insomnia.

Melatonin is a hormone that occurs naturally in the body. It is involved in regulating sleep and circadian rhythms and it can be given as an oral medication to treat sleeping problems.

There is little NICE guidance on the use of melatonin. There is only an evidence summary on the use of melatonin for treating sleep disorders in adults who are blind, and, because of insufficient evidence, NICE was unable to determine its clinical effectiveness and safety.

The BNF states that melatonin is indicated as:

·      Short-term treatment for Insomnia in adults over 55 for up to 13 weeks

·      Short-term treatment for Jet lag in adults for up to 5 days, and

·      Treatment for Insomnia in patients with learning disabilities and challenging behaviour, although this use is unlicensed and it needs to be initiated under specialist supervision

Cautions for melatonin include autoimmune disease, as exacerbations have been reported occasionally, and susceptibility to seizures, as there is a risk of increased seizure frequency

Reported side effects are, amongst others, arthralgia, increased risk of infection, drowsiness, headaches, and pain

Now, as promised let’s have a look at audit ideas on the use of hypnotics (including Z-drugs) suggested by NICE and that you could use for a Quality Improvement Project in your Practice.

The objectives for the audit would be to assess the appropriateness of use of zolpidem and zopiclone.

The patients to be included in the audit could be, for example, all those for whom zolpidem and zopiclone are prescribed for a suitable period of time, for example, 3–6 months.

Possible audit criteria could be the following four:

Criterion 1- Non-pharmacological measures are considered before prescribing:

·      The standard would be 100% of all patients without exception

Criterion 2- When prescribed, hypnotic drug therapy is prescribed for a short period of time only, in strict accordance with the licensed indications:

·      The standard would also be 100% of all patients without exception

Criterion 3- When prescribed, the hypnotic drug with the lowest cost is chosen:

·      The standard would be 100% of all patients with the exception of those who have developed side effects with a cheaper first line agent

Criterion 4- A patient is switched from one hypnotic drug to another:

·     As switching is not recommended, the standard would be 0% of all patients with the exception of those who have developed adverse effects considered to be directly related to a specific agent

Once compliance has been calculated, the Practice can identify whether clinical management can be improved, agree on a plan and repeat the measurement after a period of time to close the audit cycle and to confirm that the desired improvement has been achieved.

And there you have it, a simple project to fulfil your QIP requirements for appraisal.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guideline. You must always use your clinical judgement.

Thank you for listening and goodbye.

This podcast makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through new and updated guidelines published in November 2023 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 interpretation of the guidelines and you must use your clinical judgement.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Clinic BP targets flowchart can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFp2iUfq8rimJSmo?e=BnJaCD

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

The Full NICE News bulletin for November 2023 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2023-11-01&to=2023-11-30&ndt=Guidance&ndt=Quality+standard

The links to the update guidance covered can be found here:

Hypertension in adults: diagnosis and management:

·      https://www.nice.org.uk/guidance/ng136

Transient loss of consciousness ('blackouts') in over 16s:

·      https://www.nice.org.uk/guidance/cg109

Suspected acute respiratory infection in over 16s: assessment at first presentation and initial management:

·      https://www.nice.org.uk/guidance/ng237

Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction:

·      https://www.nice.org.uk/guidance/ta929

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Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

Music provided by Audio Library Plus  

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in November 2023, focusing on what is relevant in Primary Care only. We will be covering: postural hypotension, empagliflozin for HFpEF, and acute respiratory infections.

Make sure to stay for the entire episode because, at the end, I will go through the new tables published by NICE summarising blood pressure targets in the hypertension guideline as well as in the guidelines on type 1 diabetes and CKD. If you wish to download a version of this table, I will put a link in the episode description

The episode is fairly short so let’s jump into it.

The first clinical area is an update on the guidance on measuring and managing postural hypotension.

This update is the result of an issue raised with NICE. The previous outdated guideline recommended that for people with symptoms of postural hypotension such as falls or postural dizziness, we should take the initial measurement of blood pressure either in the seated or supine position, and then have the BP measured again with the person standing for at least 1 minute. This is to establish if there is a significant BP drop when the person is standing.

However, it was queried that measuring blood pressure in the sitting (rather than the supine position) followed by the standing position may miss a significant proportion of postural hypotension cases, particularly in older and frail people.

So, following the review, it was decided that, based on international consensus, supine to standing blood pressure measurement is the best practice and it is preferable to the sitting to standing measurements.

Therefore, the guideline was updated along these lines. However, the guidance still says that if it is inconvenient to take the blood pressure measurement in the supine position, a seated position may be considered.

This change affects not only the guideline on hypertension but also the guideline on transient loss of consciousness.

So, in summary the new recommendations state that when checking for postural hypotension, the lying down or supine position is preferred to a seated position, then we will recheck the standing BP after at least 1 minute of the patient standing and if the systolic blood pressure falls by 20 mmHg or more, or diastolic blood pressure falls by 10 mmHg or more when standing, then we will diagnose postural hypotension. In that case:

·      We will consider the likely causes including a medication review

·      We will manage the risk of falls appropriately

·      And we will consider referral to specialist care if symptoms persist

However, if the BP drop is less than these thresholds despite a suggestive history:

·      We will repeat the measurements with the person lying down if the first measurement was taken while seated and

·      We will refer the person for specialist cardiovascular assessment if the symptoms persist and remain unexplained.

As a reminder, we should check for postural hypotension in people:

·      With symptoms such as falls or postural dizziness as well as people

·      With type 2 diabetes and those

·      Aged 80 or over

And we must also remember that if there is a significant postural drop or three are symptoms of postural hypotension, we will treat to a blood pressure target based on standing blood pressure.

Finally, on a separate issue, NICE will no longer use in their guidelines the term “orthostatic hypotension” and they will only use the term “postural hypotension” instead.

The second clinical area refers to the use of empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction

You may be aware that empagliflozin is already recommended for chronic heart failure with reduced ejection fraction in adults and that dapagliflozin is recommended for both HFrEF and HFpEF.

And following this update, empagliflozin is now recommended as an option for chronic heart failure with preserved or mildly reduced ejection fraction in adults, although it should only be started on the advice of a heart failure specialist.

And let’s remind ourselves that chronic heart failure with preserved or mildly reduced ejection fraction is usually treated with standard care using loop diuretics, and treatment for other comorbidities that the patient may have and, following a recent NICE updates, patients may also have dapagliflozin.

Empagliflozin works in a similar way to dapagliflozin and evidence shows that empagliflozin also reduces cardiovascular mortality and hospitalisations for heart failure. There is no clinical trial evidence directly comparing empagliflozin with dapagliflozin but when adjustments for clinical trial differences are made, the comparison suggests that both drugs have similar clinical effect on quality of life.

Also, because empagliflozin has similar costs to dapagliflozin, empagliflozin can therefore be recommended too.

The third and final clinical area is on the initial management of suspected acute respiratory infection. And, to be honest, this update is hardly worth mentioning because it only spells out what we have always been doing, that is, that the threshold for treatment or referral may be lower for people who are more likely to have a poor outcome, for example, people with comorbidities or multimorbidity and people who are frail. So, we may be justified prescribing antibiotics early, or admitting those patients who we are most worried about because of their age, frailty or medical conditions.

And now, as promised, let’s have a look at the two tables that NICE has produced to clarify the blood pressure targets. But we must first remember that there are separate guidelines for hypertension in pregnancy.

And there are 2 tables, one for the under 80s and one for those aged 80 and over. And these tables cover people with hypertension with or without type 2 diabetes as well as people with CKD or type 1 diabetes.

So, in the under 80s we have two targets:

·      Below 140/90 for those with:

o  Hypertension, with or without type 2 diabetes

o  Type 1 diabetes and ACR less than 70 or

o  CKD and ACR less than 70

·      Below 130/80 for those with

o  Type 1 diabetes and ACR of 70 or more or

o  CKD and ACR of 70 or more

And, in those aged 80 and over, we have three targets:

·      Below 150/90 for those with:

o  Hypertension, with or without type 2 diabetes or, and this may come as a surprise,

o  Type 1 diabetes regardless of ACR levels. Then it is

·      Below 140/90 for those with:

o  CKD and ACR less than 70 and finally it is

·      Below 130/80 for those with

o  CKD and ACR of 70 or more

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom.

In this episode I will go through the NICE guideline on “Menopause: diagnosis and management” or NICE guideline NG23.

I will summarise the guidance from a Primary Care perspective only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.

There is a YouTube version of this and other videos that you

can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE guideline NG23 “Menopause: diagnosis and

management” can be found here: 

https://www.nice.org.uk/guidance/NG23

The guidance

from the Faculty of Sexual & Reproductive Healthcare on contraception for

women aged over 40 years can be found here:

http://www.fsrh.org/pdfs/ContraceptionOver40July10.pdf

The MHRA summary of HRT risks and benefits during current use and

current use plus post-treatment from age of menopause up to age 69 years, per

1000 women with 5 years or 10 years use of HRT can be found here:

https://assets.publishing.service.gov.uk/media/5d680409e5274a1711fbe65a/Table1.pdf

The summary flowchart with examples of preparations can be found here:     

https://1drv.ms/b/s!AiVFJ_Uoigq0mFjbJIiJs842urJB?e=FcfiJl

Thumbnail photo: from Freepik: https://www.freepik.com/    

Image by LipikStockMedia on

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by LipikStockMedia/a on Freepik

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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Mrs Brown sees you

because wants to discuss HRT in detail, including the pros and cons of the

various preparations available. Do you say?: “of course, ask me anything you

want” or do you go? …..

If you are in the second group then you know exactly how I feel. So, today,

we will go through the NICE guideline on the diagnosis and management of the

menopause from a Primary Care perspective.

Make sure to stay for the entire episode because, at the end, I will

also go through a one-page summary flowchart giving cost effective examples of

various preparations available which you will also be able to download

So, let’s jump into it.

And let’s start by saying that possible symptoms of

the menopause include:

·       a change in their menstrual

cycle

·       vasomotor symptoms (e.g., hot

flushes and sweats)

·       musculoskeletal symptoms (e.g.,

joint and muscle pain)

·       effects on mood (e.g., low mood)

·       urogenital symptoms (e.g.,

vaginal dryness) and

·       sexual difficulties (e.g., low

sexual desire).

When these symptoms are present, most women will

ask for a blood test to check if they are menopausal. Is this really necessary?

Well, most of the time, it isn’t. Because NICE says that we can make the

following diagnoses without checking FSH:

perimenopause in women over 45 with vasomotor

symptoms and irregular periods and

menopause in women over 45:

·       If they are not using

contraception and have had no periods for at least 12 months or

·       based on symptoms alone if the

woman does not have a uterus

Of course, diagnosis can be more difficult if they are on hormonal

treatments but still, we should not check FSH if the woman is on combined

hormonal contraception or high-dose progestogen.

However, we will consider checking FSH levels to diagnose menopause:

·       in women aged 40 to 45 with

menopausal symptoms, including a change in their menstrual cycle and

·       in women under 40 in whom the menopause

is suspected.

Once we have made the diagnosis, we will give information about lifestyle

changes, and benefits and risks of treatments, giving information about:

·       hormonal treatment, e.g. HRT

·       non-hormonal treatment, e.g.

clonidine

·      

non-pharmaceutical treatment,

e.g. CBT

We will also give information about contraception in the perimenopausal

and postmenopausal phase. I have put a link to the guidance in the episode

description but a very simplified summary is that:

·       CHC should be stopped at 50 and

switch to a safer method

·       Contraception can be stopped at

55 as the risk of pregnancy is extremely low by then

If the menopause is a result of medical or surgical treatment, we will:

·       Give information about fertility

before that treatment and

·       We will refer to a menopause

specialist

In terms of managing menopausal symptoms, this

summary is not intended for women with premature ovarian insufficiency, that is, women aged under 40

For vasomotor symptoms we will offer HRT after discussing benefits and

risks. We will offer a choice of:

·       oestrogen and progestogen to

women with a uterus or

·       oestrogen alone to women without

a uterus.

We will not routinely offer SSRIs, SNRIs or clonidine as first-line

treatment for vasomotor symptoms alone.

We will explain that there is some evidence that isoflavones or black

cohosh may relieve vasomotor symptoms but that:

·       preparations may vary

·       their safety is uncertain and

·       Drug interactions have been

reported

In terms of psychological symptoms, we will consider HRT to treat menopause

related low mood

And also consider CBT to treat menopause related low mood or anxiety

Remember that there is no clear evidence for SSRIs or SNRIs for low mood

in menopausal women without a diagnosis of depression.

We will consider testosterone supplementation for menopausal women with

low sexual desire if HRT alone is not effective. The BNF says that it is not licensed for this indication so seeking specialist

advice before initiation may be advisable

For urogenital atrophy we will offer vaginal oestrogen (including for

those on systemic HRT) and we will continue treatment for as long as needed to

relieve symptoms.

We will also consider vaginal oestrogen for urogenital atrophy in those

for whom systemic HRT is contraindicated, after seeking specialist advice.

If vaginal oestrogen does not relieve symptoms we will also seek

specialist advice before increasing the dose

However we will also explain that:

·       symptoms often come back when

treatment is stopped

·       that adverse effects from

vaginal oestrogen are very rare and

·       that they should report

unscheduled vaginal bleeding

Moisturisers and lubricants for vaginal dryness can be used alone or in

addition to vaginal oestrogen.

And finally we will not offer routine monitoring of endometrial

thickness during treatment with vaginal oestrogen.

In terms of complementary therapies we will explain that the efficacy,

safety, quality and purity of unregulated compounded bioidentical hormones may

be unknown and we will also advise that there is also uncertainty about the

appropriate use of St John's wort

Once treatment has been started, we will review patients:

·       at 3 months to assess the efficacy

and tolerability and

·       annually thereafter unless more

often is clinically indicated

We will refer women for specialist advice if:

·       treatments are ineffective or

cause side effects

·       there are contraindications to

HRT or

·       there is uncertainty about the

most suitable treatment option

In terms of starting and stopping HRT, we will explain that unscheduled vaginal

bleeding is a common side effect of HRT within the first 3 months of treatment

but it should be reported at the 3-month review, or promptly if it occurs after

the first 3 months

When stopping HRT we will consider the choice of gradually reducing or

immediately stopping treatment explaining that:

·       gradually reducing HRT may limit

recurrence of symptoms in the short term but that

·       either approach makes no

difference to their symptoms in the longer term

There are separate guidelines on the treatment of

menopausal symptoms for women with, or at high risk of, breast cancer, but

in general:

·       we will refer to a menopause

specialist

·       and ensure that paroxetine and

fluoxetine are not given if the patient is on tamoxifen

In terms of long-term benefits and risks of HRT, there

is an MHRA summary of HRT risks and benefits that we can refer to explain the

absolute rates per 1000 women with 5 years or 10 years use of HRT. It is a

useful one-page resource and I have included a link to this table in the

episode description.

But in summary, let’s go through the different possible risks.

In terms of venous thromboembolism we will explain that:

·       the risk of VTE is increased by

oral HRT

·       that the risk is greater for

oral than transdermal preparations and

·       that the risk of transdermal HRT

is no greater than baseline

Therefore we will consider transdermal rather than oral HRT if the woman

is at increased risk of VTE, including those with a BMI over 30

But we will consider haematology referral if the patient is at high

risk, e.g.:

·       if there is a strong family

history of VTE or thrombophilia

For cardiovascular disease we will explain that HRT:

·       does not increase CVD risk if

aged under 60 and

·       that it does not affect the

cardiovascular mortality

And we must remember that cardiovascular risk factors are not a

contraindication to HRT as long as they are optimally managed.

So we will explain that:

·       the baseline CVD risk varies

depending on risk factors

·       that HRT with oestrogen alone is

associated with no, or reduced, risk of coronary heart disease

·       and that HRT with oestrogen and

progestogen is associated with little or no increase in the risk of coronary

heart disease

But we will also explain that oral oestrogen is associated with a small

increase in the risk of stroke but that the baseline risk under 60 is very low

We will indicate that HRT does not increase the risk of developing type

2 diabetes and does not have an adverse effect on glucose control but we will consider

comorbidities and specialist advice before giving HRT in type 2 diabetes

In terms or breast cancer risk, we will make it

clear that:

·       the baseline risk varies

according to risk factors

·       that HRT with oestrogen alone is

associated with little or no change in the risk

·       that HRT with oestrogen and

progestogen can be associated with an increase in the risk of breast cancer but

·       that any increase in the risk is

related to treatment duration and it goes down after stopping HRT

When discussing osteoporosis, we will give women advice on bone health

and inform them that the risk of fragility fracture around menopausal age is

low and varies from one woman to another.

We will say that their risk of fragility fracture is reduced while

taking HRT and that this benefit:

·       remains during treatment but

decreases once HRT stops and

·       that it may continue for longer

for those who take HRT for longer

We will tell patients that the effect of HRT on the

risk of dementia is unknown

And that:

·       HRT may improve muscle mass and

strength

·       And that Being active helps

maintain muscle mass and strength

We will now touch on the diagnosis and management

of premature ovarian insufficiency

And we will diagnose premature ovarian insufficiency under 40 years of

age based on:

·       menopausal symptoms (including

no or infrequent periods) and

·       elevated FSH levels on 2 samples

taken 4–6 weeks apart

We will not diagnose premature ovarian insufficiency on a single blood

test and we will not routinely check anti-Müllerian hormone to diagnose it

If there is doubt about the diagnosis, we will seek specialist advice

For their management we will consider referral but

we may also offer a choice of HRT or a combined hormonal contraceptive unless

contraindicated

We will explain:

·       the importance of hormonal

treatment either with HRT or a combined hormonal contraceptive until at least

the age of natural menopause

·       that the baseline population

risk of diseases such as breast cancer and cardiovascular disease increases

with age and is very low in women aged under 40

·       that HRT may have a beneficial

effect on blood pressure when compared with a combined oral contraceptive

·       that both HRT and combined oral

contraceptives offer bone protection and

·       that HRT is not a contraceptive 

If hormonal treatment is contraindicated we will give advice on bone and

cardiovascular health.

Now, as promised, let’s have a look at our one-page summary flowchart,

giving you some cost-effective examples of preparations that we can use.

Obviously, these will change from time to time so keep an eye on your local

formulary too. You can download this flowchart by clicking on the link in the

episode description.

And we will start with the transdermal options remembering that they

should be the first-choice route particularly for women with high risk factors,

including a BMI over 30, as they are unlikely to increase the risk of VTE or

stroke, unlike the oral preparations.

Examples of oestrogen only preparations for women with no uterus, we

have twice weekly patches like evorel and estradot with their different

strengths as well as gels and sprays like oestrogel, sandrena and lenzetto. We

may also use these preparations for women with a uterus if we avoid endometrial

hyperplasia and the increased risk of endometrial cancer by giving

progestogenic opposition with a levonorgestrel IUS or Mirena Coil or micronized

progesterone like utrogestan capsules.

As an example of sequential combined HRT causing a monthly bleed for

women with a uterus, we have twice weekly Evorel sequi patches

Continuous period free combined HRT, is not suitable in the

perimenopause or within 12 months of the last menstrual period and an example

would be twice weekly evorel contipatches

We will now look at the oral options.

And an example of an oestrogen only oral preparation is Elleste Solo

with two different strengths

Examples or oral sequential combined HRT offering a monthly bleed are

femoston and elleste duet also with their two different strengths

 And examples of period free oral

continuous combined HRT preparations, again not suitable in the perimenopause

or within 12 months of the last menstrual period we have femoston conti and its

low dose version, indivina, kliofem and elleste duet conti. Second line

preparations would be bijuve and tibolone but researching the pros and cons of

these last two may be advisable

We also have a few boxes about low oestrogen options, for example for

women 60 or over like evorel 25 patch and oestrogel as unopposed oestrogens or,

as continuous combined preparations, femoston conti with 0.5mg of oestradiol or

kliovance.

We also have a reminder about addressing lifestyle factors and optimally

managing conditions like hypertension and diabetes.

And also, that herbal medicines are not available on prescription and

they are largely unregulated products lacking consistency.

And for urogenital atrophy we can use ovestin cream, vagirux vaginal

tablets, imvaggis pessaries, estring vaginal rings and blissel gel

And finally, of course, we have over the counter vaginal moisturisers

such as replens MD and Yes VM

We have come to the end of this episode. Remember that this is not

medical advice and it is only my summary and my interpretation of the

guideline. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/1Cwvoflk3LQ

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

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 Thyroid disease: assessment and management [NG145], always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this episode is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

●      Apple podcast: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

●      Spotify: https://open.spotify.com/show/2kmGZkt1ssZ9Ei8n8mMaE0?si=9d30d1993449494e

●      Amazon Music: https://music.amazon.co.uk/podcasts/0edb5fd8-affb-4c5a-9a6d-6962c1b7f0a1/primary-care-guidelines?ref=dm_sh_NnjF2h4UuQxyX0X3Lb3WQtR5P

●      Google Podcast: https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5yZWRjaXJjbGUuY29tLzI1ODdhZDc4LTc3MzAtNDhmNi04OTRlLWYxZjQxNzhlMzdjMw%3D%3D

●      Redcircle: https://redcircle.com/shows/2587ad78-7730-48f6-894e-f1f4178e37c3

There is a YouTube version of this and other videos that you can access here: 

●       The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Thyroid disease: assessment and management -NICE guideline [NG145] can be found here:

●      https://www.nice.org.uk/guidance/NG145

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●       Music provided by Audio Library Plus 

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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 NICE guideline on Thyroid disease, always focusing on what is relevant in Primary Care only.

Right, we are not going to waste any time so let’s jump into it.

We will check TFTs if there is:

●     a clinical suspicion of thyroid disease, bearing in mind that 1 symptom alone may not be indicative of thyroid disease

●     type 1 diabetes or other autoimmune diseases, (but we will not offer testing only because of type 2 diabetes).

●     new-onset AF

●     depression or unexplained anxiety

●     abnormal growth in children and young people, or with an unexplained change in behaviour or school performance.

●     And we will be aware that in menopausal women symptoms of thyroid dysfunction may be mistaken for menopause

We will not test for TFTs during an acute illness unless we suspect the acute illness is due to thyroid dysfunction, because it may affect the test results.

So, what tests do we do as initial screening when thyroid dysfunction is suspected?

This will depend on whether we suspect a primary cause, that is, a cause arising from the thyroid gland, or a secondary cause, that is, a cause arising from the pituitary gland. Although the path lab will have processes to decide what tests are included when we request TFTs, it is important for us to understand what tests results we should expect according to the clinical presentation.

So, we will always measure TSH. Then, if a primary cause is suspected in an adult:

●     if the TSH is high, that is, suggestive of hypothyroidism, we will need the free thyroxine (FT4) level

●     if the TSH is low, that is, suggestive of hyperthyroidism, we will need FT4 and free tri-iodothyronine (FT3)

However, if we suspect a secondary cause, that is, pituitary disease, or if we are testing a child or young person, we will need results for both TSH and FT4 and:

●     If the TSH is low, that is, suggestive of hyperthyroidism, we will need FT3

So, in summary, we test TSH and T4 in hypothyroidism but in hyperthyroidism we need to add FT3 too.

We can repeat these tests if symptoms worsen or new symptoms develop (but no sooner than 6 weeks from the most recent test).

We will also ask patients about their biotin intake because a high consumption of biotin from dietary supplements may lead to falsely high or low test results.

Looking at the management, and monitoring different rules may apply to children and young people and given that we are likely to be getting advice from the paediatricians , I will not cover them here. If a recommendation applies to children, I will mention it, but otherwise this episode will focus on adults unless otherwise specifically stated.

So, we are going to cover:

●     Primary hypothyroidism: which is caused by an insufficient hormone production by the thyroid gland. In this situation the TSH is high, and FT4 is low.

●     Subclinical Primary hypothyroidism: This can sometimes happen as a precursor of clinical hypothyroidism and it is when the TSH is high, but FT4 is normal.

●     Thyrotoxicosis or Primary hyperthyroidism: Thyrotoxicosis is when there is excess thyroid hormone leading to a low TSH and a high FT4 and / or FT3. This can be caused by:

○     Increased production and secretion, as in primary hyperthyroidism or by

○     The release of stored thyroid hormones, as it happens in thyroiditis.

●     Subclinical Primary hyperthyroidism: This can also sometimes happen as a precursor of hyperthyroidism and it is when TSH levels are low, but FT3 and FT4 are normal.

●     And we will also cover Thyroid enlargement with normal thyroid function, which is self explanatory

So let’s start with the management of primary hypothyroidism

So, for all people with confirmed primary hypothyroidism, that is, when we encounter a high TSH and a low FT4, we will:

Check thyroid peroxidase antibodies (TPOAbs)

But in adults, we will not repeat TPOAbs testing. If the antibody test is positive, it maybe worthwhile mentioning that NICE also recommends testing for coeliac disease in people with a diagnosis of autoimmune thyroid disease.

For the actual management, for both adults and children, we will:

Offer levothyroxine as first-line treatment and we will not routinely offer liothyronine or natural thyroid extract for primary hypothyroidism, either alone or in combination with levothyroxine, because there is not enough evidence that it offers benefits over levothyroxine monotherapy, and the long-term adverse effects are uncertain.

We will start levothyroxine at a dosage of 1.6 micrograms per kilogram of body weight per day (rounded to the nearest 25 micrograms) for adults under 65 with primary hypothyroidism and no history of cardiovascular disease.

However, if they are over 65 or with a history of cardiovascular disease, we will start levothyroxine at a dosage of 25 to 50 micrograms per day with titration

How should we follow-up and monitor primary hypothyroidism?

We will aim to maintain TSH levels within the reference range when treating with levothyroxine. If symptoms persist, we will adjust the dose to achieve optimal wellbeing, but we will avoid using doses that cause TSH suppression or thyrotoxicosis.

We also need to be aware that the TSH level can take up to 6 months to return to normal for people who had a very high TSH or a prolonged period of untreated hypothyroidism.

In terms of monitoring, we will need to measure TSH every 3 months until the level has stabilised (that is, until we have had 2 similar measurements within the reference range 3 months apart), and then once a year. But we will also check FT4 as well as TSH if they continue to have symptoms on levothyroxine.

Let’s now look at subclinical hypothyroidism

Once we have confirmed subclinical hypothyroidism, with a high TSH and normal FT4, we will also check TPOAbs.

In terms of the management, we will:

take into account features that might suggest underlying thyroid disease, such as, for example, symptoms of hypothyroidism, or raised levels of thyroid autoantibodies.

Consider levothyroxine if the TSH is 10 mlU/litre or higher on 2 separate occasions 3 months apart, monitoring as per in hypothyroidism

We will also consider a 6-month trial of levothyroxine for adults under 65 with subclinical hypothyroidism who have:

●     a high TSH but lower than 10 mlU/litre on 2 separate occasions 3 months apart, and

●     symptoms of hypothyroidism.

If symptoms do not improve after starting levothyroxine, we will recheck the TSH and if the level remains raised, we will adjust the dose. If symptoms persist when TSH is within the reference range, we will stop levothyroxine and continue monitoring.

So, how do we monitor untreated subclinical hypothyroidism and after stopping treatment?

For them, we will check TSH and FT4:

●     once a year if they have features suggesting underlying thyroid disease, such as previous thyroid surgery or raised levels of thyroid autoantibodies, or

●     once every 2 to 3 years if they have no features suggesting underlying thyroid disease.

Let’s now have a look at thyrotoxicosis

First, we will have confirmed the diagnosis with a low TSH and raised FT4 and / or FT3.

Then we will need to differentiate between thyrotoxicosis with hyperthyroidism (for example, Graves' disease or toxic nodular disease) and thyrotoxicosis without hyperthyroidism (for example, transient thyroiditis). We will do so by:

●     measuring TSH receptor antibodies (TRAbs) to confirm Graves' disease. and

●     considering technetium scanning of the thyroid gland if TRAbs are negative.

We will only consider ultrasound for thyrotoxicosis if they have a palpable thyroid nodule. In terms of treatment, we need to be aware that transient thyrotoxicosis without hyperthyroidism like in thyroiditis usually only needs supportive treatment (for example, beta-blockers).

Otherwise we can consider antithyroid drugs along with supportive treatment for adults with hyperthyroidism who are waiting for specialist assessment and further treatment, bearing in mind that the use of carbimazole is subject to MHRA advice on contraception (Drug Safety Update, February 2019) and risk of acute pancreatitis (Drug Safety Update, February 2019).

Before starting antithyroid drugs,we will check a full blood count and liver function tests.

Antithyroid drugs for hyperthyroidism secondary to a single or multiple toxic nodules, will normally be with a titration regimen of carbimazole.

However, we will consider propylthiouracil for adults:

●     who experience adverse reactions to carbimazole

●     who are pregnant or trying to become pregnant within the following 6 months or

●     with a history of pancreatitis.

We will stop and do not restart any antithyroid drugs if a person develops agranulocytosis and we will refer to a specialist for further management options.

For the monitoring of antithyroid drugs, we will check:

●     TSH, FT4 and FT3 every 6 weeks until their TSH is within the reference range, then

●     TSH every 3 months until antithyroid drugs are stopped, rechecking FT4 and FT3 if the TSH becomes suppressed at any stage.

We will not monitor full blood count and liver function while taking antithyroid drugs unless there is a clinical suspicion of agranulocytosis or liver dysfunction.

After stopping antithyroid drugs in adults, we will check:

●     TSH within 8 weeks of stopping the drug, then

●     TSH every 3 months for a year, then

●     TSH once a year.

●     Always rechecking FT4 and FT3 if the TSH becomes suppressed at any stage.

I will not cover the follow-up and monitoring of hyperthyroidism after radioactive iodine treatment or surgery, as this will be guided by secondary care

In terms of the management and monitoring of subclinical hyperthyroidism, that is, when TSH is low and FT4 and FT3 are normal, We will seek specialist advice if they have:

●     2 TSH readings lower than 0.1 Miu/litre at least 3 months apart and

●     evidence of thyroid disease (for example, a goitre or positive thyroid antibodies) or symptoms of thyrotoxicosis.

Otherwise, in untreated subclinical hyperthyroidism, we will check TSH every 6 months and if the TSH level is outside the normal range, we will also check FT4 and FT3.

We will consider stopping TSH measurement if the TSH level stabilises (that is, we have 2 similar measurements within the normal range 3 to 6 months apart

Let’s now have a look at thyroid enlargement with normal thyroid function

We will:

Offer an ultrasound if there is palpable thyroid enlargement or focal nodularity if malignancy is suspected.

When making decisions about whether to refer for fine needle aspiration cytology, we will take into account the ultrasound comments on echogenicity, microcalcifications, vascularity and lymphadenopathy amongst other factors.

How should these patients be managed?

Well, we will not offer any treatment in non-malignant thyroid enlargement, normal thyroid function and mild or no symptoms unless:

●     they have breathing difficulty or

●     there is clinical concern, for example, because compression is suspected.

But we will repeat the thyroid ultrasound scan and TSH, if:

●     malignancy is subsequently suspected, or

●     compression is suspected or

●     the person's symptoms worsen or

●     they develop symptoms, such as hoarseness, or shortness of breath.

Obviously, if the thyroid enlargement is causing compressive symptoms, we will refer them for further management.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the NICE guideline on “Headaches in over 12s: diagnosis and management”, or NICE guideline CG150.

I will summarise the guidance from a Primary Care perspective only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE guideline CG150 “Headaches in over 12s: diagnosis and management” can be found here:

·      https://www.nice.org.uk/guidance/cg150/chapter/Recommendations

Thumbnail photo: from Freepik: https://www.freepik.com/

·      Image by Drazen Zigic on Freepik

·      a href="https://www.freepik.com/free-photo/low-angle-view-distraught-man-holding-his-head-pain-while-sitting-living-room_26343742.htm#query=headache&position=2&from_view=search&track=sph"Image by Drazen Zigic/a on Freepik

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

• Music provided by Audio Library Plus  
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 



Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE guideline on headaches and I will summarise the guidance from a Primary Care perspective only.

So, let’s jump into it.

We will start by looking at the diagnostic clinical features that could help differentiate between tension‑type headache, migraine and cluster headache.

·      First, we have the Pain location which:

o  In Tension headache:  is usually Bilateral

o  In Migraine: can be Unilateral or bilateral

o  And in Cluster headache: is Unilateral (usually around the eye, above the eye and along the side of the head/face)

·      Then we look at the Pain quality which:

o  In Tension headache: is usually Pressing or tightening and non‑pulsating

o  In Migraine: is generally Pulsating (although it can be described as throbbing or banging in those aged 12 to 17 years)

o  And in Cluster headache: it is Variable (sharp, boring, burning, throbbing or tightening)

·      The Pain intensity is:

o  Mild or moderate in Tension headache:

o  Moderate or severe in Migraine:

o  And Severe or very severe in Cluster headache:

·      In terms of the Effect on activities we find that:

o  Tension headache: Is Not aggravated by routine activities

o  Migraine: is Aggravated by, or causes avoidance of, routine activities

o  And Cluster headache: causes Restlessness or agitation

·      Looking at Other possible symptoms we find that:

o  Tension headache: doesn’t usually have any

o  Migraine: usually produces Sensitivity to light and/or sound or nausea and/or vomiting. There can also be aura symptoms, which we will cover in more detail later.

o  and Cluster headache: will normally present On the same side as the headache:

• red and/or watery eye
• nasal congestion and/or runny nose
• swollen eyelid
• forehead and facial sweating
• constricted pupil and/or drooping eyelid

·      and finally, in terms of Duration of the headache:

o  Tension headaches can be from 30 minutes to continuous:

o  Migraine: can be 4 to 72 hours in adults but 1 to 72 h in those aged 12 to 17 

o  And Cluster headache:  usually lasts 15 to 180 minutes

Episodic tension-type headaches or episodic migraines occur on fewer than 15 days per month. Chronic tension-type headaches or chronic migraines occur on 15 or more days per month for more than 3 months. Chronic migraine and chronic tension‑type headache commonly overlap so, if there are features of migraine, we will diagnose chronic migraine.

On the other hand, Episodic cluster headaches occur from once every other day to 8 times a day with a pain-free period of more than 1 month. Chronic cluster headaches have the same frequency, that is from once every other day to 8 times a day but with a pain-free period of less than 1 month in a 12-month period.

And now let’s look at Migraine with aura in more detail.

And we will Suspect aura with or without headache if the symptoms:

·      are fully reversible and

·      develop gradually over at least 5 minutes and

·      last for 5 to 60 minutes. 

And typical aura symptoms include:

·      visual symptoms that may be positive (for example, flickering lights, spots or lines) and/or negative (for example, partial loss of vision)

·      sensory symptoms that may be positive (for example, pins and needles) and/or negative (for example, numbness)

·      and speech disturbance. 

We can diagnose migraine with aura if typical aura symptoms are present, but we will Consider further investigations and referral if the symptoms are atypical such as:

·      motor weakness 

·      double vision 

·      visual symptoms affecting only one eye 

·      poor balance or

·      decreased level of consciousness. 

We will Suspect Menstrual‑related migraine if it’s predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles. 

And now we will touch on Medication overuse headache, which we will Consider if taking the following drugs for 3 months or more:

·      triptans, opioids, ergots or combination analgesics on 10 days/month or more or

·      paracetamol, aspirin or an NSAID on 15 days per month or more. 

In terms of Management of all headache disorders we will consider further investigations and referral if there worrying symptoms or signs such as:

·      worsening headache with fever

·      thunderclap headache or a sudden‑onset headache with maximum intensity within 5 minutes

·      new‑onset neurological deficit

·      new‑onset cognitive dysfunction

·      change in personality

·      impaired level of consciousness

·      recent head trauma (within the past 3 months)

·      headache triggered by cough, Valsalva, sneeze or exercise

·      orthostatic headache (headache that changes with posture)

·      symptoms suggestive of giant cell arteritis- Branches of the carotid artery and the ophthalmic artery are usually involved, giving rise to symptoms of headache, visual disturbances and jaw claudication.

·      symptoms and signs of acute narrow angle glaucoma, which may include headache with a painful red eye and misty vision or haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster headache by the presence of a semi‑dilated pupil compared with the presence of a constricted pupil in cluster headache.

·      And a substantial change in the headache. 

We will also consider further investigations and/or referral if there is new‑onset headache with:

·      compromised immunity, for example, by HIV or immunosuppressive drugs

·      age under 20 years and a history of malignancy

·      a history of malignancy known to metastasise to the brain

·      and vomiting without other obvious cause. 

If we want to consider a headache diary, it should be followed for a minimum of 8 weeks.

Now let’s have a look at the acute and prophylactic treatments of the various types of headaches. 

For the Acute treatment of Tension‑type headache we will Consider aspirin, paracetamol or an NSAID but we will not offer opioids and because of Reye's syndrome, aspirin should not be offered to under 16s

For the Prophylactic treatment of tension-type headache we will Consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks

For the Acute treatment of Migraine with or without aura, we will Offer combination of an oral triptan and an NSAID, or an oral triptan and paracetamol. If aged 12 to 17 years consider a nasal triptan in preference, for example nasal sumatriptan. And For people who prefer to take only one drug, we will consider monotherapy with an oral triptan, NSAID, aspirin (900 mg) or paracetamol.

We will not offer ergots or opioids for the acute treatment of migraine but we will Consider additional anti‑emetic even in the absence of nausea and vomiting. 

If oral preparations (or nasal preparations if aged 12 to 17 years) are ineffective or not tolerated:

·      we will consider a non‑oral preparation of metoclopramide or prochlorperazine (for example buccal prochlorperazine) and

·      we will consider adding a non‑oral NSAID or triptan if they have not been tried.

And following a recent update, NICE says that the drug Rimegepant can be used, only if:

·      at least 2 triptans have been tried before but were ineffective or

·      if triptans cannot be used, and Paracetamol and NSAIDs are not effective.

For migraine prophylaxis, we will advise that riboflavin (400 mg once a day) may be effective for some people and that this is available as a food supplement. We will also offer topiramate or propranolol and we will consider amitriptyline but we will not offer gabapentin. We will then Review the need for continuing migraine prophylaxis after 6 months.

When prescribing migraine prophylaxis, we will consider:

·      consider the risk of foetal malformations with topiramate

·      discuss the risk of reduced effectiveness of hormonal contraceptives with topiramate

·      explain the importance of effective contraception with topiramate, for example, by using medroxyprogesterone acetate depot injection, an intrauterine method or combined hormonal contraception with a barrier method, bearing in mind that we will not routinely offer combined hormonal contraceptives if there is migraine with aura. 

·      And we will Use caution when prescribing propranolol if there is a history of depression as they could be at an increased risk of using propranolol for self-harm.

If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks

For Menstrual-related migraine we will Consider frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) on the days migraine is expected. 

And for Treatment of migraine during pregnancy, we will Offer paracetamol but we may Consider triptan or an NSAID after discussing the risks during pregnancy and we will Seek specialist advice for migraine prophylaxis during pregnancy. 

For the Acute treatment of Cluster headache we will Discuss with a specialist the need for neuroimaging for people with a first bout of cluster headache and we will then Offer oxygen and/or a subcutaneous or nasal triptan. 

When using oxygen for the acute treatment of cluster headache:

·      We will use 100% oxygen at a flow rate of at least 12 litres per minute with a non‑rebreathing mask and a reservoir bag and

·      We will arrange provision of home and ambulatory oxygen. 

When using a subcutaneous or nasal triptan, we will prescribe an adequate supply calculated according to their history and on the manufacturer's maximum daily dose. 

And we will not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for cluster headache. 

As Prophylactic treatment of cluster headache, we will Consider verapamil and, The BNF says that it should be initiated under specialist supervision, including advice on ECG monitoring and we will seek specialist advice if it does not respond or during pregnancy. 

For Medication overuse headache we will Explain that it is treated by withdrawing the overused medication and we will Advise to stop overused medications for at least 1 month and to stop abruptly rather than gradually. 

We will also explain that headache is likely to get worse before they get better and we will provide them with close follow‑up and support, considering prophylactic treatment for the underlying primary headache disorder.

We will Consider specialist referral and inpatient management for people who are using strong opioids, or have relevant comorbidities, or if previous attempts have been unsuccessful. 

We will then Review the diagnosis and management 4 to 8 weeks after stopping overused medication. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guideline. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the NICE guideline on “Heavy menstrual bleeding: assessment and management”, or NICE guideline [NG88.

I will summarise the guidance from a Primary Care perspective only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE guideline NG88 “Heavy menstrual bleeding: assessment and management” can be found here:

·      https://www.nice.org.uk/guidance/ng88/chapter/Recommendations

The Menorrhagia mind map or flow chart can be downloaded here:

·      https://1drv.ms/i/s!AiVFJ_Uoigq0mFegr4-vdKdhitAI?e=BJRIDK

Thumbnail photo: from Freepik: https://www.freepik.com/

·      Image by benzoix on Freepik

·      a href="https://www.freepik.com/free-photo/young-woman-with-pain-stomach-holding-hands-belly-feeling-terrible-ache-menstrual-cramps-stand_34232826.htm#query=heavy%20periods&position=17&from_view=search&track=ais"Image by benzoix/a on Freepik

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

• Music provided by Audio Library Plus  
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE guideline on menorrhagia or, to be precise, “Heavy menstrual bleeding: assessment and management” and I will summarise the guidance from a Primary Care perspective only.

So, let’s jump into it.

We will obviously start with the history including the nature and impact of the bleeding and we will particularly pay attention to what NICE refers to as “related symptoms”. These are symptoms such as:

·      Persistent intermenstrual bleeding

·      Pelvic pain and/or

·      Pressure symptoms, because

they might suggest a uterine abnormality.

What may come as a surprise is that NICE says that if none of these symptoms are present, that is, no IMB, no pain and no pressure symptoms, we will consider pharmacological treatment without necessarily carrying out a physical examination.

But the converse is true, a physical examination is recommended if such symptoms exist or if we are considering a levonorgestrel-releasing intrauterine system [LNG IUS], that is, a Mirena coil or similar. 

In terms of blood tests:

·      we will perform a FBC for all patients and

·      we will consider testing for coagulation disorders if they have had heavy periods since they started and there is a personal or family history suggestive of it

·      However, NICE says that there is no need for routine ferritin, hormone or thyroid testing

We will then consider investigations for the cause of the HMB but

We will also consider starting pharmacological treatment without investigating the cause if we feel that there is a low risk of uterine abnormality.

If we do investigate further, we will consider the need for:

·      Hysteroscopy

·      A pelvic USS or

·      A transvaginal USS

And we will choose each investigation depending on whether we suspect:

·      submucosal fibroids, polyps or endometrial pathology (in which case a hysteroscopy would be needed)

·      larger fibroids (in which case a pelvic USS would be needed) or

·      adenomyosis (when a transvaginal USS would be recommended)

And we will use our clinical judgement to decide which one of those we should consider as most likely. For example:

·      We will suspect submucosal fibroids, polyps or endometrial pathology (and therefore the need to refer for possible hysteroscopy plus / minus biopsy) if, for example:

o  They are taking tamoxifen

o  They have persistent intermenstrual or irregular bleeding,

o  They have infrequent heavy bleeding and are obese or have PCOS or if

o  They have not responded to treatment. 

·      We will think about larger fibroids (and therefore the need to request a pelvic USS) if:

o  there is a palpable uterus on abdominal examination,

o  a Pelvic mass is suspected and

o  we will also consider a pelvic USS if the examination is inconclusive or difficult, because, for example, obesity

·      And we will think about adenomyosis (and therefore the need for a transvaginal USS) if:

• There is a bulky, tender uterus on examination or
• There is significant dysmenorrhoea or period pain but we also need to be aware that pain may be caused by endometriosis rather than adenomyosis

If hysteroscopy is declined, we will consider a pelvic ultrasound, explaining its limitations

If a transvaginal ultrasound is declined or unsuitable, we will consider a transabdominal ultrasound or MRI, also explaining their limitations.

Let’s now look at the management of menorrhagia. As we have previously said, we will refer for hysteroscopy those patients in whom we suspect an endometrial pathology, so we will leave their management in the hands of secondary care. 

So, from a Primary Care perspective, and for the purpose of their management we need to group the remaining patients into two types:

·      Patients with no identified pathology, with fibroids less than 3 cm in diameter, or with adenomyosis and

·      Patients with fibroids of 3 cm or more in diameter

For the first group, that is, patients with no identified pathology, with small fibroids, or adenomyosis, we will consider an LNG-IUS first line, as long as, if there are small fibroids, they do not cause distortion of the uterine cavity 

On offering this treatment, we will explain to them:

·      about the anticipated changes in bleeding pattern, particularly in the first few cycles and maybe lasting longer than 6 months and

·      that it is advisable to wait for at least 6 cycles to see the benefits of the treatment. 

If LNG-IUS is declined or unsuitable, we will consider pharmacological treatments, either:

·      non-hormonal like:

o  tranexamic acid and

o  NSAIDs or

·      Hormonal like:

o  combined hormonal contraception and

o  cyclical oral progestogens, also bearing in mind that

o  Progestogen-only contraception may suppress menstruation, which could be beneficial for some patients too

If the symptoms are severe or do not respond to pharmacological treatment, or the patient declines pharmacological treatment, we will refer.

For the second group, that is, patients with fibroids of 3 cm or more in diameter

We will consider referral and, if pharmacological treatment is needed while waiting investigations, we will consider tranexamic acid and/or NSAIDs, but we need to be aware that the effectiveness of pharmacological treatments may be limited if fibroids are substantially greater than 3 cm in diameter. 

Depending on the size, location and number of fibroids, and the severity of the symptoms a number or other treatments may be considered by secondary care, including further pharmacological or surgical treatments.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guideline. You must always use your clinical judgement.

Thank you for listening and goodbye.

This podcast makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through new and updated guidelines published in October 2023 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 interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel:  

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulleting for October 2023 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2023-10-01&to=2023-10-31&ndt=Guidance&ndt=Quality+standard

The links to the update guidance covered can be found here:

Rimegepant for treating migraine:

·      https://www.nice.org.uk/guidance/ta919

Thyroid disease: assessment and management

·      https://www.nice.org.uk/guidance/ng145

Tirzepatide for treating type 2 diabetes

·      https://www.nice.org.uk/guidance/ta924

Suspected cancer: recognition and referral

·      https://www.nice.org.uk/guidance/ng12

Suspected neurological conditions: recognition and referral

·      https://www.nice.org.uk/guidance/ng127

Hearing loss in adults: assessment and management

·      https://www.nice.org.uk/guidance/ng98

Daridorexant for treating long-term insomnia

·      https://www.nice.org.uk/guidance/ta922

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

• Free Download / Stream: https://alplus.io/halfway-through 
• Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in October 2023, focusing on what is relevant in Primary Care only. We will be covering: migraines, thyroid function tests, diabetes, suspected cancer and insomnia.

So let’s jump into it.

The first clinical area is an update on a new migraine medication, rimegepant.

And NICE says that Rimegepant is recommended, only if:

·      at least 2 triptans have been tried before but were ineffective or

·      if triptans cannot be used, and Paracetamol and NSAIDs are not effective.

What is Rimegepant?

Well, gepants are a new class of drugs that have been developed specifically for the treatment of migraines. Rimegepant is a calcitonin gene-related peptide receptor antagonist so it works by blocking this CGRP receptor. And although the mechanism of action is not fully understood, we know that this receptor is involved in the development of migraines. Gepants can be used as an acute treatment and, although rimegepant has a licence for migraine prophylaxis, NICE does not recommend it for this indication.

Unlike triptans, gepants do not cause vasoconstriction so they do not have the same cardiovascular contraindications and cautions as triptans. Rimegepant is an oral lyophilisate that should be placed on the tongue or under the tongue and it will disintegrate in the mouth and can therefore be taken without liquid.

The next update refers to thyroid disease and it says that when ordering thyroid function tests, patients should be routinely asked about biotin use. This is because the MHRA has reported that biotin may cause thyroid test results to be falsely increased or decreased, leading to inappropriate management. Biotin is increasingly found in dietary supplements which are typically taken for hair, skin and nail health so we should always check whether patients are taking such supplements over the counter.

The third area refers to a new diabetic agent, tirzepatide, and, like GLP1 receptor agonists, it is recommended if type 2 diabetes is not controlled:

·      on triple therapy with metformin and 2 other drugs, and

·      they have a BMI of 35 or more, with obesity related health problems, or

·      they have a BMI of less than 35, and:

o  insulin therapy would have significant occupational implications, or

o  weight loss would benefit other significant complications.

But we will use lower BMI thresholds (usually reduced by 2.5) for people from non-white family backgrounds.

We all know the supply issues that we have had with various GLP1 receptor agonists, so is tirzepatide a new GLP1 drug coming to the rescue? Well, not really. Because Tirzepatide is both a GIP and a GLP-1 receptor agonist, so it is a dual agent. It is a weekly injectable and clinical trials suggest that tirzepatide reduces HbA1c and BMI more than semaglutide. Weight reduction with tirzepatide is more pronounced with higher doses, whereas reductions in HbA1c seem less dose-dependent. 

No dose adjustment is required for patients with hepatic and renal impairment including end stage renal disease (ESRD) but experience with these patients is limited so we should exercise caution.

The Mechanism of action of tirzepatide is by increasing Insulin secretion and sensitivity, reducing Glucagon and delaying Gastric emptying

The next clinical area refers to suspected cancer: recognition and referral, and the guidance has been updated to reflect the new NHS standard on faster cancer diagnosis.

So, what this means is that, rather than focusing on these patients being seen within 2 weeks, the aim now is for them to have a diagnosis or have cancer ruled out within 28 days from referral.

This change applies when:

·      the referring GP suspects cancer

·      there are breast symptoms even where cancer is not initially suspected or when

·      there is an abnormal National Cancer Screening result.

So, this update will also appear in a number of other guidelines including, for example:

-         Neurological conditions

-         Ovarian cancer and

-         Urinary incontinence

Next there is also an update saying that we should use a suspected cancer pathway for adults of Chinese or south-east Asian family origin who develop hearing loss and a middle ear effusion not associated with an upper respiratory tract infection.

This is because of the higher incidence of nasopharyngeal carcinoma (NPC) in these populations. Nasopharyngeal carcinoma is rare in most parts of the world, but it’s much more common in East and Southeast Asia, which suggests that genetic and/or environmental factors can contribute substantially to its development.  

The final guidance is on Daridorexant for treating long-term insomnia. And NICE says that Daridorexant is recommended for insomnia lasting for 3 nights or more per week for at least 3 months, with affected daytime functioning but only if:

·      cognitive behavioural therapy for insomnia (CBTi) is ineffective or

·      it is not available or is unsuitable.

What is daridorexant? Well, unlike benzodiazepines and Z-drugs, which work by increasing sedation, daridorexant is a new type of drug, an orexin antagonist, which works in a different way. It inhibits arousal mechanisms. To understand this, we need to know that orexins are neuropeptides produced by the hypothalamus which promote a state of wakefulness. Therefore, daridorexant, by blocking the orexin receptors, reduces wakefulness and helps sleep

And the good news is that, in clinical studies, there has been no evidence of abuse or withdrawal symptoms indicative of physical dependence.

NICE recommends that the length of treatment should be as short as possible and the treatment should be reviewed within 3 months of starting and at regular intervals thereafter.

However, it is worth mentioning that, in October 2023, Daridorexant was still not available on the BNF.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the "National Institute for Health and Clinical Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a fictitious clinical case of a patient created by Chat GPT to see how the NICE guidelines could apply to it. 

I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.   

There is a YouTube version of this and other videos that you can access here: 

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 
• https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk 

The patient was created using the following Chat GPT prompt:

A)   Provide a fictitious patient. Details that you should include are:

1)   patient's medical information including:

·      name

·      age

·      sex

·      ethnicity

·      BMI

·      blood pressure

2)   medical history- you must include:

·      either one or two of the following poorly controlled conditions:

·      type 2 diabetes

·      hypertension

·      dyslipidaemia,

·      Asthma or COPD

·      Any number of other medical conditions of your choice, along with whether they are well controlled or not – the medication for these conditions should appear in the next section “medications”

1. Medications given:

·      indicate whether the patient is currently taking medication for each medical condition or not.

·      If medication is prescribed for a condition, indicate the specific drug(s) and their dosages. You may choose to prescribe one, two, or three drugs for each condition as appropriate.

3)   State whether the patient tolerates the medication well or not, and if not, describe the side effect(s) and their severity.

4)   blood test results (give a bulleted list but do not number them):

·      HbA1c expressed in % and mmol/mol

·      renal function tests to include creatinine (expressed first in µmol/L and then in mg/dL), eGFR, urea, sodium, and potassium (expressed in UK units first and then USA units)

·      lipid profile expressed both in mmol/L first and then in mg/dL.

·      If the patient has asthma, give the peak flow reading expressed as a percentage of their best or expected reading.

·      If the patient has COPD, give the FEV1 reading expressed as a percentage of the predicted reading

·      include any other relevant test results for the patient, expressing them in both UK and USA units. If the patient has hypothyroidism or takes levothyroxine medication, provide the results of their thyroid function tests, including both T4 and TSH levels, in both UK and USA units. Also, include the normal range for these investigations.

B)  Provide the patient's cardiovascular risk using the QRISK2 tool, calculated as a percentage of the likelihood of experiencing a cardiovascular event over the next 10 years.

C)   At the end of the patient information, ask: 'What treatment recommendations would you make?' – do not make recommendations yourself

D)  Do not include a disclaimer that the patient is fictitious.

The NICE hypertension flowcharts can be found here: 

• Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517 
• Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn 

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

• Website: https://www.nice.org.uk/guidance/NG136 
• Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus 

The full NICE Guideline on Type 2 diabetes (NG28) can be found here: 

·      https://www.nice.org.uk/guidance/ng28 

The full NICE guidance on cardiovascular disease risk reduction (CG181) can be found here: 

·      https://www.nice.org.uk/guidance/cg181

The full NICE guidance on asthma (NG80) can be found here: 

·      https://www.nice.org.uk/guidance/ng80 

The full NICE guidance on depression in adults (NG222) can be found here:

·      https://www.nice.org.uk/guidance/ng222 

The full guidance on obesity (CG189) can be found here:

·      https://www.nice.org.uk/guidance/cg189

Thumbnail photos-

From: www.freepik.com

·      Image by Freepik: Image by a href="https://www.freepik.com/free-photo/excited-young-friends-running-beach_9057871.htm#page=2&query=45%20year%20old%20obese%20woman&position=10&from_view=search&track=ais"Freepik/a 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

• Free Download / Stream: https://alplus.io/halfway-through 

Transcript  

Hello everyone. My name is Fernando and I am a GP in the United Kingdom. Today we are looking at a fictitious patient generated by Chat GPT with a view to looking at the NICE guidelines from a practical perspective.  

Right, so let’s jump into it.

Patient Information:

·      Name: Sarah Davis

·      Age: 45

·      Sex: Female

·      Ethnicity: Caucasian

Examination:

·      BMI: 32 (Obese)

·      Blood Pressure: 153/91 mm Hg

Medical History:

·      Type 2 Diabetes

·      Hypertension

·      Dyslipidemia

·      Asthma

·      Obesity

·      Depression

Medications:

·      Metformin 1000 mg twice daily

·      Gliclazide 80 mg once daily

·      Amlodipine 10 mg once daily

·      Indapamide MR 1.5 mg once daily

·      Atorvastatin 20 mg once daily

·      Salbutamol inhaler as needed

·      Sertraline 50 mg once daily

Medication Tolerance:

·      Sarah tolerates her medications well. She has not reported any significant side effects.

Blood Test Results:

·      HbA1c: 8.5% (69 mmol/mol)

·      Renal Function:

o  Creatinine: 90 µmol/L (1.02 mg/dL)

o  eGFR: 91 mL/min/1.73m²

·      Lipid Profile:

o  Total Cholesterol: 5.2 mmol/L (200 mg/dL)

o  LDL Cholesterol: 3.0 mmol/L (116 mg/dL)

o  HDL Cholesterol: 1.2 mmol/L (46 mg/dL)

o  Triglycerides: 2.5 mmol/L (220 mg/dL)

Cardiovascular Risk (QRISK3):

·      Sarah's 10-year cardiovascular risk is estimated at 18%.

So, what treatment recommendations would we make?

Although there is a lot that we can do from a lifestyle perspective, we will focus on the drug treatment only.

Right, let’s start with her diabetes, which is poorly controlled with an hba1c of 8.9% or 74 mmol/mol. Sarah is on metformin 1gr BD and gliclazide 80 mg OD and we know she is at high risk of cardiovascular disease with a QRISK3 of 18%.

NICE says that for step 2 treatment after metformin, if a patient is at high risk of CVD, we should choose an SGLT2 inhibitor. But this patient has been given gliclazide instead. We would like to see if there is a reason for this and whether an SGLT2 inhibitor was tried before but not tolerated.

So, assuming that there have been no issues, I would recommend starting an SGLT2 inhibitor.

SGLT2 inhibitors are also associated with a degree of weight loss, and given that Sarah is obese, this will be good for her.

Gliclazide on the other hand is associated with weight gain, which is the last thing that Sarah needs. The question now is whether we should stop gliclazide and, if so, when.

In my opinion, gliclazide should be definitely stopped and substituted by another diabetic agent which is weight neutral, for example, a DPP4 inhibitor.

A more difficult question would be when to make this switch. Doing it straightaway has got the disadvantage that, if a side effect develops, we may not know which drug is the culprit. Also, we do not know how much the HbA1c will drop with the SGLT2 inhibitor so there could be a risk of overtreatment.

Right, a balanced decision that you can make depending on your clinical judgement.

I think that I would start the SGLT2 inhibitor first, so, I would start her on something like dapagliflozin 5 mg OD initially and, if tolerated, I may increase it to 10 mg daily fairly quickly, possibly within 3 or 4 weeks to get the maximum effect as soon as possible.

Research studies have shown that the introduction of an SGLT2 inhibitor can lead to a drop in Hba1c of around 1%. Although this could vary depending on the individual patient, Sarah’s HbA1c is poor at 8.9% so even after the SGLT2 inhibitor, she is likely to require a third diabetic agent.

NICE says that if dual therapy with metformin and another oral drug is not enough, we should consider either triple therapy by adding a DPP‑4 inhibitor, pioglitazone or a sulfonylurea or starting insulin. Because of the risk of weight gain, I would try to avoid gliclazide and insulin.

Given that she is on gliclazide 80 mg daily, that is, a quarter of the maximum daily dose of gliclazide, I would probably switch Sarah to a DPP4 inhibitor as soon as she is tolerating the full dose of dapagliflozin. So, we could stop gliclazide and start her on, for example, sitagliptin 25mg daily, which is also a quarter of the maximum daily dose of 100mg.

But I do not think that there is a right or wrong approach in terms of the gliclazide switch. The decision about the timing is very dependent on the individual patient and your clinical judgement. Switching early has some more uncertainty about treatment response whereas switching later may mean that the patient remains on a potentially unsuitable drug for longer.

We have to make sure that we inform the patient that SGLT2 inhibitors have been associated with an increased risk of DKA, toe and lower limb amputations and Fournier’s gangrene.

So, on starting the SGLT2 inhibitor:

1.   We will educate her about DKA symptoms and when to seek advice.

2.   We will also advise against ketogenic diets to lose weight while on an SGLT2 inhibitor, as this also increases the risk of DKA.

3.   We will improve foot care and

4.   We will advise patients to seek urgent medical advice if they experience pain, erythema or swelling in the genital or perineal area, as this may precede Fournier’s gangrene or necrotising fasciitis. 

If we were managing her diabetes according to the European or American guidelines, we would be talking a lot more about GLP 1 receptor agonists, given that they are also recommended for patients with high CVD risk and they are much better in terms of weight loss. We are following the NICE guidelines, which are more restrictive with GLP1 receptor agonists, but we can always use our clinical judgement to deviate from the guideline if we think that it is appropriate for a particular patient. 

Now that we have dealt with her diabetes, let’s look at her hypertension. 

Unless we have specific concerns, we do not need to arrange an ABPM or HBPM because NICE says that we can use clinic blood pressure measurements to monitor drug treatment for people already diagnosed with hypertension. However, NICE also say that in diabetes, we should check both the sitting and standing BP because of their higher risk of postural hypotension, especially if there is autonomic neuropathy. 

Sarah’s BP is 153/91 and NICE says that the target BP for people under the age of 80 is below 140/90. So, her BP is high.

She is on amlodipine and indapamide, which is not in keeping with NICE guidance. NICE says that, for people with diabetes of any age and any ethnicity background, an ACEI or ARB should be used as first line treatment.

So, I would have a look to see if an ACE inhibitor or ARB has been tried before and then stopped because of side effects like a cough or angioedema. Both of these side effects can happen with ACEIs and they are normally managed by switching to an ARB. But, although much rarer, these symptoms can also be a side effect of ARBs 

Assuming that there is no previous problem, I would start her on an ACE inhibitor, for example lisinopril 2.5 mg daily monitoring her renal function and titrating up according to response. 

If the target BP is achieved at a lower dose than the maximal dose of the ACE inhibitor, then I would recommend stopping indapamide and continue titrating up the ACE inhibitor dose to compensate. Thiazide like diuretics can worsen diabetes so stopping indapamide and replacing it with a higher dose of lisinopril would be the right thing to do.   

Once indapamide has been stopped, if the target BP is achieved before the ACE inhibitor is at the maximal dose, we could consider reducing the dose of amlodipine while we increase the ACE inhibitor further, because of the benefits that ACE inhibitors have particularly in diabetes. 

Now, let’s look at her hyperlipidaemia. Sarah has no history of cardiovascular disease so she is on atorvastatin 20 mg daily for primary prevention.

NICE says that we should offer atorvastatin 20 mg for the primary prevention of CVD if they have a QRISK score of 10% or more.

After atorvastatin 20mg has been started, and unlike secondary prevention, there are no specific lipid targets in primary prevention but, if we judge the person to be at higher cardiovascular risk, we will consider increasing the dose of atorvastatin in order to achieve a greater than 40% reduction in non‑HDL cholesterol.

In Sarah’s case, both her cholesterol and QRISK3 score are still high on atorvastatin 20 mg, so we could consider her to be at higher risk and, if the 40% drop in non HDL cholesterol has not happened, we could increase atorvastatin to 40 mg and monitor her blood tests.

Let’s now move on to her asthma. Sarah is on step 1 treatment, that is, on-demand Salbutamol inhaler as needed. If Sarah has infrequent symptoms, this is fine, but we should check that she has no symptoms that could indicate the need for maintenance therapy, for example, asthma-related symptoms 3 times a week or more, or symptoms causing waking at night. In that case, we should offer a low dose of an ICS, for example standard beclomethasone 100mcg, one or two inhalations twice daily. 

The next issue is Sarah’s depression, for which she takes sertraline 50 mg daily. We don’t know how long she has been taking them for but NICE recommends that SSRIs are taken for at least 6 months (and for some time after symptoms remit). So we should assess how long she has been on it and if she wishes to continue treatment or whether the time has come to consider stopping after a gradual reduction of the dose. 

It is worthwhile mentioning that the BNF says that SSRIs should be prescribed with caution in diabetes because SSRIs can affect diabetic control. We are advised to monitor blood glucose when starting or stopping an SSRIs. 

Finally, let’s have a look at her obesity. Her BMI is 32. Apart from the obvious dietary and lifestyle changes, NICE recommends a number of pharmacological treatments for obesity such as orlistat, liraglutide and semaglutide. They all have different BMI thresholds and I would advise you to look at the different criteria before prescribing. 

Except orlistat, liraglutide and semaglutide can only be given for obesity by a secondary care service. However, as discussed earlier and based on our clinical judgement, we could deviate from the NICE guideline and give a GLP1 receptor agonist for her diabetes instead of an SGLT2 inhibitor. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE" as well as other institutions such as the British Association of the Urological Surgeons, as well as the American and European Urology Associations. 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 video I will go through clinical guidance and advice on erectile dysfunction provided by the following institutions:

·      BAUS- British Association of Urological Surgeons

·      AUA- American Urology Association

·      EAU- European Association of Urology

·      NICE- National Institute for Health and Care Excellence

I will summarise the guidance from a Primary Care perspective only.

I am not giving medical advice; this podcast is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here:  

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The guidelines can be found here: 

·      BAUS: https://www.baus.org.uk/patients/conditions/3/erectile_dysfunction_impotence

·      NICE : https://cks.nice.org.uk/topics/erectile-dysfunction/

·      EAU: https://www.europeanurology.com/article/S0302-2838(21)01813-3/fulltext

·      AUA : https://www.bing.com/ck/a?!&&p=c5356f703dad5a45JmltdHM9MTY5Njg5NjAwMCZpZ3VpZD0xM2M1MGRhYS1mMDZkLTZlM2EtMWIzYi0wMTRhZjQ2ZDZkYjcmaW5zaWQ9NTI1OQ&ptn=3&hsh=3&fclid=13c50daa-f06d-6e3a-1b3b-014af46d6db7&psq=erectile+dysfunction+american+guideline&u=a1aHR0cHM6Ly93d3cuYXVhbmV0Lm9yZy9kb2N1bWVudHMvR3VpZGVsaW5lcy9QREYvRUQtSlUucGRm&ntb=1 

The shortened Sexual Health Inventory for Men (SHIM/IIEF-5) can be found here:

·      https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/SHIM.pdf

Thumbnail photo:

·      Image by Drazen Zigic on Freepik

·      a href="https://www.freepik.com/free-photo/young-man-having-headache-holding-his-head-pain-home_26343730.htm#query=upset%20men&position=1&from_view=search&track=ais"Image by Drazen Zigic/a on Freepik 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

• Free Download / Stream: https://alplus.io/halfway-through 

Transcript 

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through clinical guidance and advice on erectile dysfunction. For this I have looked at guidance by the:

·      BAUS- British Association of Urological Surgeons

·      AUA- American Urology Association

·      EAU- European Association of Urology

·      NICE- National Institute for Health and Care Excellence

·      As well as other local NHS Hospital Trusts protocols available in the London area.

I will summarise the guidance from a Primary Care perspective only.

So let’s jump into it.

Erectile dysfunction is seen in 50 - 55% of men between 40 and 70 years old. It is often associated with obesity, high blood pressure, high cholesterol and diabetes and most treatable causes can be identified by a clinical history, physical examination and routine blood tests.

And we will start by taking a detailed sexual history. It is advisable to use validated patient questionnaires, such as the shortened Sexual Health Inventory for Men (SHIM/IIEF-5), to assess the presence, severity, and impact of erectile dysfunction. A link to this questionnaire can be found in the episode description. Otherwise, we will ask about:

·      onset, duration, and quality of erections;

·      whether night-time or early-morning erections are still present

·      whether there are problems with their sex drive or libido, arousal, and orgasm;

·      whether there are symptoms of premature ejaculation or symptoms of prostatic obstruction because they are often associated with erectile dysfunction and

·      whether the relationship with their partner is affected.

We will then ask about lifestyle factors such as their:

·      Job and work pressures

·      Ability to exercise

·      Smoking and alcohol and

·      Drug consumption

And we will then look at their past medical history for other medical conditions which may be contributing to it. We must remember that ED can be a marker for cardiovascular disease.

Then we will perform a general physical examination checking their:

·      BP, heart rate,

·      Height, weight and waist circumference,

·      peripheral pulses and the nerve reflexes in their legs.

·      We will also look for any abnormality of the penis or testicles and

·      We will check for gynecomastia or possible signs of hypogonadism.

·      Rectal examination may be performed to assess the anal tone and to examine the prostate.

After this we should do a few routine tests that will normally include:

·      HbA1c, lipid profile, and fasting morning testosterone level (that is, before 11AM) in all men.

·      Other blood tests such as a FBC, renal, liver and thyroid function tests, and PSA can be done depending on our clinical judgement.

·      We should also consider urinalysis to test for glycosuria and haematuria

If the free testosterone level is low or borderline, we will repeat it together with FSH, LH, sex hormone binding globulin, and prolactin levels. If on repeat testing, testosterone is still low and LH is high, then we are talking about primary hypogonadism, whereas if testosterone is low and LH is also low, then it would be secondary hypogonadism.

When considering the possible cause, we should bear in mind that a physical cause normally has a gradual onset of symptoms, lack of tumescence, and low-to-normal libido, whereas a psychogenic cause normally has a sudden onset, low libido, and good quality spontaneous or self-stimulated erections.

A psychological component, often called "performance anxiety", is common in men with ED, as well as relationship issues; stress; anxiety; and depression. However, a purely psychological problem is seen in only 10%.

Of the 90% of men who have an underlying physical cause, the main abnormalities found are:

·      Up to 40% of men may have cardiovascular disease, for example, heart disease, hypertension and peripheral artery disease

·      Up to 33% of men may have diabetes 

·      Up to 11% of men may have hormonal or drug problems. Examples of

o  Hormonal problems are hyperprolactinaemia and hypogonadism and

o  Drugs commonly associated with ED are:

§ Antihypertensives and diuretics,

§ Antipsychotics and antidepressants,

§ Antihistamines,

§ methadone and

§ recreational drugs such as heroin and cocaine.

§ If a drug cause is suspected, we will consider stopping or switching the medication, depending on our clinical judgement.

·      Around 10% of men may have neurological disorders, for example, MS, Parkinson's disease, stroke, or other diseases of the spinal cord or central nervous system

·      Up to 3-5% of men may have a history of pelvic surgery or trauma and

·      Between 1 to 3% of men will have anatomical abnormalities like phimosis, short penile frenulum, Peyronie’s disease, inflammation, penile curvature and prostate cancer

When it comes to treatment in Primary care, we should advise on sources of information and support as well as encouraging lifestyle improvements. In fact, losing weight and increasing exercise can dramatically improve erectile dysfunction. by up to 70%.

We should obviously optimise the management of any underlying conditions and, if clinically appropriate, we should consider drug treatment with a phosphodiesterase-5 (PDE-5) inhibitor.

However, before offering PDE-5 inhibitors we will need to do a cardiac risk stratification which will assess men into low-, intermediate-, or high-risk cardiovascular categories, depending on their risk factors and co-morbidities. Men at low risk would be asymptomatic doing moderate exercise, and may have controlled hypertension, mild stable angina, mild valvular heart disease and mild heart failure or may have had an uncomplicated MI or a successful revascularisation procedure

Men with a more significant cardiac history will be at intermediate or high risk and we would normally arrange a referral to a cardiologist for advice and recommend stopping all sexual activity until the specialist assessment.

The European Association of Urology estimates that sexual activity is equivalent to walking 1 mile on the flat in 20 min or briskly climbing two flights of stairs in 10 seconds. Men who can complete this level of exercise without symptoms are deemed to be low risk and those who would struggle would be referred to cardiology for further assessment, including an exercise ECG. Sexual activity is generally considered to be equivalent to 4 min of the Bruce treadmill protocol.

We should refer to secondary care:

·      As an emergency if there is priapism (that is, painful prolonged erection for more than 4 hours following ED treatment).

·      To Urology if there is anatomical abnormality; young age or not responding to maximum tolerated dose of at least two PDE-5 inhibitors.

·      To Endocrinology if we suspect testosterone deficiency or hypogonadism.

·      To Cardiology if at high or intermediate cardiac risk of sexual activity and

·      To Psychosexual and relationship counselling, or mental health services if there is a psychogenic cause or severe mental health condition.

Alternatively, if we decide to prescribe a PDE-5 inhibitor in Primary Care, we will:

·      Explain that these drugs will have no effect on their sex drive and that they require sexual stimulation to be effective

·      And that sildenafil 50 mg tablets (Viagra Connect®) can be purchased over-the-counter without a prescription.

·      We will warn, however, that ED medications are amongst the most commonly counterfeited medicines in Europe and that buying online should only be through legitimate sources like registered pharmacies 

·      and we will advise about the importance of dose timing.

o  Sildenafil should be taken about one hour before planned sexual intercourse and the effect can last about 4-5 hours. We also need to explain that food intake can reduce the absorption of sildenafil by an average of one hour.

o  On the other hand, tadalafil for example needs to be taken only 30 minutes before sexual intercourse, has a duration of up to 36 hours and food ingestion has not effect on it.

·      We will also explain that PDE-5 inhibitors, except generic sildenafil, are not automatically prescribable on the NHS. Therefore, before prescribing it, we need assess whether the man qualifies for an NHS prescription and, if not, we will offer a private prescription. NHS prescriptions should be endorsed SLS if the man qualifies for NHS treatment because of:

o  diabetes,

o  Neurological conditions such as multiple sclerosis, Parkinson's disease, spina bifida etc,

o  prostate cancer,

o  pelvic trauma like in pelvic injuries, radical pelvic surgery or prostatectomy,

o  renal failure treated with dialysis or by transplant or

o  Is experiencing 'severe distress' as assessed by a specialist

o  However, as already mentioned, generic sildenafil does not need to be endorsed with 'SLS' for NHS prescribing.

·      Phosphodiesterase-5 (PDE-5) inhibitors are usually taken intermittently as needed, normally as one treatment dose per week on the NHS. However, if clinically appropriate, NICE says that a higher frequency may also be prescribed on the NHS.

After the initial prescription:

·      we will follow-up the patient after 6–8 weeks, and, if there is a poor response,

·      we will consider increasing to the maximum dose, trying each PDE-5 inhibitor 4–8 times at the maximum tolerated dose before switching to an alternative.

·      We will suggest a trial of at least two different PDE-5 inhibitors taken sequentially before considering the patient as a 'non-responder'.

·      If taking tadalafil, we can consider increasing the dose frequency, such as switching to once daily (rather than 'on-demand') dosing depending on our clinical judgement.

o  The BNF states that tadalafil may be prescribed daily as a dose of 5 mg once daily, for patients who anticipate sexual activity at least twice a week, although the dose can be reduced to 2.5 mg once daily, depending on the response,

·      We also need to be aware that hypogonadism and a low testosterone level may result in a reduced response or non-response to phosphodiesterase-5 (PDE-5) inhibitors.

I will now give just an overview of some prescribing information and, in terms of contraindications, we will not prescribe a phosphodiesterase-5 (PDE-5) inhibitor if there is:

·      Unstable angina or angina occurring during sexual intercourse.

·      Regular or intermittent use of nitrates in any form

·      Hypotension (that it, a systolic blood pressure below 90 mmHg).

·      A Recent MI or stroke or

·      A history of non-arteritic anterior ischaemic optic neuropathy (NAION).

There are a number of other contraindications for specific PDE-5 inhibitors in renal or hepatic impairment and other cardiovascular conditions, so I would recommend looking at the specific recommendations for whichever drug you intend to prescribe. Equally, there is also a long list of cautions which we would need to check for each individual patient.

In terms of drug interactions, there is a severe interaction with nitrates and concurrent use of PDE-5 inhibitors and nitrates, including nicorandil, or amyl nitrate (also known as 'poppers') are absolutely contraindicated due to the risk of hypotension.

There is also an increased risk of hypotension with alpha-blockers and sacubitril/valsartan so caution is advised. 

Finally, just to mention that other treatments available for Erectile Dysfunction are:

·      Penile injections

·      Medicated urethral system for erection (MUSE)

·      Vacuum erection assistance devices (VEDs)

·      Vascular surgery/angioplasty and

·      Penile prostheses

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This podcast makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through a real-life case of a young woman with hypertension. It will focus on the NICE guidance on Hypertension in pregnancy: diagnosis and management addressing issues relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The link to the PDF version of this episode can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEqfJs8aMAUqULYy?e=wDydMJ

The visual summary- pre-pregnancy advice can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEsJdGIU4F7fR9MF?e=7nTS0f

The Full NICE guideline Hypertension in pregnancy: diagnosis and management [NG133] can be found at:

·      https://www.nice.org.uk/guidance/ng133/chapter/Recommendations 

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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through a real-life case of a young woman with hypertension. We will focus on the NICE guidance addressing issues relevant to Primary Care only. 

So let’s jump into it.

Maria is a 31-year-old woman of mixed Afro-Caribbean family origin. She has hypertension and, because of her young age, she has been fully investigated for secondary causes and her diagnosis is essential hypertension.

Her medication is amlodipine 10 mg daily and she is otherwise fit and healthy.

Her blood pressure is 155/92 mmHg.

What should we do?

She is on step 1 treatment with 1 drug, in this case the maximum dose of amlodipine, a calcium channel blocker, which is the preferred choice for people who do not have diabetes and who are of Afro-Caribbean background.

NICE says that if the BP is not controlled with a CCB alone, we have to start step 2 treatment with two drugs adding either:

·      an ACE inhibitor or an ARB, and if the person is of Afro-Caribbean background an ARB should be used in preference to an ACE inhibitor

·      or alternatively we can prescribe a thiazide-like diuretic

So, our instinct will probably tell us to start an ARB, something like, for example, losartan 25 mg daily and titrate it up according to response. This seems to be fairly straightforward so far.

But then she tells you: doctor, I am actively trying to get pregnant. Is that going to be OK?

And obviously, it will not be OK. In fact, we should have thought about it even before she mentioned it because, being a woman of childbearing age, it is a possibility that we must always bear in mind.

And this is where we need to look at the NICE guideline: Hypertension in pregnancy: diagnosis and management which was last updated in April 2023 and which not only covers hypertension during pregnancy, but also includes advice for women with hypertension who wish to conceive.

We know that ACE inhibitors and ARBs have an increased risk of congenital abnormalities if taken during pregnancy and NICE recommends an alternative if the woman is planning to get pregnant.

There is also an MHRA drug safety advice, which states that the use of ACEIs or ARBs in women who are planning pregnancy should be avoided unless absolutely necessary, in which case the potential risks and benefits should be discussed.

So, if a woman taking an ACEI or ARB becomes pregnant, it should be stopped preferably within 2 working days and we should offer an alternative.

Equally, we should advise women taking thiazide or thiazide-like diuretics that there may be an increased risk of congenital abnormalities and we should also offer an alternative.

We should explain to the patient that antihypertensive treatments other than ACE inhibitors, ARBs, thiazide or thiazide-like diuretics have not shown an increased risk of congenital malformation, although the evidence is limited.

So how should we treat her?

NICE recommends offering referral to a specialist in hypertensive disorders of pregnancy to discuss the risks and benefits of treatment. And perhaps we should do just that.

Should we be doing something else in the meantime?

Well, we could if we are worried. But this is where, apart from the usual lifestyle advice, NICE does not give specific drug advice for this group of patients.

It does say, though, that for women who are pregnant  and who have chronic hypertension we should consider:

·      Labetalol first

·      Then we will consider nifedipine if labetalol is not suitable, but we will bear in mind that some brands of nifedipine were specifically contraindicated in pregnancy by the manufacturer, so we will check the specific product characteristics for each preparation of nifedipine

·      And lastly, methyldopa if both labetalol and nifedipine are not suitable.

This patient is already taking amlodipine as a calcium channel blocker, so we would not be considering nifedipine. If I wanted to add a second agent, I would recommend starting labetalol, for example 100mg BD while waiting to see the specialist.

In summary, we will:

·      Refer her to secondary care for expert advice

·      And we may consider adding labetalol in the meantime if we are worried.

Please note that this is the advice for chronic hypertension in pregnancy, that is, women with hypertension who become pregnant. It is different from gestational hypertension, that is, hypertension that develops during pregnancy, which has different recommendations. Gestational hypertension, including pre-eclampsia, should be assessed, and managed in secondary care.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through new and updated guidelines published in September 2023 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 interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel:  

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The link to the PDF version of this video can be downloaded here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEl3L2KH_8bOGFrM?e=NqGNSZ 

The Full NICE News bulleting for September 2023 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2023-09-01&to=2023-09-30&ndt=Guidance&ndt=Quality+standard

The links to the update guidance covered can be found here:

Chronic obstructive pulmonary disease in adults: quality standard

·      https://www.nice.org.uk/guidance/qs10

Semaglutide for managing overweight and obesity: Technology appraisal

·      https://www.nice.org.uk/guidance/ta875

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•  Music provided by Audio Library Plus  

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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in September 2023, focusing on what is relevant in Primary Care only. 

So, let’s jump into it.

The first clinical area is an update on COPD because some of the quality standards have changed.

And the first one says that we have to refer patients with COPD to a pulmonary rehabilitation programme if they have a score of 3 or above on the Medical Research Council (MRC) dyspnoea scale. And this is because pulmonary rehabilitation improves exercise capacity, quality of life, and levels of anxiety and depression.

And let’s remember what a score of 3 or above means on the MRC dyspnoea scale:

Grade 3 is defined as 'walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace'.

Grade 4 is defined as 'stops for breath after walking about 100 metres or after a few minutes on level ground' and

Grade 5 is defined as 'too breathless to leave the house, or breathless when dressing or undressing'.

NICE also specifies that pulmonary rehabilitation will be at least 6 weeks in duration and include a minimum of twice‑weekly supervised sessions of structured training.

The second Quality standard change refers to patients being discharged from hospital after an acute COPD exacerbation. We will be able to expect these patients to receive a care bundle before discharge which means that before they leave hospital they will have:

·      a good understanding of their medication and inhaler use,

·      a self-management plan,

·      a smoking cessation intervention,

·      a referral to pulmonary rehabilitation if appropriate, and

·      a follow-up within 72 hours from discharge

The second clinical area refers to the use of Semaglutide for managing overweight and obesity. The update in September 2023, is not a clinical one and it refers to the company’s commercial arrangement that makes semaglutide available to the NHS with a discount.

But let’s quickly review the recommendations for semaglutide for managing overweight and obesity.

Semaglutide is recommended with a low-calorie diet in adults, only if:

·      it is used for a maximum of 2 years, with specialist input, and

·      they have at least 1 weight-related comorbidity and:

o  a BMI of 35.0 or more, or

o  a BMI between 30.0 and 35 and meets other referral criteria (for example failure of conventional treatment or when we are considering surgery).

·      We will use lower BMI thresholds (usually reduced by 2.5) for people from non-White family backgrounds. This is because they have an equivalent risk from obesity at a lower BMI than people from a White ethnic family background

And we will consider stopping semaglutide if less than 5% of the initial weight has been lost after 6 months of treatment.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go summarise the pharmacological management of neuropathic pain reviewing the guidelines on Neuropathic Pain and, because of the overlap in the clinical areas, also the guideline on Low Back Pain and Sciatica, both by the National Institute for Health and Care Excellence (NICE).

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.   

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The link to the PDF summary can be downloaded here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEiBizIQiitY4as7?e=HS9lhY 

The Full NICE guidance can be found at:  

·      Neuropathic pain : https://www.nice.org.uk/guidance/cg173

·      Low back pain and sciatica: https://www.nice.org.uk/guidance/ng59

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•  

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE guideline on neuropathic pain and, because of a slight clinical overlap, I will also touch on the management of sciatica. Please note that I will only be focusing on the pharmacological treatment from a primary care perspective.

So let’s jump into it.

And we will start with a very straightforward condition: trigeminal neuralgia.

And for this, we will offer carbamazepine initially 100mg once or twice a day, increasing gradually according to response. The usual dose is 200mg 3-4 times a day but it can be increased to a maximum of 1.6 gr daily in divided doses. Of course, we will bear in mind that there is a risk of major congenital malformations in pregnancy and advise contraception accordingly.

And we have nothing else to offer in primary care so, if carbamazepine is not effective, or suitable, we will need to refer.

For all other neuropathic pain

We will discuss with the patient whether to give oral or topical treatment.

And if the neuropathic pain is localised and they wish to avoid or cannot tolerate oral treatments, we will consider capsaicin cream. 

Otherwise, we will offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as the initial treatment. Gabapentin and pregabalin are controlled drugs so it would make sense to start with either amitriptyline or duloxetine first to minimise the risk of dependency.

If the initial treatment is not effective or tolerated, we will offer one of the remaining 3 drugs, and consider switching again if the second and third drugs are also not effective or not tolerated.

And, as a general rule, when withdrawing or switching treatment, we will taper the dose to minimise any withdrawal symptoms.

So, for me, considering the cost of drugs and risk of dependency, I would consider:

1.   Amitriptyline first

2.   Then duloxetine,

3.   Then gabapentin and

4.   Lastly pregabalin

We will refer if despite treatment the pain is severe, disabling or affecting their sleep or if their underlying condition has deteriorated.

As acute rescue therapy, we could consider tramadol, but only for short term use.

The rest of the guidelines is going to sound like this:

No, no, no, no, no

Because it is going to tell us what treatments should not be used. And we should not start:

·      cannabis extract

·      capsaicin patch

·      opiates like morphine and tramadol (this is referring to long-term use; because careful short-term use of tramadol is allowed)

·      venlafaxine

·      antiepileptics such as lacosamide, lamotrigine, levetiracetam, oxcarbazepine, topiramate or sodium valproate

For sciatica, there is a separate guideline.

And from a Pharmacological perspective, we are very limited because nothing really seems to work very well in sciatica.

We can give NSAIDs but we need to be aware of their risks and limited evidence that they are of much benefit.

If prescribing NSAIDs for sciatica:

·      We will take into account gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age

·      think about risk factors, and the use of gastroprotective treatment

·      use the lowest effective dose for the shortest possible time. 

Can we use anything else if NSAIDs do not work?

For acute low back pain, we can consider weak opioids (with or without paracetamol) but only when managing acute low back pain and only if an NSAID hasn’t worked or can’t be used. We should not offer paracetamol alone for low back pain. 

But we should not be giving opioids for on-going, non-acute sciatica

For chronic sciatica, if NSAIDs are not effective, we are going to encounter the same as before.

So, we should not offer:

·      Gabapentinoids

·      other antiepileptics

·      oral corticosteroids

·      benzodiazepines

·      opioids 

If a person is already taking any of these drugs, we will consider a safe and gradual withdrawal regime

Although we are focusing on the pharmacological treatment, I would like to say that we should also discuss non-pharmacological treatments, for example, physical and psychological therapies and surgery.

We will advise self-management and appropriate exercise, including return to work programmes if possible.

Psychological therapy or manual therapies like spinal manipulation or massage should be offered only as part of a treatment package including exercise and

Combined physical and psychological programmes should be offered for people with persistent and significant symptoms that have not responded to treatment.

We should not offer:

·      Orthotics such as belts, corsets or foot orthotics

·      Traction

·      Acupuncture

·      Ultrasound

·      Electrical nerve simulation, either percutaneous or transcutaneous (PENS or TENS)

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through the new diagnostic guidance on Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care, which was published in August 2023 by the National Institute for Health and Care Excellence (NICE).

I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel:  

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The link to the PDF summary can be downloaded here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEQYDkYwIy2vUALl?e=RcrJuC 

The Full NICE guidance can be found at:

·      https://www.nice.org.uk/guidance/dg56

Joint guidelines from ACPGBI and BSG can be found at: 

·      https://www.acpgbi.org.uk/resources/1075/fit_in_patients_with_signs_or_symptoms_of_suspected_crc_a_joint_guideline_from_acpgbi_and_bs 

Other references:

·      https://gpnotebook.com/en-gb/simplepage.cfm?ID=x20230616201913313209&linkID=82871 

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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the new NICE guidance on faecal immunochemical tests, commonly known as FIT tests, to guide colorectal cancer referrals and which represents a change in the criteria for cancer referrals

So let’s jump into it.

John Smith is 77 and has recurrent rectal bleeding. He has no other symptoms and his abdominal and rectal examination is normal. What should we do next?

·      Should we refer?

·      Or should we do a FIT test?

And NICE now says that we need to do a FIT test.

And you may ask yourself, why? If the test is positive, it is not going to tell us anything that we did not already know and, if it is negative, are we not going to refer him for further investigations? So, what’s the point?

Well, let’s have a look at the new guidance and try to understand it. But first let’s remind ourselves that FIT tests detect blood in stools using antibodies specific to human haemoglobin. Human haemoglobin, degrades as it travels through the gastrointestinal tract, so FIT tests are less accurate in upper gastrointestinal bleeding. They were developed as an alternative to the old technique of faecal occult blood tests, which could react with chemicals in food and medicines resulting in false positive results.

Before considering the rationale of the NICE recommendations, let’s look at them first. And it is probably easier if we start by looking at when we will NOT need to request a FIT test, which is when there is:

·      a rectal or anal mass, or an unexplained anal ulceration. They are what NICE refers to as “red flags” or “bypass symptoms”, meaning that they will trigger an automatic urgent cancer referral

And what about an abdominal mass? Is that a bypass symptom? Well, yes and no, depending on how you look at it. It is not a bypass symptom given that you should still request a FIT test because, if it is positive, it will point towards a colorectal cause and will help us refer the patient to the appropriate service. But, and this is a big BUT, we are going to refer the patient regardless of the result. So, if the result is positive, we will refer to a colorectal service, and if it is negative, provided that we have a clinical suspicion of cancer, we will refer them urgently to another secondary care service. Which one will depend on our clinical judgement. However, if we have concerns that the patient may delay or not engage with the FIT test because of any reason, we should consider making the urgent cancer referral without the FIT test.

And now let’s look at when we will organise the FIT test. And please note that some of these clinical situations would have triggered an urgent cancer referral according to the old guidelines. Also, we need to remember that a FIT test should still be offered even if the patient has had a negative result through the screening programme because the thresholds are different.

So, a FIT test should be requested for:

1.   Adults of any age:

·      with an abdominal mass,

·      with a change in bowel habit,

·      with iron-deficiency anaemia,

2.   If they are 40 or over with:

·      unexplained weight loss AND abdominal pain

3.   If they are under 50 with rectal bleeding AND either:

·      abdominal pain or

·      weight loss,

4.   If they are 50 or over with either:

·      rectal bleeding

·      abdominal pain or

·      weight loss,

5.   And lastly, if they are 60 or over with anaemia even in the absence of iron deficiency.

And we will organise an urgent cancer referral if the FIT test result is 10 or more.

And now let’s try to understand why NICE has made these recommendations.

And it is basically because FIT tests are an excellent way of assessing a patient’s risk of having colorectal cancer. A patient with a FIT test <10 has a less than 1% of risk of having colorectal cancer and we should consider alternative diagnoses and investigatory. This means that colonoscopy resources can be prioritised for people who most need them.

In the old cancer referral guidelines, patients with 'high risk' symptoms were referred urgently without a FIT test.

However, many of these referred patients did not have cancer following colonoscopy, even in situations such as iron deficiency anaemia and rectal bleeding. So, NICE concluded that using FIT tests could reduce the number or the urgency of patients referred for colonoscopy and therefore also reduce the waiting times.

It is all good so far but, are there any drawbacks?

Well, there are concerns about patients that may not return the FIT test, which may be related to sociodemographic factors or disability and this group of patients may need more support.

There is also the concern of those patients with symptoms and a FIT test <10.

We said earlier that a patient with a FIT test <10 has a less than 1% risk of having colorectal cancer. However, this low risk partly reflects the rarity of colorectal cancer in the general population and we need to be aware that between 10 and15% of patients with colorectal cancer may have a FIT test result which is <10. Therefore, if we have any concerns or any reasons for suspecting cancer, it is reasonable to refer the patient to rule it out. 

The joint guideline from the Association of Coloproctology of Great Britain & Ireland and the British Society of Gastroenterology also recommend referral of patients with persistent or recurrent anorectal bleeding for flexible sigmoidoscopy even if the FIT test result is <10.

So, the summary is that for patients who have not returned a faecal sample or who have a FIT test result < 10 we should either:

·      Refer them if we are concerned because of cancer or unexplained symptoms or

·      Provide safety netting. Now, what safety netting actually means is going to vary according to our clinical judgement and it may include things like:

o  management in Primary Care following a “watch and wait” approach or

o  offering further tests, including another FIT test or tests for other possible conditions.  

So, let’s quickly go back to John, our 77-year-old patient with rectal bleeding. We are going to do a FIT test and if it is 10 or more, we will organise an urgent colorectal cancer referral. And if it is <10 we will refer him for further investigations, possibly a flexible sigmoidoscopy. The urgency of this referral will depend on our clinical judgement and on how concerned we may be.

The take home message is that FIT testing is, despite imperfections, the best method that we have to assess the urgency of a referral to exclude colorectal cancer, but we can still refer if we think it is needed.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through new and updated guidelines published in August 2023 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. 

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel:  

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The link to the PDF version of this video can be downloaded here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEMuxr60pkhK-T5g?e=n81cOC 

The Full NICE News bulleting for August 2023 can be found at:

·      https://www.nice.org.uk/guidance/published?from=2023-08-01&to=2023-08-31

The links to the update guidance covered can be found here:

Otitis media with effusion in under 12s

·      https://www.nice.org.uk/guidance/ng233

Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care

·      https://www.nice.org.uk/guidance/dg56

Venous thromboembolic diseases: diagnosis, management and thrombophilia testing

·      https://www.nice.org.uk/guidance/ng158

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• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

• Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE guidance and advice published in August 2023, focusing on what is relevant in Primary Care only. 

It’s a fairly short and straightforward episode today so let’s jump into it.

The first clinical area is an update on the management of otitis media with effusion, also known as 'glue ear', in under 12s. Please don’t confuse the term otitis media with effusion with acute or chronic otitis media, which we are not covering today. 

The updated paragraphs of the guideline refer to giving information about the fluctuating nature of the condition and its impact on hearing, language development, behaviour, and emotional wellbeing. We should also explain that exposure to smoking increases the risk of developing glue ear in children.

OME often present with one or more of the following: hearing difficulties, delayed speech and language development, ear discomfort and tinnitus. Also, behavioural problems, poor educational progress, and balance difficulties (for example, clumsiness).

NICE now also says that we should consider snoring as a reason to suspect glue ear.

If OME is clinically suspected based on the history and examination, we will make a referral for a formal assessment which will include a hearing test.

I will not cover all the various recommendations following referral as this is outside the scope of primary care. But it is worthwhile mentioning that we should not offer any of the following for OME or its related hearing loss: antibiotics, oral or nasal steroids, antihistamines, leukotriene receptor antagonists, mucolytics, anti-reflux medications, PPIs or decongestants 

Equally, we will advise against homeopathy, cranial osteopathy, acupuncture, massage, and dietary modification, including probiotics

And finally, we will treat children with otorrhoea after grommet insertion with non-ototoxic topical antibiotic ear drops (such as ciprofloxacin) for 5 to 7 days.  

The next clinical area refers to Venous thromboembolic diseases. There is not much to say as it does not really affect primary care too much, other than making you aware that there are updated recommendations for PEs and DVTs for people with COVID-19 and we are advised not to stop short-term interim anticoagulation for these patients following negative tests and to follow the COVID-19 rapid guideline instead. 

The last clinical area refers to the recognition and referral of suspected colorectal cancer, in particular the use of quantitative faecal immunochemical testing, commonly referred to as a FIT test.

I found this extremely interesting and I will dedicate a separate video to the subject. For now, I will just say that the updated guidance recommends FIT tests in some clinical situations where before a two-week rule cancer referral pathway would have been recommended. FIT tests are now recommended in adults:

·      with an abdominal mass,

·      with a change in bowel habit,

·      with iron-deficiency anaemia,

·      aged 40 and over with unexplained weight loss and abdominal pain,

·      aged under 50 with rectal bleeding and either:

o  abdominal pain or

o  weight loss,

·      aged 50 and over with either:

o  rectal bleeding

o  abdominal pain or

o  weight loss,

·      and lastly, those aged 60 and over with anaemia even in the absence of iron deficiency

But I think that this issue deserves more reflection so watch out for my next episode, which will look into it in more detail, including the rationale for changing and other considerations.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/kYcJ3Ym3C0A

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.

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 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

There were no updated guidelines or quality standards but, apart from some radiotherapy treatments, there were five technology appraisals, none of which were really relevant to Primary care. However, I give them a very quick overview

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.  

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: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for July 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-07-01&to=2024-07-31&ndt=Guidance&ndt=Quality+standard

The links to the current consultations can be found here:

Lebrikizumab for treating moderate to severe atopic dermatitis in people 12 years and over:

·      https://www.nice.org.uk/guidance/ta986/chapter/1-Recommendations

Tenecteplase for treating acute ischaemic stroke:

·      https://www.nice.org.uk/guidance/ta990/chapter/1-Recommendations

Ivacaftor–tezacaftor–elexacaftor, tezacaftor–ivacaftor and lumacaftor–ivacaftor for treating cystic fibrosis:

·      https://www.nice.org.uk/guidance/ta988/chapter/1-Recommendations

Etranacogene dezaparvovec for treating moderately severe or severe haemophilia B:

·      https://www.nice.org.uk/guidance/ta989/chapter/1-Recommendation

Trastuzumab deruxtecan for treating HER2-low metastatic or unresectable breast cancer after chemotherapy:

·      https://www.nice.org.uk/guidance/ta992/chapter/1-Recommendations

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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 am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in July 2024. This month we have not had any new guidelines or quality standards but we have had a few new technology appraisals, that is, when NICE reviews new treatments to decide whether they should be recommended on the NHS. Apart from some radiotherapy recommendations, there were 5 other new treatments. Although none of them were really relevant to Primary care, I will give you a very quick overview so that we understand where new therapies are coming from and so that we have some knowledge if we come across them.

But do not worry, it is a real summary, and today will be a very brief episode. 

So, let’s jump into it.

The first area refers to the treatment of moderate to severe atopic dermatitis or eczema.

We know that standard treatment includes the topical use of emollients and steroids. If these treatments are not effective, systemic immunosuppressant treatments such as ciclosporin and methotrexate can be added. If there is an inadequate response or they are unsuitable, other agents such as a Janus kinase (JAK) inhibitor or a biological medicine (such as dupilumab or tralokinumab) can be used.

NICE has evaluated a new biological medicine alternative, lebrikizumab and indirect comparisons with Janus Kinase inhibitors and other biological treatments suggest that it is equally effective at an acceptable cost.

The biological treatments lebrikizumab, dupilumab, and tralokinumab are monoclonal antibodies that inhibit interleukin processes, thus reducing inflammation and modulating the immune response in conditions such as eczema and asthma. They are administered via subcutaneous injection and they can now all be used as  treatment options.

The next area covers the treatment of acute ischaemic stroke.

We know that once an intracranial haemorrhage has been ruled out, thrombolytic treatment can be started within 4.5 hours of the onset of stroke symptoms. The current standard thrombolytic treatment for this is alteplase.

Tenecteplase is an alternative to alteplase.  Tenecteplase, just like alteplase, turns plasminogen into plasmin, an enzyme that digests fibrin and acts like a pair of scissors to cut up the fibrin mesh in the clot, leading to clot dissolution and restoration of blood flow.

The evidence shows that tenecteplase is at least as effective as alteplase and a cost comparison suggests that it is less expensive, so it is also recommended.

The next area covers the treatment of cystic fibrosis, which we know affects the lungs, digestive system, and liver, and which reduces life expectancy and quality of life. Usual treatment is very physically demanding and time consuming for patients and their carers.

There are a number of tongue-twisting treatments namely ivacaftor, tezacaftor, elexacaftor, and lumacaftor, which work by improving the transport of chloride across cell membranes which in turn helps to hydrate and thin the mucus, particularly the lungs. They have been shown to improve lung function, growth and weight gain and reduce the number of lung infections.

They come as tablets or sachets and although expensive, NICE considers them to be cost effective, so, they are recommended.

The next area covers a gene therapy for Haemophilia B, etranacogene dezaparvovec, which reduces the number of bleeding episodes a person has each year. However, there is not enough evidence on how well it works in the long term so it is unclear as to whether it is cost effective. It is therefore not recommended for routine use in the NHS, but it can be used with managed access in order to try and collect more data.

The final area refers to the treatment of certain breast cancers with a combination drug, trastuzumab deruxtecan, which works by combining a monoclonal antibody targeting HER2-positive cancer cells with a potent chemotherapy drug, delivering the chemotherapy directly to the cancer cells. However, the cost-effectiveness estimates are unacceptably high, so, it is not recommended.

So that is it, very brief review of the new treatment updates.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

This video makes reference to guidelines produced by the "National Institute for Health and Clinical Excellence" in the UK, also referred to as "NICE". 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 NICE.

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I go through the Guideline in Dementia by the National Institute for health and Clinical Excellence guideline, guideline [NG97], Published: 20 June 2018:

Dementia: assessment, management and support for people living with dementia and their carers 

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

·      The NICE GP YouTube Channel: https://youtube.com/@practicalgp?si=a99JH9FBPB3BVtFd 

The full guideline can be downloaded here: 

·      https://www.nice.org.uk/guidance/ng97 

You can download a summary of my summary / interpretation of the guidance here:  

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mDynkIBny7vD2G-O?e=f0XrDp 

Thumbnail photos- Image by rawpixel.com on Freepik:

<a href="https://www.freepik.com/free-photo/hands-holding-puzzle-business-problem-solving-concept_18836375.htm#query=solution&position=42&from_view=search&track=sph#position=42&query=solution">Image by rawpixel.com</a> on Freepik 

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Transcript

Hello everyone and welcome, I am Fernando, a GP in the UK. In this episode, we look at the NICE guidelines on dementia and we start by emphasising the importance of involving patients in the decision-making process regarding their care. As we know, Dementia has symptoms, that include memory loss, challenges in reasoning and communication, and personality changes. As a result, often, people with dementia are inadvertently excluded from these crucial decisions, and information may not be well communicated. Additionally, many patients may not readily share their thoughts on their care. Considering this, we should actively encourage and enable them to express their views and opinions, using structured tools to enhance communication.

We also need to give clear information about their specific dementia subtype. We should also discuss advance care planning to ensure a proactive approach in addressing evolving care needs. Moreover, at each care review, we must provide patients with the opportunity to revisit and modify any advance statements and decisions they have previously made."

One of the most important parts of the initial assessment and diagnosis in Primary Care is obtaining a thorough history. Ideally, this should not only come from the patient but also from someone that knows the patient well.

In cases where dementia is suspected following the initial assessment, our next step involves a full physical examination and relevant blood and urine tests to rule out any reversible causes for cognitive decline. Additionally, we should incorporate cognitive testing into the evaluation process. When using cognitive tests in primary care, we should opt for brief, validated tools like the 10-point cognitive screener (10-CS), mini COG, or the 6-item cognitive impairment test (6CIT), as opposed to longer assessments such as the MMSE. But we need to be aware that a normal score alone does not rule out dementia.

After investigating reversible causes of cognitive decline, if we still suspect dementia, we must refer the patient to a specialist dementia service.

We must remember that ordering of imaging in primary care is not recommended and this should be done by specialist services.

Furthermore, case finding for suspected dementia should only be done as part of a clinical trial. 

In terms of Interventions to promote cognition, we can offer group cognitive stimulation therapy, group reminiscence therapy and cognitive rehabilitation in mild to moderate dementia. But we will not provide acupuncture or cognitive training as part of the intervention plan.

Starting pharmacological treatment for Alzheimer's disease should be done exclusively under the guidance of a specialist. However, once the decision to commence treatment with a cholinesterase inhibitor or memantine has been made, the initial prescription may be issued in primary care.

Cholinesterase inhibitors such as donepezil, galantamine, or rivastigmine can be given in Alzheimer’s as monotherapy.

Memantine may be considered for those with moderate Alzheimer's disease, but only as monotherapy when the patient cannot tolerate a cholinesterase inhibitor.

In cases of moderate and severe Alzheimer's disease, a combination of a cholinesterase inhibitor and memantine can be used.

Cholinesterase inhibitors should not be discontinued in patients with Alzheimer's disease only because of disease severity.

For people already diagnosed with Alzheimer's disease and currently taking a cholinesterase inhibitor, we have the option to initiate memantine in Primary Care without requiring specialist advice.

In cases of dementia with Lewy bodies, we can use donepezil, rivastigmine, galantamine, and memantine.

We will consider the use of cholinesterase inhibitors or memantine in vascular dementia only when we suspect comorbid Alzheimer's, Parkinson's, or dementia with Lewy bodies.

Cholinesterase inhibitors or memantine should not be offered to patients with frontotemporal dementia. 

Many commonly prescribed medications are linked to increased anticholinergic burden, which can lead to cognitive impairment. These drugs have the potential to exacerbate cognitive symptoms in dementia or even lead to inaccurate diagnoses. There are validated tools, such as the Anticholinergic Cognitive Burden Scale and we should consider reducing these medications whenever possible, and look for alternatives."

In terms of managing Non-Cognitive Symptoms such as agitation, distress, depression, anxiety, and sleep problems we will say that before initiating any treatment, we need to investigate potential causes for their distress and provide psychosocial and environmental interventions to alleviate it.

Antipsychotic medications should only be used when they are at risk of harming themselves or others, or when they are suffering from severe distress due to agitation, hallucinations, or delusions.

We must remember that patients with Parkinson's or dementia with Lewy bodies, antipsychotics can exacerbate the motor symptoms of their condition.

When employing antipsychotics:

We will use the lowest effective dose and for the shortest duration possible.

We will review the treatment at least every six weeks and we will stop it if there is not a clear and ongoing benefit from it.

Furthermore, valproate should not be offered as a means to manage agitation or aggression in dementia, unless indicated for another medical condition.

For mild to moderate depression or anxiety, we will consider psychological treatments and antidepressants should not be the primary approach, unless there is a pre-existing severe mental health condition. 

We should not give melatonin for insomnia in Alzheimer's disease.

We will use a structured observational pain assessment tool for those who seem to be in pain or show signs of behavioural changes that may be caused by pain and we will use a stepwise treatment protocol that balances pain management and potential adverse events.

We must remember that multifactorial falls interventions may not be suitable for patient with severe dementia and

We will consider relaxing HbA1c targets for people with severe dementia who have type 2 diabetes.

We will consider referring adults with cognitive impairment to an audiology service for a hearing assessment, as hearing loss may be a comorbid condition.

For adults with diagnosed dementia or mild cognitive impairment without hearing loss, we should refer them for a hearing assessment every two years. We will also encourage them to have an eye test every two years. 

We must be aware of the increased risk of delirium following hospital admission, and we should consider the importance of maintaining a familiar environment for these patients.

As part of palliative care, the routine use of enteral feeding should not be used in cases of severe dementia, unless there is a specific indication related to a potentially reversible comorbidity.

Finally, we should ensure that carers are informed of their entitlement to undergo a formal needs assessment, including for respite, psychoeducation, and skills training.  

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I go through a real-life case of an asymptomatic patient with an isolated raised alkaline phosphatase level. I will describe a recommended approach to investigate and manage them according to guidelines. 

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

·      The NICE GP YouTube Channel: NICE GP - YouTube 

You can download a summary of my summary / interpretation of the guidance here:  

·      My Summary: https://1drv.ms/b/s!AiVFJ_Uoigq0mC4pm_bYELFa9wEx?e=07p2dJ

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Transcript

Interpreting Isolated Raised Alkaline Phosphatase in Asymptomatic Patients

Hello and welcome. I’m Fernando, a GP in the UK. Today, we're going to explore what to do when we encounter an isolated raised serum Alkaline Phosphatase level in an asymptomatic patient. Please like and subscribe to support the channel.

Right, so let's dive right in!

Introduction

Before we start, let’s remember that Alkaline Phosphatase is present in various tissues, including the liver, bone, kidney, intestine, and placenta. Reference ranges can vary with age and gender, so mild increases may not indicate disease.

Examples of Physiological Causes are:

·      Growth spurts in adolescents

·      Pregnancy in women

·      Age-related increases and

·      Medications like some antibiotics, antiepileptics, antihistamines, oestrogens, and steroids

Some potential causes of isolated raised serum Alkaline Phosphatase include:

·      Congestive cardiac failure

·      Bone diseases

·      Hyperthyroidism

·      End-stage renal disease

Clinical case

So, let’s have a look at our patient. She is a 49-year-old lady who had some blood tests because she was feeling a little tired. Her results came back normal with the exception of an alkaline phosphatase level of 186 (NR 30-130). Physical examination was normal and that there were no signs or symptoms of disease. In addition, she does not drink alcohol at all.

What should be our next steps?

The baseline investigations for someone with an isolated Alkaline Phosphatase are the following tests:

·      Liver function tests adding GGT

·      Calcium and phosphorus adding vit D and PTH

·      Renal and thyroid function tests and

·      A full blood count

We know that the most likely sources of Alkaline Phosphatase are either the bone or the liver. And, in order to differentiate between them, this is why we measure GGT (which is typically elevated in liver issues) and vitamin D levels and PTH levels, which may point towards bone causes.

So, for this patient we will need to repeat the Alkaline Phosphatase levels and checking gamma-GT, vitamin D and parathyroid hormone to try to determine the cause, as well as making sure that the other tests, that is, renal, and thyroid function tests, calcium, phosphorus and a full blood count have also been checked

We will talk more about our patient a little later but now let’s say that, in general terms, if all these tests come back normal, further investigations can be deferred for three months, during which Alkaline Phosphatase levels should be rechecked. Rechecking it earlier than three months is generally unnecessary unless you have specific concerns.

If Alkaline Phosphatase is raised with elevated GGT levels, it's likely of hepatic origin. Further steps that we will need to consider include:

·      Abdominal ultrasound scan (to check for cholestasis and hepatic space-occupying lesions)

·      Antimitochondrial antibodies test (to explore the possibility of primary biliary cirrhosis)

However, if these liver investigations are normal, and the Alkaline Phosphatase level is less than 1.5 times the upper reference limit, observation and monitoring every 3 to 6 months is recommended.

However, if the Alkaline Phosphatase level is more than 1.5 times the upper reference limit and a hepatic origin is suspected, referral for further liver investigations is recommended.

Now, if GGT levels are normal, the raised Alkaline Phosphatase is most likely from a non-hepatic source, often bone-related. This can be due to vitamin D deficiency, Paget's disease of bone, or growth spurts in adolescents.

And how do we manage this? Obviously, if the vitamin D levels are low, we will treat the deficiency accordingly. And if there is any abnormality in the PTH levels, we will also manage it and investigate it further.

If Vitamin D and PTH are normal and if the Alkaline Phosphatase level is less than 1.5 times the upper reference limit and we have no clinical concerns, then observation and monitoring every 3-6 months is usually enough.

However, for those with non-hepatic Alkaline Phosphatase levels more than 1.5 times the normal level, bone scintigraphy may be considered to detect conditions like asymptomatic Paget's disease.

In cases of diagnostic uncertainty and significant increases in serum Alkaline Phosphatase, checking Alkaline Phosphatase isoenzymes will be considered. This will be more precise in determining the origin of the raised levels.

So, there we have it, a guide on what to do when you encounter an isolated raised serum Alkaline Phosphatase level in an asymptomatic patient.

But, what happened to our patient?

Repeat testing showed normal results including GGT, Vitamin D and PTH but the Alkaline Phosphatase went from 186 to 204. Her history and examination remained unremarkable but she started to complain about some abdominal discomfort.

Because of the rise in the Alkaline Phosphatase level and her symptoms, as a precaution, an USS of the abdomen was arranged as well as another check of her Alkaline Phosphatase 6 weeks later.

The results showed that the Alkaline Phosphatase was still high but it had decreased slightly to 191 and her USS showed steatosis of the liver.

So, we conclude that she has non-alcoholic fatty liver disease or NAFLD. Although her liver function tests and GGT results were normal, it is likely that the raised Alkaline Phosphatase level is due to this.

By the way, if you are unsure about how to diagnose and manage NAFLD, please check the corresponding episode on this channel.

By the way, if you are unsure about how to diagnose and manage NAFLD, just click here or in the link that I have put in the episode description which will take you to the corresponding episode on this channel.

And because the Alkaline phosphatase level is less than 1.5 times the upper limit of normal, we will monitor it every 3-6 months.

Remember, that this is not medical advice, it is only my summary of the guidelines consulted and you must use your clinical judgement.

Thanks for watching, and goodbye!

Thank you for listening and goodbye!

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I go through a real-life case of a patient with abnormal Liver Function Tests and non- alcoholic fatty liver disease or NAFLD. I will describe a recommended approach to diagnose and manage them according to guidelines. 

I am not giving medical advice; this podcast is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

·      The NICE GP YouTube Channel: NICE GP - YouTube 

The links to the websites that can calculate these scores are in the episode description:

·      The NAFLD Fibrosis Score (NFS) is available at https://www.thecalculator.co/health/NAFLD-Fibrosis-Score-Calculator-969.html 

·      The Fibrosis 4 (FIB-4) Score available at https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver-fibrosis 

You can download a summary of the episode here:  

·      Summary of NAFLD patient case: https://1drv.ms/b/s!AiVFJ_Uoigq0mBYIbok6DSu5vTnY?e=2W11Jd

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Transcript

Hello everyone and welcome. My name is Fernando and I am a GP in the United Kingdom. 

In today’s episode I go through a real-life case of a patient with abnormal Liver Function Tests and non- alcoholic fatty liver disease or NAFLD, describing the recommended approach for its diagnosis and management according to guidelines.

By the way, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the various guidelines consulted so you must use your own clinical judgement.

If you want to download a summary of the episode, the link is in the episode description.

Remember that there is also a YouTube version of these episodes so have a look in the episode description. 

Right, so let’s get straight into it.

Our patient is a 55-year-old man of Hispanic family background who consults you following a routine blood test done one week earlier. This was a repeat blood test because 4 months previously he had been found to have a mildly raised alanine aminotransferase or ALT of 75 (NR 0-55).

The results of all his blood tests were normal with the exception of the ALT which was still high at 65.

His PMH includes:

·      Prediabetes

·      Hyperlipidaemia and

·      Overweight with a BMI of 27.8

His only medication is atorvastatin 20 mg daily for hyperlipidaemia.

He denies alcohol excess. In fact, he is teetotal and does not drink alcohol at all. He has otherwise no symptoms.

In the previous consultation he had been told that raised liver transaminase were not uncommon during the prescribing of statins but that statins need not be stopped for raised liver transaminase levels as long as they are less than 3 times the upper limit of normal.

However, as a result of that consultation, the patient decided to stop the statin of his own accord so he has not been taking it for the last 3 months.

So, in summary, we have a patient with a background of overweight, prediabetes and dyslipidaemia with a slightly elevated ALT for 3 months without an obvious cause.

What should we do?

When we face this situation, we should consider all the possible causes and investigate them fully. But we must primarily consider the most common reason for abnormal liver blood tests in the UK, which is non-alcoholic fatty liver disease, or NAFLD.

This condition happens when excess fat builds up in the liver. But for the diagnosis to be made, we must also exclude other secondary causes.

Let’s quickly remind ourselves that NAFLD has a spectrum that goes from simple hepatic steatosis, meaning that there's fat in the liver, but it's not causing any significant inflammation or damage, to something more serious called non-alcoholic steatohepatitis, or NASH which involves inflammation and injury to liver cells which can lead to liver fibrosis and cirrhosis.

Most people don't have any specific symptoms. However, some might experience fatigue, or mild abdominal discomfort.

In our patient's case, we know that he is overweight, which is typical. However, NAFLD can affect even non-obese individuals. Surprisingly, about 40% of all NAFLD cases worldwide are found in non-obese people, and around 20% in those who are lean.

We also know that NAFLD is closely tied to the metabolic syndrome, involving insulin resistance, obesity, impaired glucose regulation, and hypertension and our patient does have some of these factors. While the exact cause of NAFLD isn't fully clear, it is thought that both environment and genetics play a role.

The outlook for NAFLD depends on the stage of the disease:

• For those with simple steatosis, the outlook is generally positive.
• However, if someone has non-alcoholic steatohepatitis (NASH), they're at higher risk for cirrhosis, liver failure, and even liver cancer.

Complications of NAFLD can be serious. They include:

• Hepatic and metabolic complications and
• Above all, cardiovascular disease, which is the leading cause of death for people with NAFLD.

We should suspect that someone has NAFLD if:

• There are risk factors linked to the metabolic syndrome.
• There are high levels of alanine aminotransferase (ALT) for more than 3 months, and it's usually higher than another enzyme called aspartate aminotransferase (AST).
• They're not consuming excess alcohol, in which case it would be alcoholic fatty liver disease.
• An ultrasound scan reveals a fatty liver.
• They are nor on medication that can cause a fatty liver, e.g. tamoxifen or amiodarone.

So based on all this, we will suspect that our patient could have NAFLD.

How should we confirm the diagnosis?

Next, we'll arrange some more blood tests to get a clearer picture and exclude secondary causes. We will do:

• Liver function tests, to include AST as well as ALT.
• A full blood count, which can help detect low platelets, which is a sign of advanced fibrosis.
• A clotting screen, as it might be off in advanced fibrosis.
• Screening for viral hepatitis B and C, and test for auto-antibodies that could suggest autoimmune hepatitis.
• Ferritin and transferrin saturation to screen for haemochromatosis,
• Serum caeruloplasmin for Wilson's disease,
• Alpha-1-antitrypsin levels to screen for deficiency
• Immunoglobulin (IgA) tissue transglutaminase antibody (tTGA) as coeliac disease can present with cryptogenic liver disease.
• HbA1c, Lipid profile, ESR, CRP, Renal and thyroid function tests as general screening.

Additionally, we could request a liver USS to exclude any other structural issue that we could be missing.

Right, so we organise these tests and we see the patient a few weeks later to discuss the following:

An USS of the abdomen confirms that he has steatosis of the liver.

His blood tests showed that:

ALT has improved but it is still high at 59 (NR 0-55) and AST is also high at 49 (NR 5-34). The rest of his liver function tests were normal.

His FBC was normal with a platelet count of 219 (NR 150-400 10*9/L)

His HbA1c is in the prediabetes range at 43 or 6.1%.

He has normal clotting screen, ESR, CRP, renal and thyroid function tests.

And all other investigations for secondary causes were also normal: viral hepatitis serology, autoantibody screen, ferritin, transferrin saturation, caeruloplasmin, Alpha-1-antitrypsin levels and Immunoglobulin (IgA) tissue transglutaminase antibody (tTGA) as coeliac screen.

His cholesterol was slightly high at 5.1 with an HDL of 1, an LDL of 3.9 and TG of 1.5.

His BP was 147/82 and his CVD risk score using QRISK3 is 8%.

I summary, we have confirmed steatosis of the liver on USS and, given that we have not found secondary causes for the liver function test abnormality, we can conclude that this is indeed NAFLD.

As part of our consultation, we also do a thorough examination looking out for signs of advanced liver disease, of which he has none.

As the next step, we should estimate the level of fibrosis, or scarring of the liver, by using non-invasive tools. There are two simple tests that we can use in Primary care:

·      One, the Fibrosis-4 score or FIB-4, which uses the person's age, AST, ALT, and platelet count.

·      And two, the NAFLD Fibrosis Score (NFS) which measures age, body mass index, blood glucose, platelet count, albumin, and the AST to ALT ratio.

·      The Enhanced Liver Fibrosis (ELF) test is another option but this is really only available in secondary care because of the complexity of the parameters required.

The links to the websites that can calculate these scores are in the episode description:

·      The NAFLD Fibrosis Score (NFS) is available at https://www.thecalculator.co/health/NAFLD-Fibrosis-Score-Calculator-969.html 

·      The Fibrosis 4 (FIB-4) Score available at https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver-fibrosis

If the fibrosis score is low, we may be able to manage this patient in Primary Care.

We calculate the FIB4 score for this patient and it is 1.92. which means that further investigations are needed. The interpretation of the scores is as follows:

·      If FIB-4 is < 1.45: we can be reasonably confident that there is absence of cirrhosis

·      If FIB-4 is between 1.45 - 3.25:  the test is inconclusive and

·      If FIB-4 is > 3.25: we can be reasonably confident that there is cirrhosis

So let's move on to the management.

The Primary Care approach would be as follows:

• We will advise lifestyle changes including weight loss, if the person is overweight.
• We will recommend a Mediterranean diet, which can actually reduce liver fat even without weight loss.
• We will encourage moderate-intensity exercise.
• We will offer alcohol advice.
• We will optimise management of co-morbidities such as hypertension, hyperlipidaemia, or type 2 diabetes. In this case, we may revisit his statin therapy because he has two independent risk factors for CVD, prediabetes and NAFLD.
• We need to be aware that statins, if prescribed, don't pose additional liver risks for people with NAFLD. In fact, they can help improve various aspects of the condition.

So, in summary, the primary care approach to NAFLD involves empowering patients to make lifestyle changes, ensuring associated conditions are managed, and offering support and information along the way.

If a person has a working diagnosis of NAFLD and other liver disease causes have been ruled out, and if non-invasive tests indicate a low risk of advanced liver fibrosis (using NFS, FIB-4, or ELF), then primary care management is in order.

However, because his FIB4 score is inconclusive in this case, we will refer him to secondary care for a second opinion.

Other reasons to refer to a Specialist are:

• If there's a high risk of advanced liver fibrosis.
• If there are clear signs of advanced liver disease during examination.
• In cases where there's uncertainty about the diagnosis.

We also need to be aware that specialist management may involve amongst other things:

• Transient elastography, also known as fibroscan, which measures liver stiffness non-invasively, which correlates with the degree of liver fibrosis.
• Liver biopsy.
• In cases of non-alcoholic steato-hepatitis (NASH), pioglitazone, and Vitamin E supplementation might be considered.
• Bariatric surgery, has led to the resolution of steatosis in 66% and fibrosis in 40% of patients.
• Considering liver transplantation. However, NASH recurrence after transplantation is possible.

Finally, this patient should be reviewed regularly in Primary Care. Patients with NAFLD should have an annual review, more frequently if necessary, as per our clinical judgement:

During the review, we will:

• Identify any signs that might indicate liver disease.
• Measure blood pressure and BMI.
• Check liver and renal function, HbA1c and a lipid profile.
• Reassess the CVD risk
• And, every three years, reassess the risk of advanced liver fibrosis and refer if the person has a high risk of advanced liver fibrosis

But remember that this is only a summary and my interpretation of the guidelines.

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

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I go through the NICE guidelines “Attention deficit hyperactivity disorder: diagnosis and management” or NICE guideline NG87, Published in March 2018 and last updated in September 2019. 

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

·      The NICE GP YouTube Channel: NICE GP - YouTube 

The full NICE guidance can be found here: 

·      NICE Guideline NG87: https://www.nice.org.uk/guidance/ng87

·      ADHD NICE CKS: https://cks.nice.org.uk/topics/attention-deficit-hyperactivity-disorder/ 

You can download my summaries here: 

·      Summary of NICE guideline NG87: https://1drv.ms/b/s!AiVFJ_Uoigq0mAekn-9SQlZAl5kD?e=WYqHT7

·      Additional Clinical ADHD information: https://1drv.ms/b/s!AiVFJ_Uoigq0mAhXL3J6CRjq5QoD?e=P8cL7K

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Transcript

Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom. 

In today’s episode I go through the NICE guidelines on ADHD from a primary care perspective. Make sure that you stay for the whole episode because at the end, I am going to give you additional information on the condition including possible causes, pathophysiology, prognosis and the biochemical reasons why pharmacological treatment is so beneficial in ADHD. 

By the way, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the guidelines so you must use your own clinical judgement. 

If you want to download a copy of my summaries of the NICE guidelines or the additional clinical information, the links are in the episode description.

Remember that there is also a Youtube version of these episodes so have a look in the episode description.  

Right, so let’s get straight into it. 

The guideline covers the recognition, diagnosis and management of ADHD both in children and adults. It is aimed at doctors who specialise in ADHD but I have summarised it focusing on what we need to know in Primary care. 

We should be aware that there is an increased prevalence of ADHD in people:

·      with any mental health condition or conduct disorder

·      with epilepsy or neurodevelopmental disorders

·      with a FH of ADHD

·      who are born preterm or have an acquired brain injury

·      who are looked-after or are known to the Justice System  

But we also need to remember that ADHD is under-recognised in females. 

If a child has symptoms suggestive of ADHD, NICE says that we should refer to secondary care if the symptoms are severe or persist after a period of watchful waiting of up to 10 weeks with group-based ADHD-focused support. This support can be offered without waiting for a formal diagnosis. 

In adults suspected of ADHD we should refer them if they have a childhood diagnosis of ADHD or without a childhood diagnosis if the symptoms are moderate or severe and cannot be explained by other psychiatric diagnoses 

But a diagnosis of ADHD: 

·      Should be made by a specialist.

·      Should not be made solely based on a rating scale.

·      In children, we should assess their parents' or carers' mental health.  

We should offer information about the importance of structure in daily activities and how ADHD could affect their life including relationships and driving because the diagnosis must be declared to the DVLA if it affects safe driving. 

And we should involve, with consent, other healthcare professionals and educational centres so that reasonable adjustments and environmental modifications can be implemented. ADHD is considered a disability and there are legal obligations on employers and education providers to make sure patients are not substantially disadvantaged in their jobs or education. 

Although the management of ADHD is going to be decided by the specialist team, I am going to give a brief outline of what we can expect in Primary Care: 

·      In Patients under 17 years of age, the first line treatment is an ADHD-focused group parent-training programme, followed by medication and CBT if there is significant impairment. Medication should not be offered to children under 5 without a second specialist opinion, preferably from tertiary care.

·      In Adults, CBT and medication should be offered for symptoms that persist after environmental modifications.

·      Examples of environmental modifications may include changes to seating arrangements, changes to lighting and noise, reducing distractions (for example, using headphones), shorter periods of focus with movement breaks, reinforcing verbal requests with written instructions and, for children, the appropriate use of teaching assistants at school. 

In terms of diet, we should not advise elimination of artificial colouring and additives but if there are foods or drinks that appear to influence hyperactive behaviour:

·      They should keep a food diary

·      We will refer to a dietitian if the diary supports a link

·      Any specific dietary elimination should have specialist input. 

We will not advise dietary fatty acid supplementation and we will explain that there is no long-term evidence about a 'few food' diet for children. 

Before starting medication, a full health assessment should be performed, including:

·      Height and weight

·      Pulse and blood pressure

·      A cardiovascular assessment: However, an ECG is not needed before starting stimulants, atomoxetine or guanfacine, if cardiovascular history and examination are normal and the person is not on medicines that increase cardiovascular risk 

A cardiology opinion should be sought before starting medication if there are cardiac concerns of a high BP 

A paediatric hypertension specialist should be involved if the BP is above the 95th centile. 

The recommended medication choices are as follows:

·      For Patients aged 5 to 17 years of age

o  Methylphenidate first line

o  then lisdexamfetamine if methylphenidate ineffective.

o  then dexamfetamine if responding to but not tolerating lisdexamfetamine.

o  Atomoxetine or guanfacine only if previous choices have not been effective or tolerated

·      For Adults

o  We can give Either lisdexamfetamine or methylphenidate first-line

o  Then switch between them if the first choice is ineffective

o  then dexamfetamine if responding to but not tolerating lisdexamfetamine and

o  Atomoxetine is an option if previous choices are not effective or tolerated

·      Unless advised by a tertiary service, the following should not be given:

o  guanfacine for adults

o  clonidine for children

o  atypical antipsychotics in addition to stimulants

o  medication not included in the recommendations

Some considerations when prescribing ADHD medication are:

·      modified-release once-daily preparations are generally preferred

·      Immediate-release preparations offer more flexible dosing during initial titration to determine correct dosing levels but there is more risk of stimulant misuse and diversion

·      A modified-release preparation of methylphenidate in the morning can be used with an immediate-release preparation at another time of the day to extend the duration of effect.

·      We should be aware of the risk of diversion for cognitive enhancement or appetite suppression.

·      After dose stabilisation, prescribing and monitoring of ADHD medication should be carried out under Shared Care Protocol with primary care. 

In terms of general monitoring, apart from monitoring the effectiveness of the medication on ADHD symptoms we should monitor other aspects such as:

·      Height and weight, measuring every 3 to 6 months depending on the patient’s age and we will seek advice if there are clinical concerns

·      Heart rate and blood pressure should be checked before and after each dose change and every 6 months.

·      We will not offer routine blood tests or ECGs unless clinically indicated.

·      Dose adjustments and referral may be necessary if there are cardiovascular concerns

If a person taking stimulants develops tics, we should think about whether:

·      the tics are related to the stimulant (tics naturally wax and wane) and whether

·      the tics outweighs the benefits of ADHD treatment.

·      If tics are stimulant related, the treatment should be reviewed. 

Other possible side effects include:

·      Erectile and ejaculatory dysfunction with atomoxetine.

·      New or worsening seizures: In this case we will stop any medication that might be contributing to the seizures, cautiously reintroducing it if appropriate

·      Disturbance of sleep and behaviour: which may require dose adjustment. 

In terms of supporting adherence to treatment

There is a whole section on this, reminding us to be aware that adherence may be an issue precisely because of the nature of the patients’ ADHD symptoms.

 And finally,

·      ADHD specialists should review medication at least once a year

·      trials of stopping medication or reducing the dose when appropriate should be considered. 

Right, so this is the end of the actual guideline. However, when I read it, I missed a bit more of general clinical information on ADHD and, as promised, let’s cover these areas now: 

And let’s remind ourselves that Attention Deficit-Hyperactivity Disorder is a psychiatric condition that has three subtypes:

1. Predominantly inattentive
2. Predominantly impulsive or hyperactive
3. Combined type

Inattentive symptoms include: lack of attention, lack of concentration, difficulty completing tasks, being forgetful, losing things, etc. Hyperactive symptoms include: fidgeting, leaving their seat, being loud, talking excessively or out of turn, having trouble waiting their turn, etc.

In adults, however, some of the core symptoms may be missing, and they may manifest as other problems such as procrastination, mood instability, and low self-esteem. They will likely be more impulsive or inattentive, as the hyperactivity symptoms can be better controlled.

Different scales are used to measure the symptoms, which can be used in adults to help identify the disorder. However ADHD is a clinical diagnosis and does not have any specific laboratory or radiologic tests. The neuropsychological tests are not always appropriate, and hence it should be diagnosed based upon the history of the patient. 

The aetiology of ADHD includes both a genetic and an environmental component. It is one of the most heritable conditions in terms of psychiatric disorders. Siblings have twice the risk of having ADHD than the general population. Similarly, viral infections, smoking and alcohol during pregnancy and nutritional deficiencies in the foetus have also been explored as possible causes of the disorder. 

ADHD is generally found in a 2:1 male to female ratio but it is thought that it is under-recognised in females. It has also been found that the inattentive subtype is more common amongst the female population. 

From a pathophysiological perspective, ADHD is associated with deficits that relate to frontal lobe activity. Therefore, these patients show disability not only in attention and focus but also in decision making and emotional regulation. There is evidence for the role of dopamine and noradrenaline receptors and pharmacotherapy is directed onto them.  

Pharmacological therapy is divided into two major categories, stimulants and non-stimulants. Stimulants are further broken into amphetamines and methylphenidates. Both types of stimulants block the reuptake of dopamine. Amphetamines also directly release dopamine. Stimulants are the mainstay of treatment for ADHD and they are effective in about 70% of patients. Side effects of stimulants include changes in blood pressure, decreasing appetite and sleep, and risk of dependency. 

Of the non-stimulant option, there are also two types: antidepressants and alpha agonists. Within the antidepressant category, atomoxetine is the best known and works as a selective norepinephrine reuptake inhibitor. It is not nearly as effective as stimulants and it has minimal antidepressant effects. It is often used in children who don't tolerate stimulants or have anxiety. Other antidepressants not endorsed by NICE include bupropion, which targets dopamine and serotonin, and as the last choice, TCAs, which work by targeting norepinephrine.

Finally, alpha agonists such as clonidine and guanfacine can be used but are associated with multiple cardiovascular effects like lowering blood pressure, sedation, weight gain, dizziness, etc. They are found to be more effective in younger children than adults.  

Trigeminal nerve stimulation has recently been shown to be helpful for children not on medications. The device generates a low-level electrical pulse which seems to suppress hyperactivity. 

In terms of prognosis, the general rule of thumb is that 50% of patients will "grow out of" ADHD, especially with treatment, and another 25% do not need treatment into adulthood. The theory is, first, that stimulants help improve the development of the frontal lobe over time, and second, that adults often choose careers that don't require sustained attention so these patients can achieve their vocational goals.

But remember that this is only a summary and my interpretation of the guidelines. 

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

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at Chat GPT generated case of heart failure with co-morbidities to see how the NICE guidelines could apply to it.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement. 

There is a YouTube version of this and other videos that you can access here: 

·      The NICE GP YouTube Channel: NICE GP - YouTube 

You can download my summary of the guideline with additional information here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0l3uRYZ7-U3R808gA?e=2LT5XI

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Transcript

Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.  

In today’s episode I look at the journey from diagnosis to treatment of a ChatGPT generated patient with heart failure and other co-morbidities to see how the NICE guidelines could be applied. Make sure that you stay for the whole episode because at the end, I am going to give you the pathophysiological reasons why ACEIs, ARBs, betablockers and MRA are so beneficial in heart failure, and I am sure that once you have understood it, you will never forget. 

By the way, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the guidelines so you must use your own clinical judgement. 

If you want to download a copy of my summary of the NICE guidelines on Chronic heart failure, the link is in the episode description.

Remember that there is also a Youtube version of these episodes so have a look in the episode description.  

Right, so let’s have a look at our fictitious patient: 

- His Name is: John Smith

- His Age: 68

- Ethnicity: Caucasian

- Past Medical History includes: Obesity, Hypertension, Type 2 Diabetes, and Hyperlipidaemia 

His Current Symptoms are:

- Shortness of breath on exertion and lying down

- a Persistent cough

- Fatigue and weakness

- Bilateral ankle swelling

- And The symptoms have been developing gradually over the last 4-6 months but recently he has noticed more rapid weight gain which could be from fluid retention 

His usual medication is:

- Amlodipine 5 mg OD for hypertension

- Lisinopril 2.5 mg OD for hypertension

- Metformin 500 mg BD for type 2 diabetes and

- Atorvastatin 20 mg OD for hyperlipidaemia 

So, we have a 65-year-old Caucasian male who presents with shortness of breath, fatigue, ankle swelling, and a persistent cough. 

On examination we find the following:  

His BMI is 34, so he is obese.

His Weight is 97 and John says that this is 4Kg more than his usual weight

His BP is 151/92 mmHg and

On auscultation, he has lung crackles. His heart sounds are regular with no murmurs, and his heart rate is 96 bpm. Palpation of the chest reveals a laterally displaced point of maximum impulse consistent with an enlarged ventricle. 

His Oxygen saturation is 98%

And his Peak Flow is: 450 L/min (which is normal for his age and sex)

Abdomen showed no hepatomegaly and there is no raised JVP 

He has Slight bilateral pitting ankle oedema

His Urinalysis and His Temperature are normal  

Right, we have someone with lung crackles and a normal temperature and no other sings of infection, so it would be reasonable to suspect HF rather than bronchopneumonia. His main symptoms are suggestive of left sided heart failure although he also has some ankle oedema which is a possible symptom of right sided heart failure. However, he is also on amlodipine and at this stage we cannot be 100% sure of whether this is a side effect of his medication or secondary to heart failure.  

Let’s remember that typical symptoms of left-sided heart failure include cool clammy skin, cyanosis, a laterally displaced point of maximum impulse consistent with an enlarged ventricle, lung crackles and a gallop rhythm. On the other hand, signs in right sided heart failure include an elevated JVP, ankle of leg oedema, ascites, hepatomegaly, and hepatojugular reflux. Signs of both left and right sided heart failure can be present at the same time.  

In order to confirm the diagnosis of heart failure, we will need to measure the levels of the N-terminal pro-B-type natriuretic peptide, or BNP levels. In addition, and in order to exclude other diagnoses, NICE says that we should also arrange an ECG, a chest X-ray, especially as he has a persistent cough, other blood tests including full blood count, renal, liver, thyroid function, lipid profile, and HbA1c. Peak flow was normal for John but if we are in any doubt about a respiratory condition, we should also request spirometry testing. 

Right, so we are going to send him off to have some tests. Should we be doing anything else in the meantime? 

Well, if we feel that, clinically, he is having signs and symptoms of congestion and fluid retention, NICE says that we should offer diuretics for short term symptomatic relief. So, I would go for a loop diuretic, something like furosemide 20-80 mg daily depending on the severity of the symptoms and, obviously, the higher the dose, the closer that you will want to monitor him. But we should be seeing him again for a review within a day or two.  

I am going to say that his symptoms and signs are significant so I will start him on furosemide 80mg daily and see him in a couple of days or sooner if he does not feel better.  

Right, so, we organise the blood tests, to be done ideally the same day of next day and then we see him again to reassess and discuss the results. 

At the next appointment, John states that his symptoms are better, his breathing is easier and his ability to do physical activities has also improved. On examination 

His weight has gone down to 94.5 Kg but John says that his usual weight is around 93Kg 

His BP is slightly better but still high at 144/87 mmHg. Remember that NICE says that for patients under the age of 80 their target BP should be below 140/90.

On auscultation, there are now minimal crackles at the lung bases and heart sounds are normal and in sinus rhythm with no murmurs. His heart rate is also lower at 80 bpm. 

Oxygen saturation is 99% and

There is also less ankle swelling.  

His Blood tests show that:

• His creatinine is 130 and his eGFR is 75 , so reasonable renal function
• His HbA1c is 60 or 8%
• He has a Normal FBC, LFT and TFTs
• His TC is 4.8, LDL 3.4, HDL 1 and TG 0.9
• And his BNP Level: 800 ng/litre

So, what do we say here?

We know that, if there is no heart failure, we would expect the BNP to be below 400 and therefore, with a raised BNP we can fairly confidently say that this is likely heart failure.  

And because the symptoms have had an insidious onset over several months, we are going to say that he has chronic heart failure rather than anything acute that we should admit him to hospital for. 

It's important to note that the BNP level does not differentiate between heart failure with reduced ejection fraction (or HFrEF) and heart failure with preserved ejection fraction (or HFpEF). We will need to organise an echocardiogram for this.  

Also, we need to be aware that certain factors like obesity, African or African–Caribbean family background, and heart failure drugs can reduce BNP levels. Equally, they may be elevated for other reasons, for example, age over 70 years, ischaemia, tachycardia, hypoxaemia [including PE and COPD], renal failure, diabetes, or liver cirrhosis. John is both obese and has diabetes so he has factors that could be influencing his BNP in both directions.  

His HbA1c is also high so we will need to intensify his diabetes treatment. 

To know if his cholesterol levels on atorvastatin 20 mg are acceptable, we will need to look at his pre statin levels to be absolutely certain that he is on the right dose. 

His other test results show that

- his ECG is normal with no signs of arrhythmia or ischaemia:

- his Chest X-ray shows: Mild pulmonary congestion and

- his Spirometry is also normal ruling out respiratory obstruction or restriction:  

So, with these test results, we will discuss the diagnosis of heart failure with the patient and we will proceed with the referral for a echocardiogram. Because the BNP level is between 400 and 2000 ng/litre, he can have the echocardiogram withing 6 weeks. If it had been over 2000 ng/litre we would need to make urgent to be done within 2 weeks.  

NICE also says that the purpose of the echocardiogram is to exclude valve disease, assess the ventricular function, and detect intracardiac shunts.  

But now that we have a working diagnosis and that we are likely to be waiting for a few weeks for the echocardiogram, we need to start him on some further active treatment. And we have several issues with him:

1.   Hypertension

2.   Chronic heart failure

3.   Diabetes

4.   Lipids and prevention of CVD and

5.   Obesity 

So, let’s start with his hypertension. John is already on step 2 treatment, a combination of two drugs, amlodipine and lisinopril, none of which are at maximal doses. So, should we simply increase the doses of those drugs and then move to step 3 with 3 drugs if necessary? That would be the standard advice on the Hypertension guidelines. But not in his case. 

The NICE guideline on hypertension says that for people with hypertension and CHF we must first follow the guidelines on CHF. So, if the HTA guidelines says that betablockers and spironolactone are considered at step 4 and the CHF guidelines say differently, we need to put the HTA guidelines to one side and give priority to the CHF guideline.  

So, let’s have a look at the guidelines on CHF. What does it say about treatment? You may be familiar with the advice to give ACEIs, betablockers, mineralocorticoid receptor agonists or MRAs etc.  

But these drugs are recommended in HFrEF and the first problem is that we do not know what type of heart failure this patient has. Is it HFrEF or is it HFpEF? Because, when it comes to treatment, the advice for each one can be different. 

Could we assume that it is the most common type of heart failure? Unfortunately, that is not going to work because, at present, about 50% of patients with heart failure have HFpEF and the other 50% HFrEF. 

By the way, remember that heart failure with preserved ejection fraction is characterised by a left ventricular ejection fraction of 50% or more. Heart failure with reduced ejection fraction has an ejection fraction of <40%. And there is now a third type, which NICE refers to as HF with mildly reduced EF which is when the ejection fraction is between 40 and 50%. 

Right, so what do we do?

Well, we could look at the treatment of heart failure from 2 different perspectives:

·      One, Symptomatic treatment

·      And two, Preventative treatment 

Symptomatic treatment addresses the congestive symptoms. And NICE says that we can give Diuretics for the relief of congestive symptoms and fluid retention in both types of HF. We will titrate them up and down according to need but, in particular, NICE says that in heart failure with preserved ejection fraction we will normally give no more than a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day) and refer if this is not enough.  

The preventative treatment on the other hand is offered in order to reduce morbidity and mortality in the long run and it does not necessarily improve symptoms in the short term. These drugs are ACEIs or ARBs, betablockers, MRAs, ARNIs (which stands for Angiotensin Receptor-Neprilysin Inhibitors) and SGLT2 inhibitors. But all these drugs except the last one, SGLT2 inhibitors, confer these long-term benefits only to HFrEF, and we should not be pushing them if the patient has HFpEF.  

Up to very recently, the same applied to SGLT2 inhibitors but, NICE changed the advice in June 2023 and now recommends dapagliflozin for all types of heart failure. 

So, we conclude that not all drugs recommended for HF with reduced Ejection Fraction are recommended for HF with preserved Ejection Fraction. However, the opposite is true. General management for HFpEF can be applied to HFrEF.  

So, let’s see what drug treatment NICE recommends for HFpEF, which is basically the recommendations for all types of heart failure, and how they apply to our patient:

·      First, as we have already said, we can give low to medium doses of a loop diuretic, say furosemide 20-80 mg daily to relieve symptoms of fluid overload

o  Our patient is on furosemide 80 mg daily and this has had a significant improvement in his symptoms. There are still some fine crackles in both lung fields and I may not rush to reduce the dose too quickly, although a careful reduction could be tried, for example to 60 mg daily advising the patient to increase the dose again if there are worsening of symptoms.

• Second, Dapagliflozin is an option for treating symptomatic chronic heart failure on the advice of a heart failure specialist only
• John still has some symptoms and this drug may be beneficial, but in order to give it for heart failure, we would need to get specialist advice. But we will touch on this a little later.
• Third, We will review drugs which may cause or worsen heart failure and stop them if appropriate- examples of these drugs would be both recreational drugs such as alcohol and cocaine as well as medication such as nonsteroidal anti-inflammatory drugs, beta-blockers, and calcium-channel blockers
• Our patient does not abuse alcohol and on our advice, he will cut down or even stop. He does not use other recreational drugs and he is not taking NSAIDs or betablockers. However, he is taking a calcium channel blocker, amlodipine. Is this going to be a problem?
• NICE says that (Calcium-channel blockers | Treatment summaries | BNF | NICE) calcium channel blockers, with the exception of amlodipine, should be avoided in heart failure as they can further depress cardiac function and exacerbate symptoms and they can also increase mortality after an MI in patients with left ventricular dysfunction and pulmonary congestion.
• So, with that said, our patient does not have to stop amlodipine, which is fortunate because he still needs to for his hypertension. There was a question mark as to whether some of the ankle oedema is secondary to amlodipine but for now, I would leave it as it is and reconsider this prescription later when more information about the patient’s condition is known.
• Number 4, we will consider An antiplatelet drug if there is atherosclerotic CVD (which is not always the case in HF)
• And John does not have this so he does not need aspirin or clopidogrel
• Number 5, we should give A statin if the patient is at risk of atherosclerotic CVD as per the NICE guidelines on CVD prevention
• John has already been found to be at high risk of CV disease and he is already on atorvastatin 20 mg daily. But the guidelines on prevention of CVD state that after statin therapy we should aim for a reduction in non-HDL cholesterol of 40% or more. His current lipids show a TC of 4.8, and an HDL of 1 so his non-HDL cholesterol is 3.8 (TC-HDL). Looking at his previous records we find that before the statin his TC was 5.9 and his HDL was 0.9, therefore then his non-HDL cholesterol was 5. 40% of 5 is 2 so his target non-HDL cholesterol should be 3 and instead it is 3.8. he is not hitting the target of a 40% reduction and I would therefore advise him to increase the dose of atorvastatin to 40 mg daily and recheck his lipids and LFTs again in 3 months.

·     Number 6, part of the CHF management is the Management of other co-morbidities such as hypertension, diabetes, CHD, obesity, AF, COPD etc

o  John has hypertension, obesity and type 2 diabetes as co-morbidities.

o  Let’s look at the hypertension first. He is already on lisinopril and amlodipine and his BP is not down to target. We are worried that his amlodipine may be aggravating his ankle oedema, so I would probably elect not to increase the dose at this stage. However, It would make sense to increase the dose of lisinopril to, for example, 5mg OD, monitoring his BP and renal function. This way, if he has HFrEF, we are titrating one of the medicines that reduce mortality and morbidity in the long run. On the other hand, if he has HFpEF, we will still be managing it correctly by lowering his BP and improving one of his co-morbidities

o  Let’s now look at his diabetes, which is not well controlled with metformin 500 mg BD. NICE says that the first step is always metformin and if metformin is not enough or not tolerated, we will assess the patient’s cardiovascular risk and status. And if the patient has heart failure, atherosclerotic CVD or is at risk of it, we should start and SGLT2 inhibitor.

o  But you may be saying… did we not have to get a specialist opinion before giving an SGLT2 inhibitor for heart failure? And the answer is yes, if you are giving it for heart failure to someone without diabetes. But if the person has diabetes, it is the perfect opportunity to give it and treat both his diabetes and his heart failure, especially as it’s recommended for both HFrEF and HFpEF.

o  But wait a minute, this patient is not on maximal doses of metformin. His eGFR is >60 so his dose could go from 500 mg BD to the maximum, double that, 1000 mg BD. Should we do that first? And my answer would be perhaps at some point. But I would not do this at this stage. Although HF is not a contraindication to metformin, the BNF says amongst other things that “the Manufacturer advises caution in chronic stable heart failure (and to monitor cardiac function), and avoid in conditions that can cause tissue hypoxia.” John’s heart failure is far from stable at the moment so I would not risk increasing the dose of metformin at this stage. With heart failure there may be a degree of tissue hypoxia which could put him at risk of the most feared side effect of metformin, lactic acidosis. In fact, some of you may be thinking that we should have stopped his metformin at the first visit, And perhaps that would have been a good option too, although you would be then be dealing with a whole lot of other issues secondary to uncontrolled hyperglycaemia. Because his oxygen saturation on the first visit was 98% and his condition had developed over many months, I wouldn’t view stopping metformin as an urgent matter. Of course, if he had been truly unwell and hypoxic, that would have been the right thing to do.

o  Another co-morbidity to consider would be his obesity. So, lifestyle advice, maybe orlistat and further referral for support will be indicated at some point. But he has enough on his plate now, so I would park this for the time being and revisit it in future.

• Finally, in HFpEF NICE says that we need to refer if there is poor response to diuretic therapy or if valve disease is discovered.
• But John has responded well to furosemide and auscultation of his heart did not detect any murmurs, so hopefully there will not be anything significant there. But we will have to wait for the echocardiogram report to be completely sure. 

So, in summary:

·      We will continue furosemide either the same dose of 80 mg daily or more likely cautiously reducing it to 40-60 mg according to our clinical judgement, especially considering that

·      We are going to start an SGLT2 inhibitor, which also have a diuretic effect. Something like for example dapagliflozin 10 mg daily would be good.

·      We will also continue amlodipine 5 mg OD and

·      We will increase atorvastatin to 40 mg daily and

·      We will increase lisinopril to 5 mg, monitoring his renal function and

·      We will advise him to continue monitoring his weight and to let us know any concerns 

I would suggest that we see him possibly 7-10 days later to review his progress and medication but we will also give him very careful safety-netting advice to come sooner if anything does not go to plan 

Ok, so, When we see him next, John is feeling very much better, his breathing has improved as well as his tolerance to exercise. 

His weight is now 92.8 which is more like his usual weight.

BP is 138/82 mmHg

On auscultation, his chest is clear and his heart sounds are normal

Oxygen saturation is 99%

Ankle oedema has all but disappeared.

And His renal function has remained reasonably stable although since increasing lisinopril, his eGFR has decreased from 75 to 69 and his creatinine has risen from 130 to 143 

We have also received his Echocardiogram Result which shows:

- that There is evidence of left ventricular hypertrophy, possibly the effect of prolonged hypertension

-Right ventricular function and cardiac valves are normal and there are no cardiac shunts but

- he has a Left ventricular ejection fraction (LVEF) of 35%, so, being <40%, he has HFrEF 

So let’s have a look at the guideline for this. For the treatment of heart failure with reduced ejection fraction NICE says that: 

1. for First-line Treatment we need to give the maximal tolerated doses of:

1.   An ACE inhibitor and

2.   A beta-blocker licensed for heart failure

·      The beta-blockers licensed for heart failure in the UK are bisoprolol, carvedilol, and nebivolol.

·      And We will not withhold betablockers solely based on age or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease, or COPD.

3.   NICE says that we should use our clinical judgement when deciding which drug to start first. 

4.   But we will not give an ACE inhibitor if there is haemodynamically significant valve disease until the valve disease has been assessed by a specialist.

5.   And We will give an ARB licensed for heart failure if there are side effects with ACE inhibitors. 

·      ARB licensed for heart failure in the UK are Candesartan, losartan, and valsartan.

6.   If there are persistent symptoms, we will then give a mineralocorticoid receptor antagonist (or MRA), such as spironolactone or eplerenone, in addition to an ACE inhibitor (or ARB) and beta-blocker 

OK, so John is already on lisinopril so we should start him on a betablocker next, for example bisoprolol starting at 1.25 mg daily increasing gradually according to the BNF. Also, we should also gradually increase his lisinopril and, as the blood pressure drops, it is likely that we will need to discontinue amlodipine. We will use our clinical judgement as to how quickly the titration of both lisinopril and bisoprolol is but NICE recommends doing so at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose of both drugs is reached.   

But we have noticed that both John’s creatinine and eGFR have deteriorated since we increased the dose of lisinopril. Is that going to be a problem?

NICE says that we only need to worry and take further action if the creatinine level increases by more than 20% or the eGFR falls more than 15%.

John’s creatinine has increased by 10% and his eGFR has only decreased by about 8% so we should not be too concerned but we will keep monitoring it. 

In terms of monitoring, we will do a full clinical assessment at every review, measuring his BP and renal function, including sodium and potassium levels, before and 1 to 2 weeks after starting the drugs, and after each dose increment. We will also assess heart rate when giving betablockers. 

And we will not forget to monitor his HbA1c and his lipids after the management changes. 

NICE says that once the target or maximum tolerated dose is reached, we will monitor the treatment monthly for 3 months and then at least every 6 months, and at any time if he becomes acutely unwell.  

NICE says that we should monitor BNP levels only if:

·      The patient is under 75

·      there is heart failure with reduced ejection fraction and

·      the eGFR is above 60. 

So, we should monitor John’s BNP levels which will help track his response to treatment. 

A follow-up echocardiogram may be performed from time to time to assess if there have been changes in the left ventricular ejection fraction  

If his symptoms do not improve with the initial treatment with an ACEI or ARB and a betablocker, We will consider the addition of Mineralocorticoid Receptor Antagonists (MRA), for example, something like spironolactone 25mg daily increasing to 50 mg, according to response.

I am obviously describing the steps that we would have to follow according to the guidelines but, in practice, we would also refer him to see a cardiologist, early on, to ensure that he gets specialist advice and that his treatment is fully optimised 

For your information, NICE recommends that the following drugs should be initiated by a Specialist only

·      Ivabradine

·      Sacubitril valsartan

·      Hydralazine in combination with nitrate

·      Digoxin 

Other General Recommendations for John will include: 

1. an annual flu vaccination and a one-time pneumococcal vaccination

3. Advise to stop Smoking and reduce alcohol to recommended levels and

6. in terms of Sodium and Fluid Consumption:

   - we will not routinely restrict them but will enquire about his intake and.

   - If John experiences dilutional hyponatremia, fluid restriction may be advised and

   - If John has high levels of salt and/or fluid consumption, he will be encouraged to reduce.

   - And Finally, we will advise him to avoid salt substitutes containing potassium. 

Right, so we will make this the end of this patient’s journey with us.   

But, as promised, let’s talk pathophysiology and the reason why ACEIs, ARBs, MRAs and betablockers have long term benefits in heart failure.

And we will start by saying that Heart failure with reduced ejection fraction, even in its early subclinical stages, leads to reduced organ perfusion, precisely because of the reduced ejection fraction. To compensate for this, the body triggers a response that stimulates the sympathetic system and the RAAS. Stimulation of the sympathetic system produces vasoconstriction and faster and stronger myocardial contractions, whilst the stimulation of the RAAS causes vasoconstriction due to the angiotensin effect and increased fluid and sodium reabsorption due to the aldosterone effect, both of which lead to an elevated blood pressure. Although these mechanisms may initially improve tissue perfusion, they also have a remodelling effect on the heart, eventually inducing harmful structural changes which exacerbate heart failure over time.

The mentioned medications act through different pathways to reduce the heart's workload, enhance cardiac output, and counteract the detrimental effects of the neurohormonal activation. The betablockers do so by blocking the sympathetic system and the ACEIs, ARBs and MRAs by blocking different sections of the RAAS. They are all essential components of evidence-based heart failure management, reducing hospitalisations and mortality.

Given that one of the problems of the RAAS is fluid and sodium retention, you might wonder why patients aren't routinely advised to reduce their fluid and sodium intake. Well, in this world of evidence-based medicine the answer is easy. The reason is that there is currently no research evidence supporting this advice. While it might seem intuitively reasonable, we should refrain from recommending it unless there is concrete evidence indicating that the patient's salt consumption or fluid intake is excessive. 

But remember that this is only my interpretation of the guidelines. 

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

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a real-life case to demonstrate how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals and you must use your clinical judgement.

The PDF version of this episode can be found here:

·      Colour version: https://1drv.ms/b/s!AiVFJ_Uoigq0l3MBwm5sUpEybW8r?e=xio6pz

·      Printer friendly version: https://1drv.ms/b/s!AiVFJ_Uoigq0l3RhABLRM2_pQQOz?e=jzuMxb

There is a YouTube version of this and other videos that you can access here:

·      The NICE GP YouTube Channel: NICE GP - YouTube

Prescribing information links:

·      Website: https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/dpp-4-inhibitors/

·      Download PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0liBvuQq8_0Cd-GSz?e=NnL56J

·      Website: https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/glp-1-receptor-agonists/

·      Download PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0liFRycIZPaVfj-lC?e=a2QTNY

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Transcript

Hello everyone and welcome. My name is Fernando and I am a GP in the United Kingdom.

We have looked at fictitious patients in previous episodes but, in today’s episode, I am going to look at a real diabetic case to see how the guidelines could apply to it. And as you know, we are focusing only on the pharmacological treatment. If you want to download a PDF version of this episode, the link is in the episode description. 

Please note that I am not giving medical advice; this is only my interpretation of the guidelines and you must use your clinical judgement 

Remember that there is also a Youtube version of these episodes so have a look in the episode description.

Right, so let’s get straight into it. The details, which have been anonymised, belong to a real patient, so we have 46-year-old man of Asian descent with T2DM who presents with the following: 

• HbA1c is 68 mmols/mol/8.4% (therefore poorly controlled) 
• Cholesterol 5.9 
• Triglycerides 5.72 
• HDL 0.97 

·      The path lab has not calculated LDL because triglycerides >4.5 

·      Liver and Renal function tests are normal with an eGFR of 97  

• Thyroid function tests show a borderline low T4 of 9 (NR 9-19.1) and a raised TSH of 9.88 (NR 0.35-4.94 
• ACR normal 
• FBC and other routine blood tests were normal.  
• His BMI is 32, so he is obese 
• His BP is 147/89 
• His PMH includes: 
• Hypothyroidism 
• T2DM 
• His regular treatment is with: 
• Levothyroxine 200mcg daily 
• Metformin 500 mg TDS 

He comes to discuss his test results, feeling well in himself. His obesity is long-standing and being managed with diet and lifestyle advice. He has had hypothyroidism for 15 years and, on prompting, he says that he is feeling a little tired 

So, let’s have a look at the guidelines. As usual I will focus on the NICE guidelines and we will have to looks at the guidelines on type 2 diabetes, hypertension, prevention of cardiovascular disease, and hypothyroidism  

Let’s look at his diabetes first. 

Firstly, NICE says that we need to consider if rescue therapy is necessary for symptomatic hyperglycaemia with insulin or a sulfonylurea. However, he is well and asymptomatic so we do not have to do this. 

We see that his current dose of metformin 500 mg 3 times a day is not enough to control his diabetes. So, given that his renal function is completely normal.  we should increase the dose to the maximum of 2000mg daily, that is, 1000mg twice a day. However, this is unlikely to be enough to bring his HbA1c of 68 or 8.4% to target. And let’s remember that according to NICE we should strive for the following targets: 

·      Lifestyle management only— 48 mmol/mol (6.5%). 

·      A single drug not associated with hypoglycaemia (such as metformin) — 48 mmol/mol (6.5%). 

·      Drug treatment associated with hypoglycaemia (such as a sulfonylurea): 53 mmol/mol (7.0%). 

·      Always adjust for people who are frail, elderly or with other co-morbidities 

This patient is young and otherwise well so we should aim to treat him aggressively. 

NICE says that for people not controlled on metformin alone, we should consider dual therapy but which?  

We need to assess the person's cardiovascular status and risk to determine whether they have chronic heart failure, established atherosclerotic cardiovascular disease, or are at high risk of developing cardiovascular disease. 

This patient does not have heart failure or cardiovascular disease but using an online calculator, his 10-year QRISK3 score is 12%. So, being over 10%, we will consider him at high risk of developing CVD.  

And NICE says that if the patient is at high risk of developing cardiovascular disease, we will consider an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin. 

This is good because it seems quite clear that his obesity is a problem and both metformin and SGLT2 inhibitors promote weight loss. 

Because we would want to manage him aggressively, I would advise him to increase metformin straightaway and as soon as we know that it is tolerated, which could be a matter of days, we could start the SGLT2 inhibitor. 

SGLT2 inhibitors with proven cardiovascular benefit includes dapagliflozin, empagliflozin and canagliflozin 

Remember that SGLT2 inhibitors are associated with an increased risk of DKA and lower limb amputation. Therefore, before starting an SGLT2 inhibitor, we need to check whether the person may be at increased risk of diabetic ketoacidosis (DKA), for example if: 

• they have had a previous episode of DKA 
• they are unwell with intercurrent illness 
• Or they are following a very low carbohydrate or ketogenic diet, and if so, not to start the SGLT2 inhibitor until they have changed their diet. We will also advise them not to start this type of diet while they are on this medication.  
• 
  
• The increased risk of lower-limb amputation has been shown with Canagliflozin but there is some concern that the risk may be a class effect. We will need to ensure that foot care is optimised before starting the SGLT2 inhibitor.  
• 
  
• So, this would be my pharmacological action from a diabetic perspective. Increase metformin to 1000mg BD and start an SLGT2 inhibitor, for example, dapagliflozin 10 mg OD. 
• 
  
• Now let’s have a look at his BP, which is elevated at 147/89. 
• 
  
• NICE says that people under the age of 80 should have a BP below 140/90. 
• 
  
• To confirm the diagnosis, we should arrange ambulatory or home blood pressure monitoring and if the average is greater than 135/85 we will start him on antihypertensive treatment. We have more or less established that he does not have end-organ damage because of his normal renal function, normal urinary albumin / creatinine ratio and, looking at his records, normal fundoscopy, as he attends for his annual diabetic retinal screening programme. To be strict, we should also arrange an ECG to ensure that there are no signs of left ventricular hypertrophy.  
• 
  
• Let’s assume that his BP is indeed above the target. What treatment should we start? 
• 
  
• NICE says that for someone with diabetes of any ethnicity and any age, we should start and ACEI or ARB. We know that ACEI confer significant renal protection in diabetes, so we will start him on an ACEI, something like lisinopril 2.5 mg daily, monitoring his renal function and increasing the dose gradually according to our clinical judgement. This patient is of Asian family background but remember that if the patient is of Afro-Caribbean family origin, we should opt for an ARB in preference to an ACEI. This is because Afro-Caribbean patients are considered “low renin responders” and therefore ACEI are less effective in this group. 
• 
  
• Now let’s look at his lipids and what we would do based on the NICE guideline on prevention of cardiovascular disease. 

Firstly, we will calculate his CV risk.Using the online QRISK3 calculator we find that his 10-year risk is 12% Further details are: 

Your 10-year QRISK®3 score 12% 

The score of a healthy person with the same age, sex, and ethnicity 2.6% 

Relative risk** 4.6 

Your QRISK®3 Healthy Heart Age 66 

But remember that NICE also says that the CVD risk may be underestimated by risk assessment tools if the triglyceride levels are raised, which is this patient’s case. 

Could this be treated with lifestyle alone? Because we need to treat him aggressively, I would say no. Furthermore, his cholesterol has been elevated well over 5 mmol/l (200 mg/dL) for the last 3 years so it is clear that diet and exercise alone are not doing the job.  

NICE says that for Primary prevention: 

• If lifestyle modification is ineffective or inappropriate, we will offer a statin, generally atorvastatin 20 mg, for the primary prevention of CVD to people who have a 10% or greater 10‑year CVD risk using the QRISK assessment tool.  
• For people 85 years or older we will still consider atorvastatin 20 mg as statins may be of benefit in reducing the risk of non‑fatal MI. 

Should we do anything different from the point of view of his triglycerides?  

Well, first of all, we will look to see if they have been this high for long. Previous entries show levels moderately elevated but not to this degree. 

Triglycerides are also affected by diabetes control and it may very well be that once his hyperglycaemia improves, and his HbA1c goes down, his triglycerides will too. 

Triglycerides may be also elevated in situations where excess alcohol is consumed. So, we should enquire about this.

And hypothyroidism can also influence lipids in general and triglycerides in particular. Improving his hypothyroidism treatment is also likely to improve the lipid situation.  

Also, atorvastatin will have some effect on the triglycerides, although this effect may not be very pronounced.     

Other drugs like fibrates, such as fenofibrate, are potent agents in reducing triglyceride levels. However, NICE do not recommend their use. In fact, NICE says that: 

• For the prevention of CVD, we should not offer Fibrates, Nicotinic acid, Bile acid sequestrants or Omega‑3 fatty acid compounds, either alone or in combination therapy. 

In summary, I would start him on atorvastatin 20 mg daily and recheck his liver tests and lipids 3 months later, perhaps on a fasting sample, to see if the triglycerides have improved too. Remember that we aim for a greater than 40% reduction in non‑HDL cholesterol and, if this target is not achieved, we will consider increasing the dose. 

And finally, what about his hypothyroidism? He has had it for some time and is on a dose of 200 mcg daily of levothyroxine but his T4 is still on the low side and his TSH is elevated. And he also complains of being tired at times. 

In terms of management of hypothyroidism, NICE says that we should adjust the dose according to symptoms and TFT results, aiming to maintain TSH and T4 levels to within or close to the normal reference range. We should also review the person and recheck TSH levels every 3 months after every dose change. 

The BNF says that for adults under 50 the dose adjustments would be in steps of 25–50 micrograms every 3–4 weeks, according to response. However, a little fly in the ointment is that the BNF recommends the maintenance dose to be up to 200 micrograms once daily. And this is precisely this patient’s dose.  

Sometimes patients do need higher doses but, perhaps we should discuss compliance with him given that it may very well be that he is not taking it regularly and this is why his tests results are not in the normal range.  

Right, so this would be my initial management of this real-life patient: more metformin, dapagliflozin, lisinopril, Atorvastatin and discuss if increasing Levothyroxine is necessary. Remember that this is only my interpretation of the guidelines. 

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. Welcome to the latest instalment in our monthly video series, "NICE News," where we discuss new and updated guidelines published by the National Institute for Health and Care Excellence (NICE), specifically as it relates to primary care.

In this video, I'll be focusing on the NICE guidance and advice published in July 2023. We'll be reviewing the latest recommendations that are relevant to primary care practitioners, with the goal of keeping you informed and up-to-date on the latest developments.  

Please note, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement. 

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw

The link to the PDF version of this video can be downloaded here: 

·      Printable version: https://1drv.ms/b/s!AiVFJ_Uoigq0l2tnS9ulRaEBT8Af?e=TCk7ZO

·      Colour & photo version: https://1drv.ms/b/s!AiVFJ_Uoigq0l2w1zRoLSYM34HhO?e=avMoqf

The links to the update guidance covered can be found here:

Obesity in adults: identification, assessment and management

·      https://www.nice.org.uk/guidance/cg189

KardiaMobile for detecting atrial fibrillation

·      https://www.nice.org.uk/guidance/mtg64

Semaglutide for managing overweight and obesity in young people aged 12 to 17 years (terminated appraisal)

·      https://www.nice.org.uk/guidance/ta910

Alcohol-use disorders: diagnosis and management:

·      https://www.nice.org.uk/guidance/qs11

Draft consultation: Vitamin B12 deficiency in over 16s: diagnosis 6 and management

·      Document: https://www.nice.org.uk/guidance/GID-NG10176/documents/draft-guideline

·      Consultation on draft guideline is open until 5pm on Tuesday 22 August 2023: https://www.nice.org.uk/guidance/indevelopment/gid-ng10176/consultation/html-content

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Transcript

Hello and welcome to another episode of NICE News. My name is Fernando Florido, a GP in the United Kingdom. Today, we'll be discussing the NICE Guidance and advice published in July 2023, specifically for Primary Care.

This month we are focusing on obesity, atrial fibrillation and alcohol misuse. If you want to download a PDF version of this episode, the link is in the episode description.

Before we begin, I want to remind you that this episode is not medical advice. It is only my interpretation, and you must use your clinical judgement.

I'd like to remind you that there is a YouTube version of this episode which can be found in the episode description.

Now, with that said, let’s get straight into it.

The first clinical area refers to the guideline on obesity.

We will refer for bariatric surgery if they:

·     have a BMI of 40 or more, or over 35 with a significant health condition that could be improved if they lost weight

·     The BMI threshold is reduced by 2.5 for South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background to account for the fact that these groups are prone to central adiposity with cardiometabolic risks at a lower BMI.

And in terms of Pharmacological interventions, NICE has not recommended naltrexone–bupropion but there is a list of three approved medicines for obesity. Liraglutide and semaglutide can only be prescribed for obesity by secondary care and orlistat, which can also be prescribed in primary care. The prescribing criteria are:

·     Liraglutide: BMI of 35 or 32.5 for members of minority ethnic groups

and

Non-diabetic hyperglycaemia (HbA1c level of 42 - 47 mmol/mol [6.0% to 6.4%] or a fasting plasma glucose level of 5.5 - 6.9 mmol/litre)

and

High risk of CVD

·     Semaglutide: BMI of 35.0 or 30.0 if they meet certain referral criteria but reduce BMI thresholds by 2.5 for people from Asian, Chinese, Middle Eastern, Black African or African-Caribbean family backgrounds

and

At least 1 weight-related comorbidity

And we will consider stopping if less than 5% of the initial weight has been lost after 6 months. We will use it for a maximum of 2 years

·     Orlistat: BMI of 30 or more or 28 or more with associated risk factors. It should not be used with other drugs aimed at weight reduction and we should continue beyond 3 months only if the person has lost at least 5% of their initial body weight. However, rates of weight loss may be slower in people with type 2 diabetes, so less strict goals may apply to theml

As a separate guidance NICE is unable to make a recommendation on semaglutide for managing overweight and obesity in people aged 12 to 17 years because the manufacturer considers that, at this time, there is not enough evidence to support it for this population.

The next topic is KardiaMobile for detecting atrial fibrillation

This guidance had been withdrawn because of technical issues but it has now been re-introduced. Therefore KardiaMobile is recommended for detecting atrial fibrillation (AF) for people with suspected paroxysmal AF, who are referred for ambulatory electrocardiogram (ECG). KardiaMobile is a portable ECG recorder and Clinical evidence shows that significantly more people had AF detected using the KardiaMobile single-lead device compared with a Holter monitor. Furthermore, cost modelling shows that KardiaMobile is cost effective.

In terms of alcohol-use disorders there are 5 new quality statements focusing on key areas. The two areas relevant to primary care are that:

1.   Adults who are being asked about their alcohol use have a validated alcohol questionnaire completed to identify any need for a brief intervention or referral to specialist alcohol services. 

2.   Adults seeking help are given information on community support networks and self-help groups. 

I will also mention that there is a first-ever NICE guideline on vitamin B12 deficiency, which at the moment is only in draft form. It basically says that older people with unexplained fatigue or mental health problems should be offered a vitamin B12 test. The draft publication offers recommendations on how to diagnose it and treat it. I will not say much more because, being in draft, it is likely to change, but it is something that we can look forward to in the near future. If you want to see the draft document or take part in their consultation, I have put the link to it in the episode description. 

And lastly, we will end with the sad news that NICE is to stop supplying print copies of the BNF. The guidance will now only be in a digital format, either online or as a mobile app, so if you have one of the printed copies of the BNF lying around, look after it because, given enough time, it may eventually become an important historic item.  

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

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I do a quick review of a mind map that I have created based on the NICE Guideline: Hypertension in adults: diagnosis and management (NG136 guideline), updated on 18th March 2022. I have summarised the guidance from a Primary Care perspective, and I have created an e-book on this too. You are welcome to download both the mind map and both versions of the e-book here:

·      Mind map: https://1drv.ms/b/s!AiVFJ_Uoigq0l2boZjh4biBJ5WGv?e=7YqdBn

·      Condensed and easy to print e-book: https://1drv.ms/b/s!AiVFJ_Uoigq0l2cepU4PPQoY_0NQ?e=xymSS3

·      Digital and fully “clickable” e-book: https://1drv.ms/b/s!AiVFJ_Uoigq0l2iI6yHrZAU0VsWg?e=VtaO9N

By way of disclaimer, nothing that I say either in the video or the downloads is medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement. 

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 

NICE Guideline NG136 can be found here:

https://www.nice.org.uk/guidance/NG136

Other links relevant to this episode:

·     guideline on hypertension in pregnancy

·     NICE's guideline on cardiovascular disease

·     patient decision aid on treatment options for hypertension

·     NICE's guideline on multimorbidity

·     NICE guidelines on chronic kidney disease

·     type 1 diabetes 

·     MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, recommendations on how to use for breastfeeding and the related clarification on breastfeeding

·      drug therapy for secondary prevention in the NICE guideline on acute coronary syndromes

·      treatment after stabilisation in the NICE guideline on acute heart failure

·      treating heart failure with reduced ejection fraction in the NICE guideline on chronic heart failure

·      drugs for secondary prevention of cardiovascular disease in the NICE guideline on stable angina

·      blood pressure management in the NICE guideline on type 1 diabetes in adults.

·     NICE's guideline on chronic heart failure

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Script

Hello everyone and welcome. My name is Fernando, a GP in the United Kingdom.

Today, we'll be doing a quick revision on hypertension and we will do it by reviewing a mind map that I have made based on the NICE Guideline on hypertension. Therefore, this episode will be fairly short but make sure that you stay for its entirety because, at the end, I am going to tell you how you can download the mind map and I will also tell you about a mini e-book that I have created that summarises the guidance, as always, from a Primary Care perspective.

Please note that this is my interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

There is also a YouTube version which you can find in the episode description.

So, with that said, let's dive in! I hope that you enjoy this episode.

So let me introduce the mind map, and here it is. We are going to quickly navigate through it.

So we’re going to start in the centre of the mind map where it tells us about the guideline NG136. And here we see that it applies to people aged 18 and over, including those with type two diabetes. It also tells us that the updated guideline in March 2022, gives us new targets and new advice on drug treatment for cardiovascular disease. It also reminds us that when measuring the blood pressure we need to consider pulse irregularity when using automated devices, and also we should consider postural hypotension as well as the need to measure the blood pressure in both arms and to repeat the measurement if the difference is greater than 15 mmHg. 

When it comes to diagnosis if the clinic blood pressure is over 140/90 then we will need to arrange ambulatory blood pressure monitoring or alternatively home Blood pressure monitoring and if the average is above 135/85, then we will confirm the diagnosis.

In terms of lifestyle interventions, we will recommend a healthy diet, regular exercise, reduced alcohol, avoid excessive caffeine, as well as low dietary sodium and smoking cessation.

With monitoring we will remember that we need to use the clinic Blood pressure for monitoring purposes although in specific situations ambulatory home blood pressure monitoring may be used and we will base the blood pressure targets on age and comorbidities as well as remembering the need for an annual review of these patients.

When it comes to investigations we will assess for secondary causes, we will estimate the cardiovascular risk and we will assess for target organ damage. This assessment will comprise of at least a urine sample for albumin creatinine ratio, a number of blood tests, fundoscopy and an ECG

For urgent, same day referral we will consider patients with a clinic blood pressure of 180/120 or more with one of the following, either life-threatening symptoms, retinal, haemorrhage, or papilloedema as well as if we suspect pheochromocytoma (pause)

We are now going to focus on the antihypertensive drug treatment and we need to remember that we need to review the treatment when type two diabetes is diagnosed, as well as considering individual factors and medication safety when treating patients and this treatment will follow a stepwise approach. Step one is when we give one drug and this can be an ace inhibitor or ARB if the patient has diabetes, regardless of age and ethnicity. Or if the patient is less than 55 and not of Afro Caribbean family origin or, alternatively we can give a calcium channel blocker is the patient is of Afro-Caribbean family origin and has no diabetes or if the patient is over 55 and has no diabetes

Step two is one we give two drugs and it could be anyone of these combinations, an ace inhibitor or ARB and a calcium channel blocker; an ace inhibitor or arb and a thiazide like diuretic, or a calcium channel blocker, and a thiazide diuretic. Step three is when we give three drugs, and this would be an ace inhibitor, a calcium channel blocker, and a thiazide like diuretic. And step 4 is when we give four drugs. If this happens, we will say that the patient has resistant hypertension and we will consider specialist referral. But if we decide to treat ourselves, we will give triple therapy with an ace inhibitor or arb, a calcium channel blocker, a thiazide like diuretic, and we will check the potassium if the potassium is less than 4.5 we will give. Spironolactone and if potassium is more than 4.5 we will give an alpha blocker or a beta blocker.

And finally, we have a section giving definitions and terms used such as accelerated hypertension, which is when the blood pressure is over 180/120 with retinal involvement, masked hypertension, as well as the three stages of hypertension. 

Right, so this is it, this is the end of the mind map tour. As promised, let me tell you about the downloads. Just click in the episode description and there you will be find a link to download the mind map for free, without the need to provide your email address or any other information. You will also find two other links to download the two versions of the mini e-book that I have created. The first one is a printer friendly e-book, for those of you that would want to have a physical copy in your hands. It is more condensed and has therefore fewer pages. It is in black and white text so you will not be wasting ink unnecessarily on pictures or background colours. The second version is a fully digital “clickable” e-book. It has a few more pages as well as photographs and links to further information. Furthermore, under each section of the mind map there is a button that says “more” and if you click on it, you will be taken directly to the section of the summary that refers to it, followed by a button to take you back to the mind map.

Over the next few episodes, I will be producing more material similar to this so make sure to stay tuned.

But please, let me reiterate again that this is only a summary and my interpretation of the guideline.

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

The video version of this podcast can be found here:

https://www.youtube.com/watch?v=uXumxdZNU8I&t=1512s

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I summarise and review the various NICE guidance on contraception focusing on the oral methods only. I have summarised the guidance from a Primary Care perspective, at times simplifying some of the guidance to make it manageable.

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

The NICE GP YouTube Channel: NICE GP - YouTube 

The various guidelines can be found following these links:

·      Summary of “Contraception – assessment” : https://cks.nice.org.uk/topics/contraception-assessment/

·      Scenario: Assessment for contraception: https://cks.nice.org.uk/topics/contraception-assessment/management/assessment-for-contraception/

·      Scenario: Comorbidities and personal characteristics: https://cks.nice.org.uk/topics/contraception-assessment/management/comorbidities-personal-characteristics/

·      Scenario: Assessment for specific contraceptive methods: https://cks.nice.org.uk/topics/contraception-assessment/management/assessment-for-specific-contraceptive-methods/

·      Contraception - combined hormonal methods: https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/

·      Scenario: Combined oral contraceptive:

https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/

·      Contraception - progestogen-only methods: https://cks.nice.org.uk/topics/contraception-progestogen-only-methods/

·      Scenario: Progestogen-only pill:

https://cks.nice.org.uk/topics/contraception-progestogen-only-methods/management/progestogen-only-pill/

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Music provided by Audio Library Plus  

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Transcript 

Hello everyone and welcome. I am Fernando Florido, a GP in the United Kingdom.

Today, we'll be reviewing the various NICE guidelines on contraception focusing on the oral contraception only. I have summarised the guidance from a Primary Care perspective and I have put the relevant links in the episode description.

Please note that this is my interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

If you prefer a video format, there’s also a YouTube version of these episodes. The link is in the episode description.

Covering contraception in general is a vast and challenging task. I must admit that there were moments when I felt overwhelmed, as condensing all the necessary information into a concise video seemed nearly impossible, even when focusing solely on oral hormonal contraception. The NICE guidance can be extremely complex, depending on factors such as the woman's place in her hormonal cycle or whether unprotected sexual intercourse has occurred at a specific time. In situations where complexity became unmanageable, I made an effort to simplify the advice while ensuring that the desired contraceptive effect was maintained.

So, with that said, let's dive in!"

The video consists of three parts: an assessment of suitability for oral contraception, information about the combined oral contraceptive, and details about the progesterone-only pill.

Let’s start with the assessment.

How should we start the assessment of a woman requesting oral contraception?

Well, we will

o  Exclude Pregnancy

o  Take a history and clinical examination. 

o  Assess the risk of sexually transmitted infections (STIs) and

o  Assess for sexual abuse, rape, and non-consensual sex especially in vulnerable women

o  Remember that the legal age of consent to sexual activity is 16 years in the UK and that Sexual activity under this age is an offence, even if consensual.

o  If a girl younger than 16 years of age requests contraception without parental consent, she should be assessed for criteria that she is competent to make this decision. In England and Wales these are the Fraser criteria but in different jurisdictions the advice will be different. I have not covered this here and if you come across such a situation, I would advise you to seek medicolegal advice.

We are now going to look at what methods of contraception are suitable for women with certain comorbidities. These sections cover the UK Medical Eligibility Criteria (UKMEC) for hormonal contraception. 

All oral hormonal contraception, that is, the COC and the POP, can be used in the following cases:

·      past or current pelvic inflammatory disease (PID)

·      history of gestational diabetes or diabetes with no vascular disease

·      a BMI of less than 35 

·      non-migrainous headaches

·      migraine without aura but if migraine without aura develops in a woman already using a COC, we should stop it and give an alternative.

·      Fibroids, previous ectopic pregnancy and menorrhagia but obviously women with unexplained vaginal bleeding should be investigated and

·      perimenopausal women, although we will need to consider possible risk factors

The POP can be used but combined oral contraception is not recommended in the following cases: 

·      diabetes with nephropathy, retinopathy, neuropathy, or other vascular disease

·      migraine with aura or with a history of it

·      multiple risk factors for cardiovascular disease

·      BMI of 35 or more

·      Hypertension, even if it is adequately controlled.

·      Current or History of VTE.

·      Major surgery with prolonged immobilization.

·      Family history of VTE in first-degree relative younger than 45 years of age.

·      Immobility for any reason

·      age 35 years or older and a smoker or stopped smoking less than 1 year ago.

In respect of postpartum and breastfeeding

·      POP can be used from day 1

·      COC can be used from 6 weeks

·      Before 6 weeks:

o  We should never use the COC in the first 3 weeks.

o  We will not use the COC before 6 weeks if breastfeeding or if there are risk factors for VTE

o  But the COC can be used from 3 weeks to 6 weeks if not breastfeeding and there are no risk factors for VTE

In respect of girls aged under 18 years

·      We will avoid regular hormonal contraception if non-menstruating girls and.

·      We will recommend barrier methods for the prevention of sexually transmitted infections 

Finally, in respect of the POP

·      We will check that the cervical screening is up to date and.

·      We will check the additional considerations for drospirenone like:

o  Not to be used in renal failure.  

o  To be avoided in hyperkalaemia or at risk of developing it and

o  To have UEs and BP monitored depending on risk factors

How should we follow up women on oral contraception, both the COC and the POP?

·      We should do a review 3 months after the first prescription, and annually thereafter.

·      At follow up visits we will:

o  Check BP and BMI.

o  Ask about headaches, especially migraine. 

o  Assess for any new risk factors.

o  Address any issues or adverse effects.

o  Check the patient’s knowledge and remind about possible drug interactions and

o  Advise about long-acting reversible contraception

·      We should stop COC at 50 years of age, and switch to and alternative such as the POP.

Before looking at the COC and the POP separately, let’s look at how we would manage a patient taking oral contraception who develops unscheduled bleeding.

·      We need to know that unscheduled bleeding is common in the first 3 months of starting the COC and in women taking the POP

·      We will always need to check for:

o  missed pills, drug interactions, and vomiting or diarrhoea.

o  STIs and as a minimum, we should test for Chlamydia trachomatis.

o  Pregnancy and we should do a pregnancy test and.

o  Gynaecological conditions such as cervical or endometrial cancer.

·      We will consider a speculum and pelvic examination if there are concerns and

·      If all is normal, the bleeding can be assumed to be caused by the COC or POP:

o  If on the COC and the bleeding does not settle, we will consider:

▪       a different COC (with a higher dose of oestrogen, or higher dose of progestogen, or different type of progestogen).

▪       another form of contraception.

o  If on the POP we will advise that

▪       although bleeding may settle with time, there is no evidence to indicate who may become amenorrhoeic, and who may experience persistent irregular bleeding.

▪       If the bleeding is unacceptable to the patient, we will consider changing to:

▪       A different POP, although there is no evidence that changing improves bleeding or

▪       A different type of contraceptive method. 

We are now going to look at the combined oral Contraception

·      Let’s remember that COC inhibit LH and FSH which stops ovulation from occurring.

·      In addition, COCs also have contraceptive effects on cervical mucus and the endometrium

·      The usual 7-day break causes vaginal bleeding mimicking menstruation. However, there is no health benefit from this and women can choose to take fewer, or no, breaks.

·      When used perfectly, there’s a 0.3% failure rate within the first year. But in the real world the failure rate can go up to 9%.

When can a woman start using a combined oral contraceptive?

·      If the COC is started on days 1–5 of the menstrual cycle: 

o  No additional contraception is required unless the woman is starting Qlaira® or Zoely®.

o  If the woman is starting Qlaira® or Zoely®, on day 1 of the menstrual cycle then no additional contraception is required

o  But if the woman is starting Qlaira® or Zoely®, on day 2-5 of the menstrual cycle we should advise a barrier method for the first 9 days (for Qlaira) or the first 7 days (for Zoely).

·      If the COC is started at any other time in the menstrual cycle:

o  We will advise a barrier method for the first 7 days (9 days for Qlaira®).

·      If pregnancy cannot be excluded and the woman wishes to start hormonal contraception without delay:

o  We will prescribe the COC and advise a pregnancy test no sooner than 3 weeks after the last episode of unprotected sexual intercourse (UPSI).

If the woman is starting a COC after oral emergency contraception:

·      For levonorgestrel, we will start the COC immediately and we will advise a barrier method for the first 7 days (9 days if taking Qlaira®).

·      For ulipristal, we will start the COC 5 days after and we will advise a barrier method for this time and the next 7 days (9 days if taking Qlaira®).

If the woman is switching from another COC, the combined contraceptive patch, or the combined vaginal ring:

·      We will start the COC on the day after the last active pill, patch, or vaginal ring. There is no need to wait for the next menstrual period. 

o  No additional contraception is required.

·      If the woman decides to take the usual break before starting the new COC, we will need to assess the need for additional contraception and emergency contraception.

If the woman is switching from a progestogen-only pill (except desogestrel) or levonorgestrel intrauterine system (LNG-IUS):

·      We will start the COC at any time in the menstrual cycle and advise a barrier method for the first 7 days (9 days for Qlaira®).

The advice on how to switch from the drosperidone progestogen-only pill, a progestogen-only implant, or a copper intrauterine device can be fairly complex depending on various factors and these patients may very well be managed by family planning clinics so I will not cover them here. But feel free to check the links in the episode description if you wish to know more. 

If the woman is amenorrhoeic but not pregnant:

·     we can start the combined oral contraceptive at any time, and additional contraception is required for 7 days (9 days for Qlaira®).

If the woman is postpartum:

·     we will advise a barrier method for the first 7 days (9 days for Qlaira®).

If the woman has had a miscarriage or termination of pregnancy:

·      If gestation is less than 24 weeks:

o  If the COC is started within 5 days (except Qlaira® and Zoely® which is 1 day). No additional contraception is required.

o  If the COC is started at any other time, use a barrier method for 7 days (9 days for Qlaira®).

·      If gestation is 24 weeks or more, we will treat them as if they were postpartum.

What types of combined oral contraceptive (COC) are available?

·      Combined oral contraceptives (COCs) contain both an oestrogen and a progestogen.

·      COC preparations differ according to:

o      How the doses vary over the menstrual cycle. For example

▪       In monophasic COCs, the amount of oestrogen and progestogen in each active tablet is constant throughout the cycle.

▪       In phasic COCs, the amounts of oestrogen and progestogen vary over the cycle. Phasic COCs can be biphasic, triphasic, or quadraphasic depending on the number of sets of active pills.

o      They can also vary depending on the dose of the oestrogen. For example

▪       Low-strength COCs contain 20 micrograms of ethinylestradiol. and

▪       Standard-strength preparations contain 30–35 micrograms of ethinylestradiol in monophasic COCs and 30–40 micrograms in phased preparations.

o      They also vary according to the type of progestogen they contain. and

o      The presence or absence of a pill-free interval.

▪       Most COCs are packaged as 21 active tablets to allow for a 7 day break every 4 weeks. However, some products have 7 placebo tablets so that a tablet is taken every day without a break

Which combined oral contraceptive (COC) should we offer first-line?

·      First-line options are monophasic preparations containing 30 micrograms of oestrogen, plus either norethisterone or levonorgestrel. Examples are Loestrin 30, Microgynon 30, Ovranette, Levest and Rigevidon

·      However, any COC can be offered first-line.

·      We should prescribe up to 12 months’ supply for initiating or continuing CHC. And

·      You can check the full availability of brands by looking at the BNF. 

Let’s look at the advice that we should give women taking the COC.

If a woman becomes pregnant while taking the combined oral contraceptive (COC) pill and she wishes to continue with the pregnancy:

o  We will stop the pill.

o  And explain that there is no evidence of harm if pregnancy occurs whilst on the COC. 

What are the advantages and disadvantages associated with combined oral contraceptives (COCs)?

Advantages are that

·      There is a reduced risk of some cancers, including colorectal, ovarian and endometrial cancer. 

·      There is a reduced risk of ovarian cysts and benign ovarian tumours.

·      There is reduced severity of acne in some women.

·      Normal fertility returns immediately after stopping the COC.

·      COCs may also reduce the risk of benign breast disease and osteoporosis, although the available evidence is conflicting.

Disadvantages are that

·      They are less effective than long-acting reversible methods of contraception and that

·      Some women experience adverse effects .

·      The most commonly reported adverse effects are: 

o  Nausea and abdominal pain.

o  Headache.

o  Breast pain and/or tenderness.

o  Menstrual irregularities in up to 20% of COC users

·      Other adverse effects include:

o  Hypertension.

o  Changes in lipid metabolism.

o  there is a very small increase in risk of MI, and two-fold increase in risk of stroke, which is greater in at risk patients.

o  There is an increased risk of VTE, but the absolute risk is very low and lower than the risk of VTE in pregnancy.

o  The risk of VTE depends on the progestogen component and:

▪       levonorgestrel, norethisterone, or norgestimate have the lowest risk

o  There is an increased risk of breast and cervical cancer which returns to normal within 10 years after stopping the COC.

o  depression is a known side effect

o  symptoms of angioedema may be induced or exacerbated by exogenous oestrogens

o  There is no evidence that COCs cause weight gain or loss of libido.

o  In addition, co-cyprindiol should not be used in hepatic disease and meningiomas have been associated with cyproterone.

We also need to be aware of drug interactions and that the effect of COC may be reduced with liver enzyme-inducing drugs like:

o  Antibiotics such as rifampicin and rifabutin.

o  Antiepileptic drugs.

o  Antiretrovirals.

o  St John's wort.

How should we manage them?

·      We should advise not to take products containing St John’s wort.

·      We should always change to an alternative contraceptive method if taking rifampicin or rifabutin. For other liver enzymes drugs the advice may be more complex depending on the duration of treatment and type of COC used. I would recommend that you look up the specific advice depending on the situation

·      We need to be aware that breakthrough bleeding may indicate low serum ethinylestradiol concentrations. If other causes of bleeding have been excluded, we could increase the dose up to a maximum of 70 micrograms.

·      We will consider the need for emergency contraception if sexual intercourse has taken place while the efficacy of the COC may have been reduced.

·      To reduce the risk of contraceptive failure, we can recommend either: 

o      An extended regimen that is, using the COC continuously until breakthrough bleeding occurs for 3 to 4 days or

o      A tricycling regimen with a shortened pill-free interval of 3–4 days, that is taking 3 pill packs continuously without a break.

·      But we need to remember that only monophasic 21-day pill packs containing at least 30 micrograms of ethinylestradiol are suitable for these two options. 

In terms of surgery, we should explain that

·      No precautions are necessary for minor surgery (such as varicose vein surgery, and tooth extraction). But

·      The COC should be stopped: 

o  Four weeks before any major surgery (which includes operations lasting more than 30 minute), all surgery to the legs, or surgery that involves prolonged immobilization of a lower limb or

o  If emergency surgery or immobilization (such as for a leg fracture) is necessary.

o  The COC can then be restarted 2 weeks after full mobilization. 

Let’s now go through what Missed pill advice we should give and 

These missed pill rules apply to all combined oral contraceptives (COCs) except Qlaira® and Zoely®.

·      If it has been 9 completed days or more since the last active pill was taken we will consider emergency contraception if unprotected sexual intercourse (UPSI) has taken place and:

o  We will advise to take the missed pill as soon as possible and to continue taking the remaining pills at the usual time.

o  We will advise a barrier method until 7 consecutive pills have been taken. 

o  We will consider a follow up pregnancy test.

·      If one pill has been missed (that is <72 hours since the last pill was taken), we will advise:

o  That emergency contraception and additional contraceptive precautions are not required if there was otherwise consistent, correct use.

o  To take the missed pill as soon as possible.

o  To continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).

·      If 2–7 pills have been missed (72 hours or more since the last pill in the current pack was taken):

o  We will consider emergency contraception if the missed pills were in week 1 after the break and if UPSI has taken place and we will also consider a follow up pregnancy test.

o  Emergency contraception is not needed if missed pills are in subsequent weeks if there was consistent, correct use in the previous 7 days.

o  We will advise to take the most recent missed pill as soon as possible. Any earlier missed pills should be ignored.

o  We will advise to continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours.

o  If there were two or more missed pills in the 7 days prior to the break, to omit the break.   

o  We will advise a barrier method until 7 consecutive pills have been taken. 

·      If more than 7 consecutive COC pills have been missed in any week of pill-taking:

o  We will Consider emergency contraception and an immediate and follow up pregnancy tests.

o  We will Restart the COC as a new user. And

o  We will advise a barrier method until 7 consecutive pills have been taken.

What advice should we give a woman who has missed pills of Qlaira or Zoely

·      If the pill is taken less than 12 hours late (Qlaira) or 24 hours late (Zoely) we will advise:

o  To take the missed pill immediately.

o  To take further pills at the usual time.

o  That additional contraception is not required.

·      If pill is taken more than 12 hours late (Qlaira) or 24 hours late (Zoely), management will depend on the day of the cycle on which it has been missed. This can get quite complicated so I have not included it here and I recommend that you look it up if you come across this situation. 

How should vomiting or diarrhoea be managed when on the COC?

·      Well, for all combined oral contraceptives (COCs) except Qlaira® and Zoely®:

o  If there is vomiting within 3 hours of taking COC, another pill should be taken as soon as possible.

o  If vomiting or diarrhoea persists for more than 24 hours:

▪       We will follow the instructions for missed pills, counting each day of vomiting and/or diarrhoea as a missed pill.

▪       We will advise a barrier method during the illness and for 7 days afterwards. and

▪       if the illness occurs while taking the last 7 pills, we will recommend not having a break and starting the next cycle immediately.

·      For Qlaira® and Zoely®:

o  If a woman vomits within 3–4 hours of taking an active pill, take the next tablet as soon as possible.

o  If more than 12 hours elapse for Qlaira® or 24 hours for Zoely®, follow the missed pills advice.

We are now going to have a look at the progestogen-only pill:

·      The POP has several independent modes of action, including thickening cervical mucus thereby preventing sperm penetration, delaying ovum transport, inhibiting ovulation, and providing an endometrium hostile to implantation.

·      It should be taken daily with no pill-free interval.

·      When used perfectly, the failure rate is 0.3% within the first year of use but in the real world, the failure rate can go up to 9%.

·      Any licensed progestogen-only pill (POP) may be used first line and we can prescribe 12 months' supply when initiating or continuing a POP. 

How should we start a progestogen-only pill except drospirenone?

·      In women with menstrual cycles:

o  We will start on days 1–5 and no additional precaution is required.

o  If no possibility of pregnancy and starting at any other time we will advise a barrier method for 2 days.

o  If there is risk of pregnancy and starting at any other time, we will:

▪       Recommend an immediate pregnancy test and a follow up test no sooner than 3 weeks after the last episode of unprotected sexual intercourse (UPSI).

▪       consider emergency contraception.

▪       Quick start the POP but delay for 5 days if ulipristal EC was given.

▪       advise a barrier method for 2 days.

▪       And This applies also to women who are amenorrhoeic and have had UPSI in the last 21 days. However,

·      In women who are amenorrhoeic and no UPSI in the last 21 days:

o  We will do a pregnancy test and

o  We will start the POP and advise a barrier method for 2 days

·      The POP can be started at any time after childbirth, including immediately after delivery regardless of breastfeeding. However:

o  If started up to day 21 postpartum no additional precaution is required but

o  After day 21 postpartum, we will ensure that the patient is not pregnant, then start the POP recommending a barrier method for 2 days 

·      In women post first- or second-trimester abortion:

o  The POP should ideally be started on the day or day after a first- or second-trimester abortion but otherwise management is no different to menstruating women.

·      If starting the POP after oral EC, we will:

o      Start the POP immediately if levonorgestrel was given or 5 days after taking ulipristal.

o      We will recommend a barrier method for 2 days. And we will

o      Advise the woman to do a pregnancy test no sooner than 3 weeks after the last episode of UPSI.

How should we switch to the progestogen-only pill (except drospirenone) from other methods of contraception?

·      If we are switching from combined oral contraceptive:

o  If we are starting on days 1–2 of the break then no additional precaution is required.

o  If we are starting on days 3–7 of the break or week 1 following the break and if there is no risk of pregnancy, then:

▪       We should advise a barrier method for 2 days.

o  If we are starting on days 3–7 of the break or week 1 following the break but unprotected sexual intercourse (UPSI) has occurred after in that time:

▪       We will restart or continue the COC until 7 consecutive pills are taken after the break then switch.

▪       No additional precautions are required.

▪       If COC cannot be continued, we will start the POP immediately and we will consider the need for emergency contraception (EC) and a pregnancy test as well as recommending a barrier for 2 days.

o  If we are starting on weeks 2–3 of COC use, no additional precaution is required providing the method has been used consistently and correctly.

·      If we are switching from a POP to another POP:

o  We will start the new POP at any time in the menstrual cycle.

▪       If switching to drospirenone, advise a barrier method for 7 days but 

▪       For all other POPs, no additional precaution is required.

o  If we are switching from drospirenone, to a different POP, the guidance is complex depending on when in the cycle the switch takes place. I have not included it here and I recommend that you look this up if considering this option. 

·      If we are switching from a progestogen-only injectable to a POP other than drosperinenone:

o  If it is 14 weeks or less since the last injection then no additional precaution is needed.

o  If it is more than 14 weeks since the last injection and no risk of pregnancy we will recommend a barrier method for 2 days.

o  If it is more than 14 weeks since the last injection and there is a risk of pregnancy then we will consider the need for EC and a pregnancy test.

·      The advice on how to switch from a progestogen-only implant and intrauterine contraception can be fairly complex depending on various factors and these patients may very well be managed by family planning clinics so I will not cover them here. But feel free to check the links in the episode description if you wish to know more.

The advice above does not include drospirenone. However, if we are giving drospirenone we need to be aware that:

·      It needs to be started on day 1 of the normal menstrual cycle so that no additional precaution is required.

·      Any barrier method advice needs to be for 7 days as opposed for 2 days for other POPs

What are the possible risks and adverse effects of progestogen-only pills?

·      Well, Menstrual irregularities are common.

·      Other possible risks and adverse effects of the POP include: 

o  Ectopic pregnancy (with the exception of desogestrel), but the absolute risk is lower than if not using contraception.

o  Breast tenderness (which is usually transient). 

o  Ovarian cysts (which may be persistent).

o  Depression and changes in mood and libido.

o  Panic attacks (with the desogestrel pill).

o  Headache and migraines.

o  Weight changes.

·      The Breast cancer risk cannot be completely excluded. Any increased risk is likely to be small and to reduce with time after stopping. 

·      In terms of Cardiovascular disease (CVD) risk, The POP is generally appropriate for women with cardiac disease and is useful as a bridging method while specialist advice is being sought about contraceptive options.  

Drug interactions of the progestogen-only pill (POP) include: 

·      Liver enzyme-inducing drugs (such as rifampicin and carbamazepine) can reduce the efficacy of POPs. Therefore, we will:

o      change to an alternative contraceptive method for as long as she is on these drugs and for 28 days after. 

o      If this is not possible and she is on short-term treatment (2 months or less), we will continue the POP but we will advise a barrier method while taking, and for 28 days after stopping, the liver enzyme-inducing drug. and

o      We will Consider emergency contraception (EC) if unprotected sexual intercourse has taken place while the efficacy of the POP may have been reduced.

o      Other examples of liver enzyme inducing drugs include:

▪       Antibiotics such as Rifampicin and Rifabutin.

▪       Antiepileptics

▪       Antiretrovirals:

▪       St John's Wort.

·      Griseofulvin may also reduce the contraceptive effect of POPs and therefore we will recommend an alternative

·      Lamotrigine may increase plasma levels of progestogen so we should monitor side effects.

·      POPs may reduce the ability of ulipristal to delay ovulation and therefore after ulipristal the patient should:

o      wait 5 days (at least 120 hours) before continuing or starting the POP, with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure.

o      We should recommend additional contraception until the POP is started and for 48 hours after, that is, for a week after Ulipristal. 

If a woman is found to be pregnant whilst using the progestogen-only pill (POP) and she wishes to continue with the pregnancy, we will:

·      stop the POP.

·      We will Inform her that there is no evidence of harm if pregnancy occurs while using the POP. and

·      We will Be alert to the possibility of an ectopic pregnancy.

Let’s look at the Missed pill advice for the POP

·      A pill is missed if the patient is: .

o  12 hours or more late (that is, more than 36 hours since the last pill) if on the desogestrel pill

o  24 hours or more late (that is 48 hours or more since the last pill) if on the drospirenone pill or

o  More than 3 hours late (that is, more than 27 hours since taking the last pill) if on any other progestogen-only pills

·      If the patient has missed a pill, we will advise:

o  To take a pill as soon as possible. If more than one pill has been missed, only one should be taken.

o  To take the next pill at the normal time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).

o  To use a barrier for 7 days if taking drospirenone, or 2 days for all other POPs.

·      We will consider prescribing emergency contraception if unprotected sexual intercourse has taken place after the missed pill and within 48 hours of restarting the POP. For drospirenone, we will consider prescribing emergency contraception in wider circumstances and I recommend that you look up the details in this case if you need to.

Let’s now look at the information and advice that we should give in the event of vomiting or diarrhoea

·      If there is vomiting within 2 hours of pill taking, another pill should be taken as soon as possible.

o  If the subsequent pill is taken more than 3 hours late (or 12 hours late for a desogestrel pill or 24 hours late for drospirenone), we will advise the missed pill rules.

o  If vomiting continues or very severe watery diarrhoea develops, we will advise the missed pill rules (counting each day of vomiting and/or diarrhoea as a missed pill) and use a barrier method during the illness and for 48 hours afterwards.

How long should the progestogen-only pill be used for?

·      If a woman aged over 50 years with amenorrhoea wishes to stop contraception before the age of 55 years:

o  We will check FSH levels on two occasions, with an interval of 6 weeks between tests.

o  If both FSH levels are more than 30 IU/L, the progestogen-only pill (POP) can be discontinued after a further year.

o  If the FSH level is in the premenopausal range, we will continue the POP and recheck the FSH level after 1 year.

·      Once a woman reaches 55 years of age, contraception can be stopped even if she is still experiencing menstrual bleeding.

o  However, if a woman aged 55 years or over does not wish to stop a particular method, consider continuing the method provided individual benefits and risks are assessed and discussed with her. 

·      The POP can be used concurrently with hormone replacement therapy (HRT) to provide effective contraception, but it should not be relied on as the progestogen component of HRT.

In conclusion, the management of oral contraception requires a comprehensive approach and it can become complex.

Please keep in mind that this is only a summary and my interpretation of the guideline. 

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. Welcome to the latest instalment in our monthly video series, "NICE News," where we discuss new and updated guidelines published by the National Institute for Health and Care Excellence (NICE), specifically as it relates to primary care.

In this video, I'll be focusing on the NICE guidance and advice published in June 2023. We'll be reviewing the latest recommendations that are relevant to primary care practitioners, with the goal of keeping you informed and up-to-date on the latest developments.  

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw

The Full NICE News bulleting for June 2023 can be found at:  

·      https://www.nice.org.uk/guidance/published?from=2023-06-01&to=2023-06-30&ndt=Guidance&ndt=Quality+standard

The links to the update guidance covered can be found here:

Depression in adults:

·      https://www.nice.org.uk/guidance/qs8

Dapagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction:

·      https://www.nice.org.uk/guidance/ta902

Atopic eczema in under 12s: diagnosis and management:

·      https://www.nice.org.uk/guidance/cg57

Decision aid to guide healthcare professional-patient discussions on sleeping pill prescriptions published:

·      https://www.nice.org.uk/news/article/decision-aid-to-guide-healthcare-professional-patient-discussions-on-sleeping-pill-prescriptions-published

·     One page summary for patients: https://www.nice.org.uk/guidance/ng215/resources/should-i-stop-my-benzodiazepine-or-zdrug-patient-decision-aid-summary-pdf-13072600333

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

• Music provided by Audio Library Plus  

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Transcript

Hello and welcome to another episode of NICE News. My name is Fernando Florido, a GP in the United Kingdom. Today, we'll be discussing the NICE Guidance and advice published in June 2023, specifically for Primary Care.

This month we are focusing on Depression, Dapagliflozin in chronic heart failure, Atopic eczema, and we will briefly touch on the prescribing of sleeping pills

Before we begin, I want to remind you that this episode is not medical advice. It is only my interpretation, and you must use your clinical judgement.

I'd like to remind you that there is a YouTube version of this episode which can be found in the episode description.

Now, with that said, let’s get straight into it.

The first clinical area refers to Depression in adults and the updated quality standards are mostly common sense, but the one that caught my eye was the advice that spells out what we instinctively knew, that when stopping antidepressants, the dose needs to be reduced in stages. We should agree with the patient the speed and duration of the withdrawal and offer follow-up appointments to check both for withdrawal symptoms and the return of depression, ensuring that any withdrawal symptoms have resolved or are tolerable before making the next dose reduction.

The next clinical area covers Dapagliflozin in heart failure. You may know that there is already guidance that recommends Dapagliflozin for chronic heart failure with reduced ejection fraction but this update refers to heart failure with preserved or mildly reduced ejection fraction.

Current treatment of heart failure with preserved ejection fraction is loop diuretics, which manage symptoms, but do not reduce hospitalisations.

However, Dapagliflozin in chronic heart failure with reduced ejection fraction reduces cardiovascular deaths and hospitalisations for heart failure.

The clinical experts noted that chronic heart failure with reduced and preserved ejection fractions should not necessarily be considered as 2 separate conditions, and that they exist on a continuum. And therefore, the committee concluded that when its preferred assumptions are incorporated, dapagliflozin is cost-effective and therefore, recommended also for chronic heart failure with preserved ejection fraction.

The next update is in the management of atopic eczema in under 12s and the main outcome is that we should now not offer emollient bath additives, because evidence has shown that, although not harmful, they are not clinically or cost effective.

Emollient creams continue to be vital in helping to manage eczema, but we need to be aware that there are warnings about fire hazards associated with build-up of emollient on clothing and bedding.

We should prescribe large quantities of leave-on emollients (up to 500 g weekly) and explain:

·      That leave-on emollients can be added to bath water

·      That they should use emollients or emollient soap substitutes instead of soap and

·      That children aged under 12 months should use emollients or emollient soap substitutes instead of shampoos and older children should use unperfumed shampoos

Finally, NICE has published a patient decision aid and a one-page summary, that provides clear and easy-to-use advice to support patients taking benzodiazepines or z-drugs to help them understand the benefits and risks of staying on their current dose, reducing their dose, or stopping the drugs altogether.  I have put links to this patient leaflet in the episode description.

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

The video version of this podcast can be found here:

https://youtu.be/so97zARpmME

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". 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 NICE.

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 recent onset cardiac chest pain [CG95], always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this episode is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Apple podcast: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

·      Spotify: https://open.spotify.com/show/2kmGZkt1ssZ9Ei8n8mMaE0?si=9d30d1993449494e

·      Amazon Music: https://music.amazon.co.uk/podcasts/0edb5fd8-affb-4c5a-9a6d-6962c1b7f0a1/primary-care-guidelines?ref=dm_sh_NnjF2h4UuQxyX0X3Lb3WQtR5P

·      Google Podcast: https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5yZWRjaXJjbGUuY29tLzI1ODdhZDc4LTc3MzAtNDhmNi04OTRlLWYxZjQxNzhlMzdjMw%3D%3D

·      Redcircle: https://redcircle.com/shows/2587ad78-7730-48f6-894e-f1f4178e37c3

There is a YouTube version of this and other videos that you can access here: 

●       The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis guideline [CG95] can be found here:

●      https://www.nice.org.uk/guidance/cg95/chapter/recommendations

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

●       Music provided by Audio Library Plus 

●       Watch: https://youtu.be/aBGk6aJM3IU 

●       Free Download / Stream: https://alplus.io/halfway-through 

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 NICE guideline on recent onset cardiac chest pain [CG95], always focusing on what is relevant in Primary Care only.

Right, without any further ado, let’s jump into it.

We are going to start by looking at the assessment and diagnosis of recent acute chest pain, suspected to be an acute coronary syndrome. The term ACS covers a range of conditions including unstable angina, ST‑segment-elevation myocardial infarction (or STEMI) and non‑ST‑segment-elevation myocardial infarction (or NSTEMI).

We will not cover the management of these conditions, given that this would be done in the hospital setting.

The first obvious thing is to check whether the patient has chest pain at the time of the consultation.

If the patient is pain free, we will check when their last episode was, particularly if they have had pain in the last 12 hours. We will see the importance of this and the impact on the possible management later.

In order to decide whether the chest pain is cardiac we will consider:

·      the history

·      the presence of cardiovascular risk factors

·      a history of ischaemic heart disease and

·      any previous treatment and investigations for chest pain. 

Symptoms suggestive of an ACS are:

·      pain in the chest and/or, for example, arms, back or jaw, lasting longer than 15 minutes

·      chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these

·      chest pain associated with haemodynamic instability and

·      new onset chest pain, or abrupt deterioration in previously stable angina, with frequent and recurrent chest pain on little or no exertion, and with episodes often lasting longer than 15 minutes. 

·      But we will bear in mind that not all people with an ACS present with central chest pain as the predominant feature and that

·      we should not use response to glyceryl trinitrate (GTN) to make a diagnosis of ACS. 

If we suspect an ACS, we will refer them to hospital. But NICE makes different recommendations as to who we should send to the emergency department and who we should send for urgent same-day hospital assessment.

So, if we suspect an ACS, we will send the patient as an emergency to the emergency department if:

·      they currently have chest pain or

·      they are currently pain free, but had chest pain in the last 12 hours, and a resting 12‑lead ECG is abnormal or not available 

Otherwise, in the absence of clinical concerns, we will refer for urgent same-day assessment if:

·      they had chest pain in the last 12 hours, but are now pain free with a normal ECG or

·      the last episode of pain was 12 to 72 hours ago 

We will also refer people for a hospital assessment if:

·      the pain has resolved and

·      there are signs of complications such as pulmonary oedema.

But for this group of patients we will use clinical judgement to decide whether referral should be as an emergency or for urgent same-day assessment. 

Right, so that is fairly clear, we will be referring straightaway patients who have had cardiac chest pains in the last 72 hours, regardless of ECG, or whether they have complications, using our clinical judgement as to whether they are for the emergency department or for urgent same day assessment. 

But what do we do if we see someone who had cardiac chest pains more than 72 hours ago and who have no complications such as pulmonary oedema?

NICE says that we should:

·      carry out a clinical assessment

·      confirm the diagnosis with an ECG and blood troponin level and

·      take into account the length of time since the suspected event when interpreting the troponin level, using clinical judgement to decide whether referral is necessary and how urgent this should be. 

And this is where it can get a little controversial.

Should we be doing troponin levels in primary care, bearing in mind that the results may not be available the same day?

If we are worried enough about an ACS to be doing troponin levels, should we be asking our hospital colleagues to assess the patient anyway?

What would be the medicolegal implications in Primary Care if the patient had a serious cardiovascular event in the intervening period?

And all this not to speak that many primary care organisations do not allow or recommend troponin testing in the primary care setting anyway.

As NICE says, it always comes back to us. They say, that we should use our clinical judgement to decide whether referral is necessary and how urgent this should be. So, it will depend on the presentation and our assessment of the risk. And it may very well be that you take the view that most, if not all, of your patients should have their troponin levels checked in hospital.

Is there anything else that we should do before referring them to hospital? Well, we should take an ECG as soon as possible, as long as this does not delay transfer to hospital and we will offer immediate treatment.

Let’s look at the ECG considerations first.

ECG changes that make the diagnosis of an ACS more likely are:

·      ST‑segment changes

·      Deep T wave inversion or

·      A presumed new left bundle branch block consistent with an acute STEMI

·      Also, even in the absence of ST‑segment changes, we will have an increased suspicion of an ACS if there are other changes such as Q waves and T wave changes but

·      Always bearing in mind that we should not exclude an ACS just because of a normal ECG. 

And now, let’s look at the immediate treatment that we should give in a way that is appropriate to the circumstances. So, as soon as we suspect an ACS, we should:

·      Offer pain relief, which may be achieved with either sublingual or buccal GTN, but we will offer intravenous opioids such as morphine, particularly if an acute MI is suspected. 

·      Offer a single loading dose of 300 mg of aspirin as soon as possible unless there is clear evidence that they are allergic to it, ensuring that we also send to hospital with the patient a written record that it has been given.

·      We will not routinely administer oxygen, but we will monitor oxygen saturation, and we will only offer oxygen if:

o  oxygen saturation (SpO2) is less than 94% if the patient is not at risk of hypercapnic respiratory failure, aiming for SpO2 between 94% and 98%

o  if the patient has COPD and is at risk of hypercapnic respiratory failure, we will aim for a target SpO2 between 88% to 92%, until blood gas analysis is available but

o  We also need to be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if it is borderline and that overestimation has been reported in people with dark skin.

If an ACS is not suspected, we will consider other causes of the chest pain, some of which may be life-threatening such as a PE, aortic dissection or pneumonia.

In these cases, and until a firm diagnosis is made, we will monitor patients with chest pain including:

·      review of symptoms and effect of pain relief

·      pulse and blood pressure

·      heart rhythm

·      oxygen saturation and

·      repeated ECGs 

OK, we have covered so far patients presenting with new onset chest pain. But what should we do for people with suspected stable angina who present with intermittent stable chest pain?

Let’s have a look at this scenario.

We will start the history and examination documenting:

·      the age and sex

·      the characteristics of the pain, including its location, radiation, severity, duration and frequency, and factors that provoke and relieve the pain

·      any associated symptoms, such as breathlessness

·      any history of angina, MI, or other cardiovascular disease 

·      any cardiovascular risk factors and

·      we will exclude other causes of chest pain and examine for non-coronary causes of angina (for example, severe aortic stenosis or cardiomyopathy) 

The diagnosis of stable angina based on our clinical assessment will depend on how typical of angina the chest pain is.

And anginal pain has these main three features:

·      it is constricting in the chest, or in the neck, shoulders, jaw or arms

·      it is precipitated by physical exertion and

·      it is relieved by rest or GTN within about 5 minutes. 

We will call it typical angina if all three features are present.

We will call it atypical angina if there are only two of the three features present.

And we will call it non-anginal chest pain if only one or none of the features are present.

The factors that make a diagnosis of stable angina more likely are:

·      increased age

·      being male

·      other cardiovascular disease or CAD like, for example, a previous MI and

·      cardiovascular risk factors such as:

o  smoking

o  diabetes

o  hypertension

o  dyslipidaemia or a

o  family history of premature coronary artery disease

On the other hand, features which make a diagnosis of stable angina unlikely are when the chest pain is:

·      continuous or very prolonged 

·      unrelated to activity 

·      brought on by breathing in and / or

·      associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing

In these cases, we will consider other causes of chest pain such as gastrointestinal or musculoskeletal pain. But if there are cardiovascular risk factors, we will still manage them appropriately.

If we suspect stable angina:

·      we will arrange blood tests to identify conditions which exacerbate angina, such as anaemia,

·      we will only consider chest X‑ray if other diagnoses, such as a lung tumour, are suspected and

·      we will arrange an ECG as soon as possible, even though we will not rule out angina just because the ECG is normal. 

There are a number of ECG changes which may indicate ischaemia or previous infarction. These include:

·      pathological Q waves

·      LBBB and

·      ST‑segment and T wave abnormalities (for example, flattening or inversion). 

If we suspect stable angina:

·      We will consider aspirin until a firm diagnosis is made but we will not offer additional aspirin if they are already taking it regularly or are allergic to it. 

·      We will follow the NICE guideline on stable angina while waiting for the results of investigations and you can check the corresponding episode on stable angina on this channel and 

·      We will refer to cardiology so that they can be offered the necessary diagnostic testing, such as CT coronary angiography or non-invasive functional testing such as myocardial perfusion scintigraphy or stress echocardiography

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I review the NICE guidance on inhalers, both for asthma and COPD. I have summarised the guidance from a Primary Care perspective and I have put the links to that guidance below.

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.   

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: 

https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw  

The following NICE guidance can be found here:

·      Asthma Inhaled corticosteroids- Last revised in April 2022: https://cks.nice.org.uk/topics/asthma/prescribing-information/inhaled-corticosteroids/

·      Asthma: Beta2 agonists- Last revised in April 2022: https://cks.nice.org.uk/topics/asthma/prescribing-information/beta-2-agonists/

·      Chronic obstructive pulmonary disease: Inhaled corticosteroids- Last revised in June 2023: https://cks.nice.org.uk/topics/chronic-obstructive-pulmonary-disease/prescribing-information/inhaled-corticosteroids/

·      Chronic obstructive pulmonary disease: Muscarinic antagonists- Last revised in June 2023: https://cks.nice.org.uk/topics/chronic-obstructive-pulmonary-disease/prescribing-information/muscarinic-antagonists/

·      Chronic obstructive pulmonary disease: Beta-2 agonists- Last revised in June 2023: https://cks.nice.org.uk/topics/chronic-obstructive-pulmonary-disease/prescribing-information/beta-2-agonists/

·      Corticosteroids - inhaled: Scenario: Corticosteroids – inhaled- Last revised in May 2020: https://cks.nice.org.uk/topics/corticosteroids-inhaled/management/corticosteroids-inhaled/#choosing-a-delivery-system

·      Corticosteroids – inhaled- Last revised in May 2020: https://cks.nice.org.uk/topics/corticosteroids-inhaled/

·      Corticosteroids - inhaled: Which inhaled corticosteroids are available in the UK?- Last revised in May 2020: https://cks.nice.org.uk/topics/corticosteroids-inhaled/background-information/types-of-inhaled-corticosteroids/

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

• Music provided by Audio Library Plus  

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Transcript 

Hello everyone, and welcome! I'm Fernando Florido, a GP in the United Kingdom.

Today, we're going to talk about inhalers – those small but powerful things that are a lifeline for people with asthma and COPD. But in the world of inhalers, things can get quite complex. With a multitude of brand names and different devices, navigating this world can feel like getting lost in a maze.

We'll try to bring order to this labyrinth by reviewing the NICE guidance on inhalers, both for asthma and COPD. I have summarised the guidance from a Primary Care perspective and I have put the links to that guidance in the episode description.

But before we begin, let's address the elephant in the room. Memorising the vast array of brand names, combinations, and different devices is no easy task. Not only would it be an overwhelming challenge, but it would also consume valuable brainpower that would be better utilised in other areas of our lives.

So, here's my advice: it's absolutely okay to look up specific inhaler brands when you need to. In today's digital age, we can quickly find the information we need without wasting our mental energy on trying to remember everything. This frees up our minds to focus on what truly matters.

If you prefer a video format, there’s also a YouTube version of these episodes. The link is in the episode description.

Please note that this is my interpretation of the guidelines, not medical advice.

So, with that said, hit that subscribe button and let's dive in!

The video has four parts, inhaled corticosteroids, inhaled beta-agonists, inhaled antimuscarinic agents and combination inhalers. 

Let’s start with inhaled steroids both for asthma and COPD.

What should we consider when initiating inhaled corticosteroids?

We should avoid prescribing generic inhalers to ensure continuity of the device type in future. 

The various inhaled corticosteroids are similar in efficacy and adverse effect profile. However, we need to remember that:

Qvar and Kelhale products have extrafine beclomethasone particles and are twice as potent as other beclometasone inhalers. 

What delivery systems are available for inhaled corticosteroids?

First, we have Pressurized metered-dose inhalers (pMDIs) which use propellant and have an environmental impact.

We also have Spacer devices with pMDIs, which are the preferred option for children under 5

Then we have the Dry powder inhalers (DPIs) which do not use propellant but require enough inspiratory effort to breathe in the powder

We also have the Breath-actuated MDIs (BA-MDIs) which also require sufficient inspiratory effort to activate the device. 

Finally, Nebulizers given as an aerosol that can be inhaled through a mask or mouthpiece. A mouthpiece is preferable to avoid adverse effects caused by exposure to the skin and eyes. 

What contraindications and cautions are associated with inhaled corticosteroids?

There are no contraindications to the use of inhaled corticosteroids and they can be given during pregnancy and breastfeeding.

Cautions are untreated tuberculosis, fungal, bacterial, parasitic, or systemic viral infections, as well as ocular herpes simplex.

What are the effects of inhaled corticosteroids?

Well, they have potent anti-inflammatory activity both the immediate and late phases of asthma.

Inhaled corticosteroids available in the UK include beclometasone, budesonide, ciclesonide, fluticasone, and mometasone.

They are also available as combination inhalers containing long-acting beta-2 agonists.

In asthma, a long-acting bronchodilator should be given in combination with an ICS. In other words, a long-acting bronchodilator should not be normally given in isolation for asthma.

Conversely, in COPD, an ICS should be given in combination with a long-acting bronchodilator, having discussed the risk of adverse effects including an increased risk of pneumonia which may require hospitalization. In other words, an ICS should not be normally given in isolation for COPD.

Local adverse effects include:

Oral candidiasis, sore mouth, dysphonia, and hoarseness, especially in high doses as well as

Paradoxical bronchospasm.

Systemic adverse effects are rare but may occur if high doses are prescribed for prolonged periods.

We will issue a steroid treatment card to:

People using prolonged high doses.

People taking drugs that inhibit steroid metabolism such as antiretroviral HIV drugs

In children, height should be monitored regularly.

And we will use the lowest dose of inhaled corticosteroid (ICS) that maintains effective control of symptoms. 

Which inhaled corticosteroids are available in the UK?

If we want to give Beclometasone dipropionate we can prescribe one of the following brands:

Clenil Modulite MDI

Easyhaler beclometasone

Kelhale MDI

QVAR MDI

QVAR Autohaler

QVAR Easi-Breathe

Soprobec MDI and

Beclu MDI

But we need to be aware that kelhale and Qvar contain beclomethasone extrafine particles and are therefore more potent.

If we want to give budesonide we will prescribe one of the following brands:

Budelin Novolizer

Easyhaler Budesonide and

Pulmicort Turbohaler

If we want to give Ciclesonide we will prescribe: Alvesco MDI

If we want to give Fluticasone we will prescribe Flixotide either the Evohaler MDI or the Accuhaler

And If we want to give Mometasone we will prescribe: Asmanex Twisthaler

What dosing regimens should we consider?

NICE has issued the following guidance on ICS dosages:

A high dose is more than 800 micrograms budesonide or equivalent in adults and more than 400 mcg in children.

A moderate dose is between 400 micrograms and 800 micrograms budesonide or equivalent in adults and between 200mcg and 400 mcg in children

A low dose is 400 micrograms or less of budesonide or equivalent in adults or 200 mcg or less in children.

Examples of dose equivalence are as follows:

Budesonide 200mcg would be equivalent to 200mcg of mometasone and 200 mcg Beclomethasone, but only 100 mcg if we prescribe Beclomethasone extrafine particles.

Equally Budesonide 200mcg would be more or less equivalent to 160 mcg of Ciclesonide or 125 mcg of Fluticasone

Let’s now move on to the section on beta agonists.

By way of introduction, we will say that

Beta-2 agonists — act directly on beta-2 receptors, causing smooth muscle relaxation and dilatation of the airways.

Short-acting beta-2 agonists or SABAs, such as salbutamol and terbutaline, have a rapid onset of action, about 15 minutes and their effects last for up to 4 hours.

Long-acting beta-2 agonists (LABAs) have prolonged receptor occupancy and

Salmeterol and formoterol have a duration of action of 12 hours and

In asthma they should only be used with an ICS.

Indacaterol and olodaterol are once daily LABAs licensed for use in COPD in adults; they are not indicated for the relief of acute bronchospasm.

Vilanterol is available only in combination with fluticasone furoate or/and with the antimuscarinic umeclidinium.

(Cautions)

Beta-2 agonists should be used with caution in people with:

Hyperthyroidism as they may stimulate thyroid activity.

Cardiovascular disease (including hypertension) because of changes to blood pressure and heart rate and an increased risk of arrhythmias especially if there is susceptibility to QT-interval prolongation.

Hypokalaemia, as this may be caused by high doses of beta-2 agonists and

Convulsive disorders.

(Adverse effects)

Adverse effects of short-acting and long-acting beta-2 agonists are similar. They are usually dose related and include:

Nervous system disorders such as tremor, headache, dizziness and seizures.

Cardiac disorders such as palpitations, arrhythmias, peripheral vasodilation and myocardial ischaemia.

Psychiatric disorders such as anxiety, restlessness and insomnia.

Metabolic disorders such as:

Hypokalaemia and

Hyperglycaemia.

Respiratory disorders such as oropharyngeal irritation and paradoxical bronchospasm (which is rare).

Musculoskeletal disorders such as muscle cramps, and

Acute angle-closure glaucoma which has been reported in people using nebulized short-acting beta-2 agonists: using a mouthpiece rather than a mask is preferable to avoid this

We should advise people who are using terbutaline turbohaler to rinse their mouth after each use to minimize systemic absorption.

What drug interactions are important with beta-2 agonists?

Because of the hypokalaemia risk, we should monitor potassium levels with:

Digoxin and

Potassium-depleting drugs like corticosteroids, diuretics, and theophylline

Non-selective B-blocking drugs such as propranolol —and the manufacturer recommends avoid.

And Ketoconazole may increase plasma levels of salmeterol.

Which short-acting beta-2 agonists are available?

Salbutamol is available in the form of:

Airomir autohaler

Airomir MDI

Salamol Easibreathe

Salamol MDI

Ventolin evohaler

Easyhaler salbutamol

Salbulin novolizer

Terbutaline in the form of:

Bricanyl turbohaler              

Which long-acting beta-2 agonists are available?

As we have said before, we can use individual LABA inhalers for COPD.

We have Formoterol:

And Formoterol can be prescribed as:

Atimos modulate

Foradil DPI

Oxis turbohaler

Formoterol Easyhaler.

Then we have Salmeterol:

which can be prescribed as:

Neovent MDI

Serevent evohaler

Serevent accuhaler and

Soltel MDI.

Indacaterol

which can be prescribed as Onbrez Breezhaler

And Olodaterol:

which ca be prescribed as:

Striverdi Respimat

And then we have the combination inhalers, both for asthma and COPD. but we are going to look at them separately in the fourth section of this video.

We are now going to look at the inhaled antimuscarinic agents.

Muscarinic antagonists cause bronchodilation by blocking the bronchoconstrictor effect of acetylcholine on airway smooth muscle.

Ipratropium is a short-acting muscarinic antagonist (or SAMA)

The maximal effect is at 30–60 minutes and

the duration of action is 3–6 hours.

Long-acting muscarinic antagonists (or LAMAs) have a prolonged bronchodilator effect. Examples are:

Tiotropium and also

Aclidinium, glycopyrronium, and umeclidinium.

Which short-acting muscarinic antagonists are available for COPD?

Excluding the preparations for nebulisers

we only have Ipratropium MDI

Which long-acting muscarinic antagonists are available for COPD?

Tiotropium: can be prescribed as:

Spiriva Respimat®

Spiriva® inhalation powder

Acopair inhalation powder,

Tiogiva inhalation powder,

Braltus® inhalation powder,

Aclidinium can be prescribed as:

Eklira inhalation powder

Glycopyrronium can be prescribed as:

Seebri Breezhaler, inhalation powder

And Umeclidinium can be prescribed as:

Incruse Ellipta DPI

When should antimuscarinics be used with caution?

Antimuscarinics should be used with caution in:

Prostatic hyperplasia and bladder-outflow obstruction

Renal impairment

Angle-closure glaucoma especially with nebulizer

And Pregnancy or breastfeeding

Additionally, Tiotropium should be used with caution in people with cardiac arrhythmias, heart failure or myocardial infarction in the previous 6 months because there is an

Increased risk of all-cause mortality following the use of this product.

Lastly, Combination ipratropium with salbutamol is contraindicated in people with hypertrophic obstructive cardio- myopathy or tachyarrhythmia.

What are the adverse effects of antimuscarinics?

The adverse effects of antimuscarinics include:

Cardiac disorders such as arrhythmias and palpitations.

Respiratory disorders such as paradoxical bronchospasm, throat irritation, and cough.

Gastrointestinal disorders such as dry mouth, abnormal taste, nausea, vomiting, constipation and diarrhoea.

ENT disorders such as nasal congestion, dryness of nasal mucosa, and epistaxis.

Nervous system disorders such as headache and dizziness.

Urinary disorders such as bladder outflow obstruction and prostatic hyperplasia.

And Visual disorders including acute angle-closure glaucoma

What drug interactions are important with muscarinic antagonists?

Concurrent use of inhaled antimuscarinics with other antimuscarinic drugs is not recommended as the effects of concurrent use have not been studied.

We now move to look at combination inhalers and

There are three types of combination inhalers

Combination of an ICS with a LABA

which can be used in both asthma and COPD

Combination of three drugs, an ICS, a LAMA and a LABA for use in COPD

Combination of a LAMA and a LABA, that is, without an ICS, for use in COPD

So, What ICS and LABA combination inhalers are available?

We have the following combinations:

Beclometasone and formoterol both as pMDI and DPI: They include

Fostair pMDI

Fostair NEXThaler and

Luforbec pMDI

We need to be aware that Fostair and Luforbec contain extra fine beclomethasone and therefore it is more potent than traditional beclometasone CFC-free inhalers so their dose should be lower.

The combination of Budesonide and formoterol come only as DPI: in the form of

DuoResp Spiromax

Symbicort Turbohaler

Fobumix Easyhaler and

WockAIR DPI

Then we have Fluticasone and formoterol both as pMDI and DPI: in the form of

Flutiform MDI

Flutiform K-haler

The biggest group belong to the Fluticasone and salmeterol combination, both as pMDI and DPI: There are 15 different inhalers such as:

o  Avenor MDI

o  AirFluSal Forspiro 

o  AirFluSal pMDI 

o  Aloflute pMDI 

o  Campona Airmaster

o  Combisal pMDI 

o  Fixkoh Airmaster

o  Fusacomb Easyhaler 

o  Sereflo pMDI 

o  Sereflo Ciphaler

o  Seretide Accuhaler

o  Seretide Evohaler

o  Sirdupla pMDI

Stalpex DPI

Seffalair Spiromax

And on the other extreme, we have just one inhaler for the Fluticasone and vilanterol combination, which is a DPI: which is

Relvar Ellipta

Next question is What ICS, LABA and LAMA combination inhalers are available? And we have 3 groups:

First, we have the Beclomethasone, glycopyrronium and formoterol combination both as pMDI and DPI: and they are

Trimbow pMDI and

Trimbow NEXThaler

Then we have the combination of Budesonide, glycopyrronium and Formoterol as an pMDI: which is

Trixeo MDI

And as the third group, we have Fluticasone, umeclidinium and Vilanterol as a DPI in the form of

Trelegy Ellipta

Finally, What LABA and LAMA combination inhalers are available?

There are four:

Glycopyrronium with formoterol as an MDI in the form of

Bevespi Aerosphere

Glycopyrronium and indacaterol as a DPI in the form of

Ultibro Breezhaler

Then aclidinium with Formoterol as a DPI as

Duaklir

And lastly, tiotropium and olodaterol as an MDI in the form of

Spiolto Respimat

I have checked the NICE guidance and the BNF in order to make this list as exhaustive as possible.

In conclusion, what is important is to know the effect and indications of the different inhaled drugs. Remembering all the different inhaler brands and combinations is tough so it's okay to look them up when you need to saving our brainpower for more important things.

Please keep in mind that this is only a summary and my interpretation of the guidance.

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

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I review the NICE Clinical Knowledge Summaries (CKS) “Osteoporosis - prevention of fragility fractures” looking at both scenarios assessment and management, last updated in April 2023. I have summarised the guidance from a Primary Care perspective.

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 

The summary on Osteoporosis - prevention of fragility fractures can be found here:

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/

The CKS “Osteoporosis - prevention of fragility fractures: Scenario: Assessment” can be found here:

·     https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/management/assessment/

The CKS “Osteoporosis - prevention of fragility fractures: Scenario: Management” can be found here:

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/management/management/

The “Osteoporosis - prevention of fragility fractures: Prescribing information” can be found here:

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/prescribing-information/

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/prescribing-information/calcium-colecalciferol-vitamin-d3-preparations/

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/prescribing-information/bisphosphonates/

To calculate dietary calcium intake, see the National Osteoporosis Foundation chart:

·      https://www.nof.org/patients/treatment/calciumvitamin-d/steps-to-estimate-your-calcium-intake/

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

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Transcript 

Hello everyone and welcome. I am Fernando Florido, a GP in the United Kingdom.

Today, we'll be reviewing the NICE Clinical Knowledge Summaries (CKS) on “Osteoporosis - prevention of fragility fractures” looking at two scenarios, assessment and management, both updated in April 2023. I have summarised the guidance from a Primary Care perspective and I have put links in the episode description.

Please note that this is my interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

If you prefer a video format, there’s also a YouTube version of these episodes. The link is in the episode description.

Please stay until the end, as I'll be sharing fictitious clinical cases created by chat GPT that will illustrate how the guideline is applied in real-life situations.

So, with that said, let's dive in!"

The video has three parts, assessment, management and prescribing information.

• Osteoporosis is characterised by low bone mass and increased bone fragility and it is asymptomatic until a fracture occurs.
• A fragility fracture is a fracture following a fall from standing height or less, typically in the wrist, spine, and hip. Vertebral fractures may occur spontaneously
• Risk factors for osteoporosis include:
• Female sex.
• Increasing age.
• Menopause.
• Oral corticosteroids.
• Smoking and excess alcohol.
• Previous fragility fracture and Parental history of hip fracture
• Inflammatory arthropathies, such as rheumatoid arthritis and
• Body mass index of less than 18.5 kg/m2.