Podcast - NICE News - April 2024
7m | May 7, 2024The 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Final draft guidance on Atogepant for preventing migraine [ID5090] | can be found here: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
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Transcript
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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 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 But, to make up for it, we also have the NICE final draft guidance on atogepant for migraine prophylaxis, which I will cover briefly after the endometriosis update.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.
