- Podcast - NICE News - April 2024
The video version of this podcast can be found here:
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:
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Final draft guidance on Atogepant for preventing migraine [ID5090] | can be found here: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.
7m - May 7, 2024 - Podcast - Hypertensive urgency or emergency? Spot the difference...
The video version of this podcast can be found here:
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:
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
NEJM article: Acute severe hypertension:
· https://www.nejm.org/doi/full/10.1056/NEJMcp1901117
Approach to HTN urgency in primary care setting
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 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.
17m - Apr 28, 2024 - Podcast - 2024 Hypertension update: NICE guideline
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.
13m - Apr 21, 2024 - Podcast - NICE News - March 2024
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:
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:
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.
9m - Apr 1, 2024 - Podcast - Non-visible haematuria: and now, what?!
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:
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:
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:
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 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.
13m - Mar 23, 2024 - Podcast - Understanding abnormal LFTs: the puzzle finally solved
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
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.
16m - Mar 17, 2024 - Podcast - NICE News (with a twist!) - February 2024
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:
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:
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.
13m - Mar 1, 2024 - Podcast - The Art of Interpreting a FBC - turning the nightmare into a sweet dream
The video version of this episode can be found here:
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
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 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.
38m - Feb 26, 2024 - Podcast - NICE News - January 2024
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:
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.
10m - Feb 5, 2024 - Podcast - 2024 Diabetes Update: NICE Guideline with Self-Test MCQs
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.
1h 17m - Jan 31, 2024 - Podcast - Is this the solution to the GLP-1 RA shortage crisis?
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
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. 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.
9m - Jan 10, 2024 - Podcast - NICE News - December 2023
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:
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.
10m - Dec 30, 2023 - Podcast - Management of male LUTS: a NICE perspective
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.
11m - Dec 20, 2023 - Podcast - Insomnia Management According to NICE: Sleep Like a Pro
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.
13m - Dec 13, 2023 - NICE News- November 2023
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:
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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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.
7m - Dec 12, 2023 - Finally cracking the HRT code: NICE on the menopause
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
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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.
15m - Nov 21, 2023 - NICE on the management of headaches: Don't get one thinking about it!
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.
12m - Nov 9, 2023 - Taking Control of Heavy Periods: NICE on Menorrhagia
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.
9m - Nov 1, 2023 - NICE News- October 2023
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:
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.
6m - Oct 27, 2023 - From AI to Reality: Navigating Multimorbidity with NICE Guidelines
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”
- 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
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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.
11m - Oct 17, 2023
