Information for Primary Healthcare workers to understand Diabetes NICE guidance.

https://s3.us-east-2.amazonaws.com/pod-public-media-files/2023/10/17/21/f5adcb85-3b4e-45be-8f26-899d37db74d8_final_podcast_chat_gpt_case_2.mp3

This episode makes reference to guidelines produced by the &#34;National Institute for Health and Clinical Excellence&#34; in the UK, also referred to as &#34;NICE&#34;. 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: <ul><li>The Practical GP YouTube Channel: </li><li><a href="https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk" rel="nofollow">https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk</a></li></ul> The patient was created using the following Chat GPT prompt: A)   Provide a fictitious patient. Details that you should include are: 1)   patient&#39;s medical information including:·      name·      age·      sex·      ethnicity·      BMI·      blood pressure2)   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”<ol><li>Medications given:</li></ol>·      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&#39;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: &#39;What treatment recommendations would you make?&#39; – do not make recommendations yourselfD)  Do not include a disclaimer that the patient is fictitious. The NICE hypertension flowcharts can be found here: <ul><li>Website: <a href="https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517" rel="nofollow">https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517</a> </li><li>Download: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn" rel="nofollow">https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn</a> </li></ul> The full NICE Guideline on hypertension (NG136) can be found here:  <ul><li>Website: <a href="https://www.nice.org.uk/guidance/NG136" rel="nofollow">https://www.nice.org.uk/guidance/NG136</a> </li><li>Download: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus" rel="nofollow">https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus</a> </li></ul> The full NICE Guideline on Type 2 diabetes (NG28) can be found here:  ·      <a href="https://www.nice.org.uk/guidance/ng28" rel="nofollow">https://www.nice.org.uk/guidance/ng28</a>  The full NICE guidance on cardiovascular disease risk reduction (CG181) can be found here: ·      <a href="https://www.nice.org.uk/guidance/cg181" rel="nofollow">https://www.nice.org.uk/guidance/cg181</a> The full NICE guidance on asthma (NG80) can be found here: ·      <a href="https://www.nice.org.uk/guidance/ng80" rel="nofollow">https://www.nice.org.uk/guidance/ng80</a> The full NICE guidance on depression in adults (NG222) can be found here: ·      <a href="https://www.nice.org.uk/guidance/ng222" rel="nofollow">https://www.nice.org.uk/guidance/ng222</a> The full guidance on obesity (CG189) can be found here:·      <a href="https://www.nice.org.uk/guidance/cg189" rel="nofollow">https://www.nice.org.uk/guidance/cg189</a>  Thumbnail photos- From: <a href="https://support.freepik.com/s/article/Attribution-How-when-and-where?language=en_US" rel="nofollow">www.freepik.com</a>·      Image by Freepik: Image by a href=&#34;https://www.freepik.com/free-photo/excited-young-friends-running-beach_9057871.htm#page=2&amp;query=45%20year%20old%20obese%20woman&amp;position=10&amp;from_view=search&amp;track=ais&#34;Freepik/a  Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   <ul><li>Music provided by Audio Library Plus  </li></ul> <ul><li>Watch: <a href="https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU" rel="nofollow">https://youtu.be/aBGk6aJM3IU</a> </li></ul> <ul><li>Free Download / Stream: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU" rel="nofollow">https://alplus.io/halfway-through</a> </li><li> </li><li> </li><li> </li></ul>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.  If you would like to know the Chat GPT prompt that I have used, you can find it in the episode description.  Right, so let’s jump into it. Patient Information:·      Name: Sarah Davis·      Age: 45·      Sex: Female·      Ethnicity: CaucasianExamination:·      BMI: 32 (Obese)·      Blood Pressure: 153/91 mm HgMedical 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 dailyMedication 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&#39;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 and4.   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.

From AI to Reality: Navigating Multimorbidity in diabetes with NICE Guidelines

https://s3.us-east-2.amazonaws.com/pod-public-media-files/2023/7/30/17/f83f197b-3868-47ae-90e5-4f37d5a13623_final_podcast_case_3.mp3

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: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0l3MBwm5sUpEybW8r?e=xio6pz" rel="nofollow">https://1drv.ms/b/s!AiVFJ_Uoigq0l3MBwm5sUpEybW8r?e=xio6pz</a>·      Printer friendly version: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0l3RhABLRM2_pQQOz?e=jzuMxb" rel="nofollow">https://1drv.ms/b/s!AiVFJ_Uoigq0l3RhABLRM2_pQQOz?e=jzuMxb</a>There is a YouTube version of this and other videos that you can access here:·      The NICE GP YouTube Channel: <a href="https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw" rel="nofollow">NICE GP - YouTube</a>Prescribing information links:·      Website: <a href="https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/dpp-4-inhibitors/" rel="nofollow">https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/dpp-4-inhibitors/</a>·      Download PDF: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0liBvuQq8_0Cd-GSz?e=NnL56J" rel="nofollow">https://1drv.ms/b/s!AiVFJ_Uoigq0liBvuQq8_0Cd-GSz?e=NnL56J</a>·      Website: <a href="https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/glp-1-receptor-agonists/" rel="nofollow">https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/glp-1-receptor-agonists/</a>·      Download PDF: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0liFRycIZPaVfj-lC?e=a2QTNY" rel="nofollow">https://1drv.ms/b/s!AiVFJ_Uoigq0liFRycIZPaVfj-lC?e=a2QTNY</a> Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: <a href="https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU" rel="nofollow">https://youtu.be/aBGk6aJM3IU</a> Free Download / Stream: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU" rel="nofollow">https://alplus.io/halfway-through</a>TranscriptHello 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: <ul><li>HbA1c is 68 mmols/mol/8.4% (therefore poorly controlled) </li><li>Cholesterol 5.9 </li><li>Triglycerides 5.72 </li><li>HDL 0.97 </li></ul>·      The path lab has not calculated LDL because triglycerides &gt;4.5 ·      Liver and Renal function tests are normal with an eGFR of 97  <ul><li>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 </li><li>ACR normal </li><li>FBC and other routine blood tests were normal.  </li><li>His BMI is 32, so he is obese </li><li>His BP is 147/89 </li><li>His PMH includes: </li><li>Hypothyroidism </li><li>T2DM </li><li>His regular treatment is with: </li><li>Levothyroxine 200mcg daily </li><li>Metformin 500 mg TDS </li></ul>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&#39;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: <ul><li>they have had a previous episode of DKA </li><li>they are unwell with intercurrent illness </li><li>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.  </li><li> </li><li>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.  </li><li> </li><li>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. </li><li> </li><li>Now let’s have a look at his BP, which is elevated at 147/89. </li><li> </li><li>NICE says that people under the age of 80 should have a BP below 140/90. </li><li> </li><li>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.  </li><li> </li><li>Let’s assume that his BP is indeed above the target. What treatment should we start? </li><li> </li><li>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. </li><li> </li><li>Now let’s look at his lipids and what we would do based on the NICE guideline on prevention of cardiovascular disease. </li></ul>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: <ul><li>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.  </li><li>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. </li></ul>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: <ul><li>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. </li></ul> 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

Real life complex patient: NICE on diabetes, hypertension, hypertriglyceridemia and hypothyroidism

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Chat GPT patient meets NICE: This is what happened!

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My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a new random case to see 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 remember that guidelines are there to be interpreted and applied using your clinical judgement. What I am doing here is sharing with you what my interpretation would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient. There is a YouTube version of this and other videos that you can access here:·      The NICE GP YouTube Channel: <a href="https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw" rel="nofollow">NICE GP - YouTube</a>This podcast also appears in: 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/id1608821148Prescribing information links: ·      Website: <a href="https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/dpp-4-inhibitors/" rel="nofollow">DPP-4 inhibitors | Prescribing information | Diabetes - type 2 | CKS | NICE</a> or·      Download PDF: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0liBvuQq8_0Cd-GSz?e=NnL56J" rel="nofollow">DPP-4 inhibitors- Prescribing information- Diabetes- type 2- NICE.pdf</a>·      Website: <a href="https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/glp-1-receptor-agonists/" rel="nofollow">GLP-1 receptor agonists | Prescribing information | Diabetes - type 2 | CKS | NICE</a> or·      Download PDF: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0liFRycIZPaVfj-lC?e=a2QTNY" rel="nofollow">GLP-1 receptor agonists- Prescribing information- Diabetes- type 2- NICE.pdf</a> Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: <a href="https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU" rel="nofollow">https://youtu.be/aBGk6aJM3IU</a> Free Download / Stream: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU" rel="nofollow">https://alplus.io/halfway-through</a> TranscriptHello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a new random diabetic case to see how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; see the description for full information about this:·     NOT medical advice·     Intended for health care professionals·     Only my interpretation of the guideline·     Use your clinical judgement And as you know, we are focusing only on the pharmacological treatment. Remember that there is also a podcast version of these videos so have a look in the description below. Remember that there is also a Youtube version of these episodes so have a look in the episode description.Right, so let’s generate our random patient. So, we have 45-year-old woman with poorly controlled T2DM with an HbA1c of 60 mmols/mol/7.6%, who has CKD stage 3a with an eGFR of 45 and who is also at high risk of CVD. She is also on triple therapy with Metformin 500 mg BD, Dapagliflozin 10 mg OD and Saxagliptin 2.5mg OD. And finally, she is severely obese with a BMI of 43So, let’s have a look at the guidelines. As usual I will focus on the NICE guidelines but at the end I will tell you what my interpretation would have been following the EASD / ADA consensus guideline.Firstly NICE says that we need to consider if rescue therapy is necessary for symptomatic hyperglycaemia with insulin or a sulfonylurea.And for the clinical presentation we will say that she has no symptoms of diabetes, her obesity is long-standing and being managed with diet, lifestyle advice and bariatric referral. We have excluded other causes of Obesity e.g. hypothyroidism or Cushing’s disease and, because of her age, other causes of CKD such as glomerulonephritis or obstructive nephropathy have also been excluded and she has the diagnosis of diabetic nephropathy.Right, so what are my thoughts? Firstly, that she is relatively young and she already has a degree of diabetic nephropathy. So we should manage her fairly aggressively to try and improve her diabetic control and improve long term outcomes.Secondly, it seems quite clear that her main problem is her weight. She is severely obese and already being managed for that. I am very pleased to see that she is not on any medication that promotes weight gain. Both metformin and SGLT2 inhibitors promote weight loss and DPP4 inhibitors are weight neutral. So Dr Spinning Wheel has done very well indeed.The first step is always metformin which would be helpful for her weight too. So I would be interested to see why she is only on 500mg BD instead of the full dose, double that, 1000mg BD.I would first look if it has been kept at that dose because of safety reasons, for example because of her renal function. You can prescribe metformin 1000 mg BD to anyone with an eGFR of 45 or above. Her eGFR is exactly that, 45. Because of being right on the limit, I would want to be sure and I would look back and see what her previous renal function tests have been. If previously the eGFR has been bumping along the high 40s or 50s that I would definitely increase the dose because the drop to 45 could be just a temporary “blip”, although, of course, we would watch her renal function closely. If on the other hand her previous eGFR readings have been in the high 30s or low 40s, then I would not increase the dose because I would want to see a stable eGFR above 45 before increasing it. If she is suitable for a dose increase, I would also like to look at previous records and see if she has not tolerated higher doses. And if that is the case, I would also want to make sure that she has been managed appropriately. NICE says that metformin should be increased gradually over several weeks to minimise the risk of gastrointestinal side effects. So, if the previous increase in dose was abrupt, I would want to revisit it. Also I would make sure that the patient is counselled and advised that for many patients the side effects are temporary and get better over a number of weeks. So, I would advise her that, if the side effects are not severe, to try and work through them to see if the short term inconvenience of the side effects can translate into a long term therapeutic benefit. And finally, if she has not been able to tolerate it despite these efforts. NICE says that we should consider a trial of modified‑release metformin, so I would offer this to her too. So I am really emphasizing that we should leave no stone unturned before giving up of the benefits of a full dose of metformin, especially in a person with such an obesity problem. So, let’s assume that she is keen and able to increase the dose, so we do that. Would I try to add or increase other medication in this consultation too?Because I want to manage her aggressively and all her medication has a very low risk of hypoglycaemia, I would say yes. True, we may advise her to delay the addition or the increase of other drugs for a few days or weeks to make sure that if side effects develop, we know which medication is the culprit. But as soon as that patient is sure that the increased dose of metformin is not causing any issues, I would add or increase the other medication. I would not want to leave her for, say, 3 months before further action is taken. So as a next step, NICE says that, for patients at high risk of CVD, we need to consider an SGLT2 inhibitor with proven cardiovascular benefit. And she is on the full dose of dapagliflozin, which is one of them. The cardiovascular benefit of SGLT2 inhibitors is a drug class effect so there isn’t necessarily any need to consider other types if there is no concern with the use of dapagliflozin. Dapagliflozin can be initiated as long as the eGFR is above 15 so her eGFR of 45 is not a problem.So, we now look at the third drug, which is a DPP4 inhibitor, saxagliptin 25mg OD. NICE says that for patients who are not controlled with dual therapy with metformin and an SGLT2 inhibitor, we should consider either:u triple therapy, including combinations with either a sulphonylurea or a DPP‑4 inhibitor or, u going directly from dual therapy to starting insulinI am definitely going to exclude insulin and a sulphonylurea at this stage because they can be associated with weight gain, which is the last thing that we want for this patient. As we have seen, DPP4 inhibitors are acceptable and saxagliptin is already prescribed. NICE says that the recommended dose of saxagliptin is 5 mg OD and the patient is only on 2.5mg OD. However, the dose of saxaglitpin has to be reduced to 2.5 mg OD if the eGFR is below 45. So, we are in the same situation as the metformin earlier. If her eGFR has consistently been above 45 you can increase the dose but not otherwise.There are many other considerations when choosing which DPPG4 inhibitor you are going to use and they all have different thresholds for renal impairment, and also other conditions like hepatic impairment, heart failure and for the elderly. So I would encourage you to look at your formulary carefully before making the decision. I will put in the episode description the link for the NICE guidance on DPP4 inhibitor prescribing in case that you are interested. <a href="https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/dpp-4-inhibitors/" rel="nofollow">DPP-4 inhibitors | Prescribing information | Diabetes - type 2 | CKS | NICE</a>It is worth saying that linagliptin is the only DPP4 inhibitor that does not require dose adjustment for renal or hepatic impairment so if there is any doubt, you can always give linagliptin at the full recommended dose of 5 mg OD. So this is my interpretation for this patient following the NICE guidelines:1- increase metformin if at all possible, 2- continue dapagliflozin at the full dose and 3- increase the dose of saxagliptin to 5 mg OD if renal function allows or switch it to linagliptin 5mg OD if there are concernsWhat would I do if I were following the EASD / ADA consensus guideline?Well, I would still try to increase metformin if at all possible and then, because this patient has a high CVD risk, she would be started on a GLP1 receptor agonist for their cardiovascular benefit, independently of the HbA1c level. This would also have the benefit of their added weight loss so that would be great for this patient too. The difference is that NICE is more restrictive when it comes to GLP1 receptor agonists and they would only be considered if the initial suggestion that I said earlier failed to control the patient. You can prescribe all of the GLP1 receptor agonists, as long as the eGFR is above 30, so not a real issue for this patient. I will put in the episode description a link to the guidance for the prescribing of GLP1 agonist so have a look if you are interested.<a href="https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/glp-1-receptor-agonists/" rel="nofollow">GLP-1 receptor agonists | Prescribing information | Diabetes - type 2 | CKS | NICE</a>Acceptable options would be:<ul><li>exenatide</li><li>liraglutide</li><li>lixisenatide</li><li>dulaglutide or</li><li>semaglutide</li></ul>The next step after Metformin and GLP1 receptor agonist according to EASD and ADA is an SGLT2 inhibitor. So my interpretation for this patient following the EASD /ADA guidelines is:1- increase metformin, if at all possible, 2- stop saxagliptin and start a daily preparation of a GLP1 receptor agonist and3- continue dapagliflozin at the full dose We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye

Diabetes guidelines in Practice-clinical case 2

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My name is Fernando Florido and I am a GP in the United Kingdom. With this episode I am starting a new series on Diabetes Guidelines in Practice, looking at how the guidelines could apply to randomly selected clinical cases. By way of disclaimer, remember that guidelines are there to be interpreted and applied using your clinical judgement. What I am doing here is sharing with you what my interpretation would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient. This episode also appears in the Primary Care guidelines podcast: ·      Redcircle: <a href="https://redcircle.com/shows/primary-care-guidelines" rel="nofollow">https://redcircle.com/shows/primary-care-guidelines</a>·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: <a href="https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148" rel="nofollow">https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148</a> There is a YouTube version of this and other videos that you can access here: ·      The NICE GP YouTube Channel: <a href="https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw" rel="nofollow">NICE GP - YouTube</a> Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]Music provided by Audio Library PlusWatch: <a href="https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU" rel="nofollow">https://youtu.be/aBGk6aJM3IU</a>Free Download / Stream: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU" rel="nofollow">https://alplus.io/halfway-through</a> TranscriptHello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.With today’s episode I am starting a new series on Diabetes Guidelines in Practice, looking at how the guidelines could apply to randomly selected clinical cases. By way of disclaimer, remember that guidelines are there to be interpreted and applied using your clinical judgement. I am not giving medical advice here and what I am only doing is sharing with you what my interpretation of the guideline would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient. So, you must always apply your clinical judgement at all times. I will also say that I will only focus on the pharmacological treatment of type 2 diabetes. By all means, we will need to advise about diet, exercise, lifestyle etc, but this will not be addressed in these episodes.Remember that there is also a podcast version of these videos so have a look in the description below.Remember that there is also a Youtube version of these episodes so have a look in the episode description.Right, so let’s get started and let’s generate our random patient. For that we are going to spin a random wheel: Right, so we have an 85-year-old man, newly diagnosed with type 2 diabetes who is poorly controlled with an HbA1c of 65 mmols or 8.1%, who also has heart failure and CKD stage 3b with an eGFR of 32. In addition, he is underweight, even possibly malnourished to some degree. Right, we are going to look at the guidelines and how to apply them. Although I will focus on the NICE guideline, in this case my interpretation and the outcome would be exactly the same if you follow the EASD recommendations or the ADA guideline.So, what does NICE say that we should do? Firstly, we need to consider if rescue therapy is necessary because, for symptomatic hyperglycaemia, we will need to consider insulin or a sulfonylurea and review when blood glucose control has been achieved. So, we are going to assume that he is well and that he has no symptoms of diabetes. He is underweight, but this has been like this for a few years. There hasn’t been rapid weight loss indicating an urgent need for insulin and his urinary ketones are negative. Other causes of unintentional weight loss such as cancer have also been excluded.So, we are just focusing on the diabetes. His HbA1c is high and has not improved with diet and lifestyle advice, so we should do something. However, given his age, we are not going to manage him too aggressively because, at 85, we are probably more concerned about harmful hypoglycaemia. But he does need treatment and certain diabetic agents could also help his co-morbidities. So, next, we must look at his medical history. He has both CKD and heart failure and we know that SGLT2 inhibitors can be beneficial for both these conditions.However, because of the benefits of metformin, NICE says that first, we should consider starting metformin alone to assess tolerability and once this has been confirmed, we could add an SGLT2 inhibitor.Arguments against using metformin at all in this patient are that his eGFR is fairly low and at 32 he is quite close to CKD stage 4.Also, because he is underweight with possible low muscle mass, we need to remember how the estimated GFR is calculated and consider that, as a result of the low muscle mass, his eGFR may be overestimated and that his actual GFR could be below 30. We know that we can use metformin quite normally if the eGFR is above 45, we need to review the dose and prescribe it cautiously if the eGFR is between 30 and 45 and then stop it completely when the eGFR falls below 30.The manufacturer of metformin also advises caution in chronic stable heart failure with the advice to monitor cardiac function closely.We also know that metformin can have potential gastrointestinal side effects and promote weight loss, which we would not want in this patient.And finally, the mode of action of metformin is primarily by reducing insulin resistance. But in an 85-year-old underweight patient, it is more likely that his diabetes is due to insufficient insulin secretion by the ageing pancreas.On the other hand, we also know that metformin has proved to have cardiovascular benefits.So, a controversial decision. You could justify both giving and not giving metformin based on this patient’s individual circumstances.Right, time to decide. What would I do?I would probably err on the side of caution and not give metformin. It can always be introduced later if his weight goes up and his renal and heart failure are stable or improve with other medication.If you really wanted to prescribe metformin, it would be best to start a very cautious introduction, maybe at 500 mg OD and then monitoring this patient very closely. Generally, the maximum accepted dose of metformin for patients with an eGFR between 30 and 45 is 500 mg twice daily but I would be quite nervous about it and I would not increase the dose above 500mg OD for this patient unless the circumstances really changed.So, we are not giving metformin but we still need to prescribe something for this patient. And NICE says that if there is a history of heart failure, we should give an SGLT2 inhibitor with proven cardiovascular benefit. NICE says that the benefits in reduction of hospitalisations for heart failure and cardiovascular mortality can be attributed to SGLT2 inhibitors as a drug class, although at present ertuglifozin has not consistently shown these cardiovascular benefits in clinical trials. So, we are likely to choose either dapaglifozin, canaglifozin or empaglifozin for this patient.Remember that SGLT2 inhibitors are also associated with possible weight loss, so along with this prescription there should be appropriate nutritional advice.We also know that there may be an increased risk of DKA associated with SGLT2 inhibitors so NICE advises us that before prescribing, we should check the patient’s individual 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 <a href="https://www.nice.org.uk/guidance/ng28/chapter/recommendations#very-low-carbohydrate-and-ketogenic-diets" rel="nofollow">very low carbohydrate or ketogenic diet</a>. In particular, I would be very keen to make sure that this patient does not continue to lose weight as this is also likely to put him at greater risk of DKA once the SGLT2 inhibitor is started.Also remember that we will need to check our formulary or BNF if you are in the UK because each drug has its own recommendations and eGFR thresholds for dose reduction, caution or avoid. Acceptable options would be:·     dapaglifozin maybe starting cautiously at 5 mg OD possibly increasing to 10 mg OD if no issues develop.·     canaglifozin starting at 100mg OD, which is the starting dose and also the maximum daily dose for anyone with eGFR &lt;60 or·     empaglifozin starting at 10 mg OD, which is also the starting dose and the maximum daily dose for anyone with eGFR &lt;60So that would probably be my first pharmacological action for this patient, but by no means is necessarily the only or best one.Remember that we need to keep monitoring the patient and consider other treatments as and when the situation changes. We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye

Diabetes guidelines in Practice-case 1

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Cardiovascular health and diabetes

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EASD ADA consensus guidelines on type 2 diabetes

https://s3.us-east-2.amazonaws.com/pod-public-media-files/2022/8/28/17/4720a82c-0340-4d8a-bd99-5f463be54705_2022_diabetes_flowchats_final_podcast.mp3

My name is Fernando Florido and I am a GP in the United Kingdom. In this video I go through the Visual summary “choosing medicines for first-line and further treatment” corresponding to the 2022 updated NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline), updated on 29th June 2022. The video focuses on the drug treatment recommendations in blood glucose management in adults with Type 2 Diabetes.This podcast will be saved on a website.There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:<a href="https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw" rel="nofollow">https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw</a>This podcast also appears in the Primary Care Guidelines podcast which can be found here:·      Redcircle: <a href="https://redcircle.com/shows/primary-care-guidelines" rel="nofollow">https://redcircle.com/shows/primary-care-guidelines</a>·      Spotify: <a href="https://feeds.redcircle.com/2587ad78-7730-48f6-894e-f1f4178e37c3" rel="nofollow">https://feeds.redcircle.com/2587ad78-7730-48f6-894e-f1f4178e37c3</a>·      Apple podcasts: <a href="https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148" rel="nofollow">https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148</a> NICE Guideline NG28 can be found here:<a href="https://www.nice.org.uk/guidance/ng28" rel="nofollow">https://www.nice.org.uk/guidance/ng28</a>  The full NG28 full guideline PDF document can be found here:·      Website:<a href="https://www.nice.org.uk/guidance/ng28/resources/type-2-diabetes-in-adults-management-pdf-1837338615493" rel="nofollow">https://www.nice.org.uk/guidance/ng28/resources/type-2-diabetes-in-adults-management-pdf-1837338615493</a>·      If outside the UK, you can download it here: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0lWqK_tYk1rnOolRO" rel="nofollow">https://1drv.ms/b/s!AiVFJ_Uoigq0lWqK_tYk1rnOolRO</a> The visual summary “choosing medicines for first-line and further treatment” can be found here:·      Website:<a href="https://www.nice.org.uk/guidance/ng28/resources/visual-summary-full-version-choosing-medicines-for-firstline-and-further-treatment-pdf-10956472093" rel="nofollow">https://www.nice.org.uk/guidance/ng28/resources/visual-summary-full-version-choosing-medicines-for-firstline-and-further-treatment-pdf-10956472093</a>·      If outside the UK, you can download it here: <a href="https://1drv.ms/b/s!AiVFJ_Uoigq0lWugUmhgaYv1PHyf" rel="nofollow">https://1drv.ms/b/s!AiVFJ_Uoigq0lWugUmhgaYv1PHyf</a> Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]Music provided by Audio Library PlusWatch: <a href="https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU" rel="nofollow">https://youtu.be/aBGk6aJM3IU</a>Free Download / Stream: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU" rel="nofollow">https://alplus.io/halfway-through</a> TranscriptThank you for listening and welcome to a new episode of this podcast bringing medical information and NICE guidance from a primary care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.Now, imagine that we have Mr. Johnson, who is 78 and has type 2 diabetes. His diabetes control is reasonable or metformin, 500mg BD. With an HbA1c of 7.1% or 54 mmol/mol, but he has just developed stable angina. How should his diabetic treatment change? We have covered the 2022 NICE diabetes management update in previous episodes, but perhaps we need a quick reminder?And this is what we’re going to do today because in this video I am going to go through the flow charts produced by NICE in respect of the blood glucose management in type 2 diabetes. The full guideline has 59 pages in a PDF format and NICE has produced a 5-page summary on the blood glucose management. This video is going to focus on the two flow charts that will advise how to choose first line medicines and how to choose medicines for further treatment.I will put in the description below a link to download the full NICE guideline as well as the five-page summary. There is a YouTube version of this episode and other NICE guidance on the NICE GP YouTube Channel and a link to access it can be found in the podcast description. Because of the visual nature of the flow chart, I would highly recommend watching the YouTube video if you can.Although describing visual aids as audio files can be challenging, I hope that you find the content clear and informative.Now the first flow chart that we are going to look at is the one about how to choose first line medicines. It is only one page and there is a combination of arrows that will guide us through the treatment pathways and a number of boxes with further information and clarification on the treatments described.Right at the top of the chart, we find a box that tells us about rescue therapy and it reminds us that for patients with symptomatic hyperglycaemia, we will consider insulin or a sulphonylurea and then review the treatment when their blood glucose control has been achieved.Then the next step is to assess the HbA1c, the cardiovascular risk and kidney function. Obviously, as you know, to calculate the cardio vascular risk with, for example, the QRISK2 tool, we will need to know the patient’s age, sex, smoking status, blood pressure and the total cholesterol/HDL ratio.Now, having checked the renal function, before starting to follow the pathway, there is a little box on the left telling us that for information on using SGLT 2 inhibitors for people with type 2 diabetes and CKD, there is specific guidance that is not on this flow chart and we will have to refer to CKD section of the diabetic guideline.So, after we have done our initial assessment with the HbA1c, cardiovascular risk and kidney function, the flow chart divides into three categories. One, it could be that the patient is not at high cardiovascular risk. Two, that the patient has chronic heart failure or established atherosclerotic cardio vascular disease. Or three, that the patient has a high risk of cardiovascular disease, which is defined as a QRISK 2 of 10% or higher over ten years, or an elevated lifetime risk.Now, the first pathway would be when the patient is not at high risk of cardio vascular disease and for these patients, we will offer metformin, or, if there are gastrointestinal side effects, we will give Metformin slow release. Now if metformin is contraindicated, we will consider one of the other antidiabetic agents, either a DPP-4 inhibitor, pioglitazone or a sulphonylurea, although it does also tell us that SGLT 2 inhibitors can also be given as monotherapy for some patients. Basically, NICE recommends an SGLT 2 inhibitor as monotherapy in people who can’t take metformin and for whom the diabetic control is poor, and only if a DPP-4 inhibitor would otherwise be prescribed and a sulphonylurea or pioglitazone is not appropriate. So, it is fairly restrictive.We also see a small note saying that using your ertugliflozin to reduce cardiovascular risk when the blood glucose is well controlled was an off-label use.So, if no cardiovascular risk, we give metformin first and if contraindicated one of the other agents, sulphonylurea, pioglitazone, DPPG4 inhibitors of an SGLT2 inhibitor, although the latter with a few restrictions.Now the second pathway would be when the patient has got chronic heart failure or established atherosclerotic cardiovascular disease. And the flow chart tells us in a box what they actually mean by established atherosclerotic cardiovascular disease, and this is fairly intuitive. It includes CHD, acute coronary syndrome, previous MI, stable angina, prior coronary or other revascularisation, cerebrovascular disease, which includes both ischemic stroke and TIAs and finally, peripheral arterial disease. So, for those patients, we will do very similar. We will start with metformin or if there are gastrointestinal side effects, we will give Metformin slow release and then, as soon as metformin tolerability is confirmed, we will offer an SGLT 2 inhibitor with proven cardiovascular benefit. And this is because SGLT 2 inhibitors have now been found to reduce cardio vascular events. However, if metformin is contraindicated, then we will give an SGLT 2 inhibitor alone. So, this is fairly straight forward.Finally, the third option after the initial assessment is that the patient has not got cardiovascular disease but is at high risk of it. In this case, the flow chart is basically fairly similar. We will give metformin or, if there are side effects, metformin slow release and then as soon as metformin tolerability is confirmed we will consider an SGLT 2 inhibitor with proven cardiovascular benefit. And also, if metformin is contraindicated, we will consider an SGLT 2 inhibitor alone.So, you may ask what is the difference between those two, having cardiovascular disease and being at high risk of CVD? And the difference is basically that, if the patient has got cardiovascular disease or heart failure, we will definitely offer an SGLT 2 inhibitor, whereas if a patient is only at high risk of cardiovascular disease, we will consider it. But in practice you will probably find that pathways are exactly the same, because you’re going to consider it seriously and you&#39;re going to give it unless a contraindication or other major consideration. In the middle of the flow chart there’s a little box that reminds us that we always have to start metformin alone to assess tolerability before adding an SGLT 2 inhibitor. So, metformin is always the start.So, this is really the flowchart on how to choose first line medicines. After this, if the person’s HbA1c is not controlled below the target or a person develops cardio vascular disease or a high risk of cardiovascular disease, then we will move to the second flow chart, which is the one about treatment options if further interventions are needed.So, there we go. The second flow chart which is on how to choose medicines for further treatment.Here, at the beginning, there’s another box telling us again about rescue therapy and using insulin, or a sulphonylurea for symptomatic hyperglycaemia until the levels are controlled.Now, if further treatment options are needed, it will be because either at any point the HbA1c is not well controlled, or at any point, the cardio vascular risk or cardiovascular status change.Right, we’re going to start with the cardiovascular risk of cardiovascular status change and we’ve got two options. The first one is that the person has or develops chronic heart failure or established atherosclerotic cardiovascular disease, and the second one is that the person develops a high risk of cardiovascular disease.If the person has or develops chronic heart failure or established atherosclerotic cardiovascular disease, we will basically switch or add treatments to make sure that we offer an SGLT 2 inhibitor if this is not already prescribed. So, if the person develops the condition, we will either add an SGLT 2 inhibitor if the HbA1c could do with lowering further or, if the HBA 1C, is fairly low and we don’t want to lower it any more then we will switch one of the existing drugs for an SGLT 2 inhibitor.On the other hand, if the person has or develops a high risk of cardio vascular disease, then we will consider an SGLT 2 inhibitor when switching or adding treatments. So, like before in the previous flow chart, giving an SGLT2 is slightly more imperative when the person has developed cardiovascular disease, whereas, if the person is just at a high risk, we will only consider it. But again, in practice it may not make much difference.Now, if at any point the HbA1c is not well controlled, there is a box that tells us that we will switch or add treatments from different drug classes up to triple therapy or dual therapy if metformin is contraindicated. So basically, we will consider any combination to dual or triple therapy of the antidiabetic agents, that is, either a DPP 4 inhibitor, pioglitazone or a sulphonylurea, although it also tells us that SGLT 2 inhibitors may also be an option both in dual therapy or triple therapy.Now you may ask when should we start insulin? Well at the bottom left corner we find a box that tells us that, when dual therapy is not enough to control the HbA1c, we can consider insulin-based therapy, with or without other drugs and there is additional guidance on how to use insulin with SGLT 2 inhibitors. So basically, if a patient goes up to dual therapy and is not well controlled, you may consider triple therapy if the patient is on metformin or just consider insulin as the next step.And finally, what is happening to GLP 1 mimetics? Well, this is where NICE has been quite restrictive in their approach because it tells us that if triple therapy with metformin and two other oral drugs is not enough, we will consider triple therapy by switching one drug for a GLP 1 mimetic, but only for people:·      who have a BMI of 35 or higher and specific psychological or other medical problems associated with obesity, although it does say that you can adjust the BMI to lower for people from Black, Asian and other minority ethnic groups, because these groups are at higher risk of cardiovascular disease and GLP mimetics have also been shown to reduce cardiovascular events, or·      we can give it to patients who have a BMI lower than 35 and for whom:o   insulin therapy would have a significant occupational implication oro  weight loss would benefit other significant obesity related comorbidities.Right, so this is it, we have finished our second flow chart and therefore we have come to the end of this episode, I hope that you have found it useful. There is also a YouTube version in the NICE GP YouTube Channel and I will leave a link in the podcast description. Thank you for listening and I hope that you will join me in the next one. Goodbye.

2022 NICE diabetes treatment flowcharts

https://s3.us-east-2.amazonaws.com/pod-public-media-files/2022/6/16/10/e6b7ba77-fcd5-4540-857a-08b75dedfe5b__updated_nice_drug_management_of_blood_glucose.mp3

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the updated NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline), updated on 31st March 2022. The podcast focuses in the new drug treatment recommendations in blood glucose management in adults with Type 2 Diabetes.This podcast will be saved on a website.There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:<a href="https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw" rel="nofollow">https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw</a> This podcast also appears in the Primary Care Guidelines podcast which can be found here:·      Redcircle: <a href="https://redcircle.com/shows/primary-care-guidelines" rel="nofollow">https://redcircle.com/shows/primary-care-guidelines</a>·      Spotify: <a href="https://feeds.redcircle.com/2587ad78-7730-48f6-894e-f1f4178e37c3" rel="nofollow">https://feeds.redcircle.com/2587ad78-7730-48f6-894e-f1f4178e37c3</a>·      Apple podcasts: <a href="https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148" rel="nofollow">https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148</a>NICE Guideline NG28 can be found here: <a href="https://www.nice.org.uk/guidance/ng28" rel="nofollow">https://www.nice.org.uk/guidance/ng28</a>Other links referred to in this episode:  ·      <a href="https://www.nice.org.uk/guidance/ng28/resources/visual-summary-full-version-choosing-medicines-for-firstline-and-further-treatment-pdf-10956472093" rel="nofollow">visual summary to provide an overview of the recommendations and additional information to support medicines choice</a>·      <a href="https://www.nice.org.uk/guidance/ng28/resources/visual-summary-short-version-choosing-medicines-for-firstline-treatment-pdf-10956472094" rel="nofollow">visual summary on first-line drug treatment</a>·      <a href="https://www.nice.org.uk/guidance/cg181/chapter/recommendations" rel="nofollow">recommendations on using risk scores and QRISK2 to assess cardiovascular disease risk in adults with type 2 diabetes in NICE&#39;s guideline on cardiovascular disease: risk assessment and reduction, including lipid modification</a>·      <a href="https://www.nice.org.uk/guidance/ta775" rel="nofollow">NICE&#39;s technology appraisal guidance on dapagliflozin for treating chronic kidney disease</a>·      <a href="https://www.nice.org.uk/guidance/ng28/resources/visual-summary-short-version-choosing-medicines-for-further-treatment-pdf-10956472095" rel="nofollow">visual summary on treatment options if further interventions are needed</a>·      <a href="https://www.nice.org.uk/guidance/ng17/chapter/1-Recommendations#insulin-delivery" rel="nofollow">section on insulin delivery in the NICE guideline on type 1 diabetes</a> Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: <a href="https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU" rel="nofollow">https://youtu.be/aBGk6aJM3IU</a> Free Download / Stream: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU" rel="nofollow">https://alplus.io/halfway-through</a>

2022 updated NICE guideline on Type 2 diabetes in adults

https://s3.us-east-2.amazonaws.com/pod-public-media-files/2021/7/21/9/0377270e-ba97-4223-a950-22f8a91b6bc1_prevention_of_diabetes_final.mp3

<h3>Type 2 diabetes: prevention in people at high risk</h3> Public health guideline [PH38]Published: 12 July 2012 Last updated: 15 September 2017Found at <a href="https://www.nice.org.uk/guidance/ph38" rel="nofollow">https://www.nice.org.uk/guidance/ph38</a>This podcast is intended for Health Care Professionals.My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline PH38: Type 2 diabetes: Prevention in people at high risk. The podcast focuses on the clinical aspects and the administrative or commissioning guidance has been removed from the podcast.This episode is the first of a trial using a computer voice rather than my own. If the trial is successful, it will enable me to produce content more efficiently and I hope that you will find it useful.This podcast will be saved on a website.Intro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fopen.spotify.com%2Ftrack%2F7GGulw&redir_token=QUFFLUhqazNZa2Zlb3FSekk4M3puME5OVEtlRkdOeS10UXxBQ3Jtc0tuTF9wRVFxNFQ5eTJnMThsY3VaMXBLZl96azNxNmd3eFlvYkl1WUVnV1ZBNERYd1RQbGk1Z01uenc1SzNrVUFKSWdsMm9VQ045UkJiTlpYei16RFBrdVJ2allzVWdxRnlRaWlNQm1BODUxY2lJX3gwbw" rel="nofollow">https://open.spotify.com/track/7GGulw</a>​...Stream on Apple Music: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fmusic.apple.com%2Fru%2Falbum%2Fwhen&redir_token=QUFFLUhqbTN5ZGNOcHNKajBDQTl2elFoTGVlV1RVeTNGd3xBQ3Jtc0ttbHRTSHYtd1ExQTMxLUFjODBYTEQ0TmpwTWNNcGxEOGZPSktIR19Ua1l6LWM1ZE55WkVCSHpyMzUxYl94VERaek9Lck91WHV4MWQ4dWh6dTNyckpMS1BvdU9TTDZXY0ZTLWZ6cGp3ZTF3M184eDZOdw" rel="nofollow">https://music.apple.com/ru/album/when</a>​...

Type 2 diabetes: Prevention in people at high risk- NICE guideline PH38

https://s3.us-east-2.amazonaws.com/pod-public-media-files/2021/5/13/22/bfb33b1a-44e3-4f57-9f2f-5e4de1434f12_episode_3_full_guideline.mp3

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline). The podcast covers the full NICE guideline, adding additional information from other clinical guidelines when a reference has been made to them. Links:NICE Guideline NG28 (Type 2 diabetes in adults) can be found here:<a href="https://www.nice.org.uk/guidance/ng28" rel="nofollow">https://www.nice.org.uk/guidance/ng28</a><a href="http://www.gov.uk/drug-safety-update/domperidone-risks-of-cardiac-side-effects" rel="nofollow">MHRA safety advice on the risk of cardiac side effects with domperidone</a><a href="http://www.gov.uk/drug-safety-update/metoclopramide-risk-of-neurological-adverse-effects" rel="nofollow">MHRA safety advice on the risk of neurological adverse effects with metoclopramide</a><a href="http://www.nice.org.uk/advice/esuom13/chapter/Key-points-from-the-evidence" rel="nofollow">evidence summary on oral erythromycin for gastroparesis in adults</a><a href="https://www.nice.org.uk/guidance/cg173" rel="nofollow">NICE guideline on neuropathic pain in adults</a><a href="https://www.nice.org.uk/guidance/ng19" rel="nofollow">NICE guideline on diabetic foot problems</a><a href="https://www.nice.org.uk/guidance/cg182" rel="nofollow">NICE guideline on chronic kidney disease in adults</a>CKD classification according to estimated GFR (eGFR) and albumin:creatinine ratio (ACR) (<a href="http://www.nice.org.uk/guidance/cg182/chapter/key-priorities-for-implementation#table-1-classification-of-chronic-kidney-disease-using-gfr-and-acr-categories" rel="nofollow">table 1</a>)<a href="https://www.nice.org.uk/guidance/cg182/chapter/1-Recommendations#frequency-of-monitoring-2" rel="nofollow">1 Recommendations | Chronic kidney disease in adults: assessment and management | Guidance | NICE</a> Intro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fopen.spotify.com%2Ftrack%2F7GGulw&redir_token=QUFFLUhqazNZa2Zlb3FSekk4M3puME5OVEtlRkdOeS10UXxBQ3Jtc0tuTF9wRVFxNFQ5eTJnMThsY3VaMXBLZl96azNxNmd3eFlvYkl1WUVnV1ZBNERYd1RQbGk1Z01uenc1SzNrVUFKSWdsMm9VQ045UkJiTlpYei16RFBrdVJ2allzVWdxRnlRaWlNQm1BODUxY2lJX3gwbw" rel="nofollow">https://open.spotify.com/track/7GGulw</a>​...Stream on Apple Music: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fmusic.apple.com%2Fru%2Falbum%2Fwhen&redir_token=QUFFLUhqbTN5ZGNOcHNKajBDQTl2elFoTGVlV1RVeTNGd3xBQ3Jtc0ttbHRTSHYtd1ExQTMxLUFjODBYTEQ0TmpwTWNNcGxEOGZPSktIR19Ua1l6LWM1ZE55WkVCSHpyMzUxYl94VERaek9Lck91WHV4MWQ4dWh6dTNyckpMS1BvdU9TTDZXY0ZTLWZ6cGp3ZTF3M184eDZOdw" rel="nofollow">https://music.apple.com/ru/album/when</a>​...

Diabetes in Primary Care UK- Full NICE guideline- Episode 3 of 3

https://s3.us-east-2.amazonaws.com/pod-public-media-files/2021/5/13/10/4589edbd-7e31-419f-9098-0251484533b6_episode_2_full_guideline.mp3

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline). The podcast covers the full NICE guideline, adding additional information from other clinical guidelines when a reference has been made to them. Links:NICE Guideline NG28 (Type 2 diabetes in adults) can be found here:<a href="https://www.nice.org.uk/guidance/ng28" rel="nofollow">https://www.nice.org.uk/guidance/ng28</a><a href="http://www.gov.uk/government/publications/at-a-glance" rel="nofollow">Driver and Vehicle Licensing Agency (DVLA)&#39;s Assessing fitness to drive: a guide for medical professionals</a><a href="https://www.gov.uk/drug-safety-update/pioglitazone-risk-of-bladder-cancer" rel="nofollow">MHRA guidance on the risk of bladder cancer with pioglitazone</a><a href="https://www.nice.org.uk/guidance/ta390" rel="nofollow">NICE&#39;s guidance on canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes</a><a href="https://www.nice.org.uk/guidance/ta315" rel="nofollow">NICE guidance on canagliflozin in combination therapy for treating type 2 diabetes</a><a href="https://www.nice.org.uk/guidance/ta288" rel="nofollow">dapagliflozin in combination therapy for treating type 2 diabetes</a><a href="https://www.nice.org.uk/guidance/ta418" rel="nofollow">dapagliflozin in triple therapy for treating type 2 diabetes</a> <a href="https://www.nice.org.uk/guidance/ta336" rel="nofollow">empagliflozin in combination therapy for treating type 2 diabetes</a><a href="http://www.nice.org.uk/guidance/ng17/chapter/1-Recommendations#insulin-delivery" rel="nofollow">the relevant section in the NICE guideline on type 1 diabetes</a> Intro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fopen.spotify.com%2Ftrack%2F7GGulw&redir_token=QUFFLUhqazNZa2Zlb3FSekk4M3puME5OVEtlRkdOeS10UXxBQ3Jtc0tuTF9wRVFxNFQ5eTJnMThsY3VaMXBLZl96azNxNmd3eFlvYkl1WUVnV1ZBNERYd1RQbGk1Z01uenc1SzNrVUFKSWdsMm9VQ045UkJiTlpYei16RFBrdVJ2allzVWdxRnlRaWlNQm1BODUxY2lJX3gwbw" rel="nofollow">https://open.spotify.com/track/7GGulw</a>​...Stream on Apple Music: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fmusic.apple.com%2Fru%2Falbum%2Fwhen&redir_token=QUFFLUhqbTN5ZGNOcHNKajBDQTl2elFoTGVlV1RVeTNGd3xBQ3Jtc0ttbHRTSHYtd1ExQTMxLUFjODBYTEQ0TmpwTWNNcGxEOGZPSktIR19Ua1l6LWM1ZE55WkVCSHpyMzUxYl94VERaek9Lck91WHV4MWQ4dWh6dTNyckpMS1BvdU9TTDZXY0ZTLWZ6cGp3ZTF3M184eDZOdw" rel="nofollow">https://music.apple.com/ru/album/when</a>​...

Diabetes in Primary Care UK- Full NICE guideline- Episode 2 of 3

https://s3.us-east-2.amazonaws.com/pod-public-media-files/2021/5/12/19/e4a8cb7b-e5f2-4e6a-bce4-9c903e645902_episode_1_full_guideline.mp3

Type 2 diabetes in adults NICE guideline -full guideline- Episode 1 of 3My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline). The podcast covers the full NICE guideline, adding additional information from other clinical guidelines when a reference has been made to them. Links:NICE Guideline NG28 (Type 2 diabetes in adults) can be found here:<a href="https://www.nice.org.uk/guidance/ng28" rel="nofollow">https://www.nice.org.uk/guidance/ng28</a>Hypertension in adults NICE guideline can be found here: <a href="https://www.nice.org.uk/guidance/ng136" rel="nofollow">Overview | Hypertension in adults: diagnosis and management | Guidance | NICE</a>Cardiovascular disease- risk assessment and reduction NICE guideline can be found here: <a href="https://www.nice.org.uk/guidance/cg181" rel="nofollow">Overview | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE</a> Intro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fopen.spotify.com%2Ftrack%2F7GGulw&redir_token=QUFFLUhqazNZa2Zlb3FSekk4M3puME5OVEtlRkdOeS10UXxBQ3Jtc0tuTF9wRVFxNFQ5eTJnMThsY3VaMXBLZl96azNxNmd3eFlvYkl1WUVnV1ZBNERYd1RQbGk1Z01uenc1SzNrVUFKSWdsMm9VQ045UkJiTlpYei16RFBrdVJ2allzVWdxRnlRaWlNQm1BODUxY2lJX3gwbw" rel="nofollow">https://open.spotify.com/track/7GGulw</a>​...Stream on Apple Music: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fmusic.apple.com%2Fru%2Falbum%2Fwhen&redir_token=QUFFLUhqbTN5ZGNOcHNKajBDQTl2elFoTGVlV1RVeTNGd3xBQ3Jtc0ttbHRTSHYtd1ExQTMxLUFjODBYTEQ0TmpwTWNNcGxEOGZPSktIR19Ua1l6LWM1ZE55WkVCSHpyMzUxYl94VERaek9Lck91WHV4MWQ4dWh6dTNyckpMS1BvdU9TTDZXY0ZTLWZ6cGp3ZTF3M184eDZOdw" rel="nofollow">https://music.apple.com/ru/album/when</a>​...

Diabetes in Primary Care UK- Full NICE guideline- Episode 1 of 3

https://s3.us-east-2.amazonaws.com/pod-public-media-files/2021/3/25/15/a2a37161-e578-403c-8bb6-d87fb6c9d0e1_episode_1_diabetes_in_primary_care_intro_music.mp3

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline). The podcast focuses in the non-insulin drug treatment recommendations in blood glucose management in adults with Type 2 Diabetes. NICE Guideline NG28 can be found here:<a href="https://www.nice.org.uk/guidance/ng28" rel="nofollow">https://www.nice.org.uk/guidance/ng28</a> The algorithm for blood glucose lowering therapy in adults with type 2 diabetes can be found here: https://www.nice.org.uk/guidance/ng28/resources/algorithm-for-blood-glucose-lowering-therapy-in-adults-with-type-2-diabetes-pdf-2185604173 Intro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fopen.spotify.com%2Ftrack%2F7GGulw&redir_token=QUFFLUhqazNZa2Zlb3FSekk4M3puME5OVEtlRkdOeS10UXxBQ3Jtc0tuTF9wRVFxNFQ5eTJnMThsY3VaMXBLZl96azNxNmd3eFlvYkl1WUVnV1ZBNERYd1RQbGk1Z01uenc1SzNrVUFKSWdsMm9VQ045UkJiTlpYei16RFBrdVJ2allzVWdxRnlRaWlNQm1BODUxY2lJX3gwbw" rel="nofollow">https://open.spotify.com/track/7GGulw</a>​...Stream on Apple Music: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Fmusic.apple.com%2Fru%2Falbum%2Fwhen&redir_token=QUFFLUhqbTN5ZGNOcHNKajBDQTl2elFoTGVlV1RVeTNGd3xBQ3Jtc0ttbHRTSHYtd1ExQTMxLUFjODBYTEQ0TmpwTWNNcGxEOGZPSktIR19Ua1l6LWM1ZE55WkVCSHpyMzUxYl94VERaek9Lck91WHV4MWQ4dWh6dTNyckpMS1BvdU9TTDZXY0ZTLWZ6cGp3ZTF3M184eDZOdw" rel="nofollow">https://music.apple.com/ru/album/when</a>​...

NICE Guidelines Type 2 diabetes

Diabetes in Primary Care UK- Type 2 diabetes NICE guideline: Non-insulin drug management of glycaemia

Information for Primary Healthcare workers to understand Diabetes NICE guidance.