Podcast - NICE News (with a twist!) - February 2024
13m | Mar 1, 2024The 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
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· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148
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The Practical GP YouTube Channel:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
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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.
