Podcast - NICE News - March 2024
9m | Apr 1, 2024The 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.
