The video version of this podcast can be found here:

·      https://youtu.be/URcxCjFEFRM

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.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, 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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

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 NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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 looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections.

Today, we are focusing on insulin-based treatment and the management of complications.

In recent episodes, we covered the earlier sections.

Right, let’s jump into it.

First, let’s look at insulin-based treatments.

When we start insulin in adults with type 2 diabetes, we should provide structured education. This education should cover aspects like injection technique, self-monitoring, dose titration, fitness to drive advice, managing hypoglycaemia, and managing acute changes in glucose.

When initiating insulin, we should continue metformin in people already taking it.

We should stop any other medicines used solely to manage hyperglycaemia.

And we should discuss the risks and benefits of continuing medicines that have other benefits, for example cardiovascular protection or weight management.

As initial insulin therapy, we should offer a basal insulin intended for once or twice daily use.

If HbA1c is very high, especially 75 mmol per mol or higher, we should consider starting with basal insulin plus a short or rapid acting insulin. This can be given as separate injections, or as a premixed, biphasic insulin preparation.

When choosing the insulin preparation, we should take into account whether the person needs help with injections, whether there is concern about nocturnal hypoglycaemia, and whether once daily injections would be preferred.

If more than one basal insulin type is equally suitable, we should choose the least expensive option.

We should consider premixed preparations that include insulin analogues rather than human insulin if the person wants to inject immediately before meals, if hypoglycaemia is a problem, or if glucose rises significantly after meals.

At each review, we should check whether someone on basal insulin also needs bolus insulin before meals, or a move to a premixed biphasic regimen.

At each review, if someone is on premixed biphasic insulin and their targets are not met, we should check whether they need to switch to a different premix or move to a basal bolus regimen.

Now let’s move to complications.

At annual review, we should advise adults with type 2 diabetes that they are at higher risk of periodontitis.

We should explain that treating periodontitis can improve blood glucose control and can reduce the risk of hyperglycaemia.

We should advise regular oral health reviews, and if periodontitis is diagnosed, we should offer dental appointments at a frequency based on their needs.

We should think about gastroparesis in adults with erratic blood glucose control or unexplained bloating or vomiting, while considering alternative diagnoses.

If vomiting is caused by gastroparesis, we should explain that there is no strong evidence that antiemetic treatments are effective. Some people may benefit from domperidone, erythromycin, or metoclopramide.

We should be clear that domperidone has specific safety risks, particularly cardiac risk and drug interactions, so we need to prescribe cautiously.

For treatment, we should consider alternating erythromycin and metoclopramide.

We should only consider domperidone in exceptional circumstances, when it is the only effective option, and in line with safety guidance.

If gastroparesis is suspected, we should consider referral to specialist services if the diagnosis is uncertain or vomiting is persistent or severe.

For painful diabetic peripheral neuropathy, we should follow the relevant guideline.

If someone loses their warning signs of hypoglycaemia, we should think about autonomic dysfunction.

We should also consider autonomic involvement of the gut in unexplained nocturnal diarrhoea.

If someone has autonomic neuropathy, we should be aware that orthostatic hypotension is more likely when taking antihypertensive medication.

If someone has unexplained bladder emptying problems, we should investigate possible autonomic neuropathy affecting the bladder.

Management should focus on the symptoms present, for example interventions for abnormal sweating or nocturnal diarrhoea.

For prevention and management of diabetic foot problems, we should follow the diabetic foot problems guideline.

As part of the annual review, we should offer to discuss erectile dysfunction when relevant, including addressing contributory factors such as cardiovascular disease and discussing treatment options.

We should consider a phosphodiesterase 5 inhibitor and initially choose the option with the lowest acquisition cost, taking contraindications into account.

If treatment is unsuccessful, we should refer to services that can offer other medical, surgical, or psychological options.

In terms of eye disease, at diagnosis, we should refer adults immediately to the local eye screening service and encourage regular attendance.

We should arrange emergency ophthalmology review for sudden loss of vision, rubeosis iridis, pre retinal or vitreous haemorrhage, or retinal detachment.

We should refer to ophthalmology in line with diabetic eye screening pathway standards, and follow the diabetic retinopathy guideline.

In this guideline, the recommendations on diagnosing and managing hypertension have been removed. For hypertension in people with type 2 diabetes, we should follow the hypertension in adults guideline, because management is broadly the same as for other people unless specified otherwise.

Finally, we should not offer antiplatelet therapy, such as aspirin or clopidogrel, for people with type 2 diabetes who do not have cardiovascular disease.

For primary and secondary prevention of cardiovascular disease, we should follow the relevant cardiovascular disease and acute coronary syndromes guidelines.

So that is it, a review of a section of the NICE guideline on type 2 diabetes.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/dp6d3yH7AJs

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.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, 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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

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 NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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 looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections.

Today, we are focusing on how to introduce medicines, how to review them, and what to do when further treatment is needed after the initial regimen.

In recent episodes, we covered the earlier sections of the guideline. In future episodes, we will move on to insulin-based treatment in more detail and the management of complications.

Right, let’s jump into it.

First, let’s look at introducing medicines.

We should introduce medicines one at a time and check tolerability and effectiveness before moving on.

When starting initial therapy with modified release metformin and other medicines, we should begin with metformin and confirm it is tolerated.

If we are using an SGLT 2 inhibitor, we should start it once metformin is at the maximum tolerated dose.

If we are also planning to use a GLP 1 receptor agonist or tirzepatide, we should introduce this once the SGLT 2 inhibitor is at the maximum tolerated dose.

So even though the initial plan may involve more than one medicine, we still introduce them sequentially one at a time and monitor carefully.

Now, let’s look at preventing diabetic ketoacidosis with SGLT 2 inhibitors.

Before starting an SGLT 2 inhibitor, we should assess the risk of DKA.

Risk factors include a previous episode of DKA, acute illness, dehydration, or following a very low carbohydrate or ketogenic diet.

We should address modifiable risks before starting treatment. For example, if someone is on a ketogenic diet, we may need to delay the SGLT 2 inhibitor until their diet changes.

We should also advise people that a very low carbohydrate diet increases the risk of DKA while on an SGLT 2 inhibitor. They should speak to a healthcare professional before starting such a diet, and treatment may need to be temporarily suspended.

Next, let’s look at general principles when reviewing treatment.

Before switching or adding medicines, we should optimise the current regimen. That means checking doses, adherence, side effects, and revisiting lifestyle advice.

Now, let’s look at reviewing metformin.

If someone is already taking standard release metformin, we can continue it.

If it is not tolerated, or if the person prefers, we should switch to modified release metformin.

Now, let’s look at reviewing other medicines.

If a person has reached their target, we should consider continuing the medicines that contributed to that success.

We should consider continuing SGLT 2 inhibitors for their cardiovascular or renal benefits, even if HbA1c targets are not fully achieved.

We should stop GLP 1 receptor agonists or tirzepatide if the person becomes underweight, with a BMI below 18.5.

We should also stop them if they are not helping the person reach glycaemic targets and they are not being used for cardiovascular benefit.

We must take into account adverse effects from combinations, such as hypoglycaemia and we should not combine a GLP 1 receptor agonist or tirzepatide with a DPP 4 inhibitor.

Now let’s move on to further medication, group by group.

For people with no relevant comorbidity who need further treatment, we should add a DPP 4 inhibitor.

If this is contraindicated, not tolerated, or not effective, we should add a sulfonylurea, pioglitazone, or insulin-based treatment.

For people with heart failure who need further treatment, we should also add a DPP 4 inhibitor.

If that is not suitable or not effective, we should add a sulfonylurea or insulin-based treatment.

For people with atherosclerotic cardiovascular disease who develop this after initial treatment, we should add subcutaneous semaglutide, up to 1 mg once weekly, for cardiovascular and renal benefit.

If further glycaemic control is needed, we should add a sulfonylurea, pioglitazone, or insulin-based treatment.

For people with early onset type 2 diabetes who need further treatment, we should consider adding a GLP 1 receptor agonist or tirzepatide.

If these are not suitable, we should add a DPP 4 inhibitor.

If that is also not suitable or not effective, we should add a sulfonylurea, pioglitazone, or insulin-based treatment.

If they are already taking a GLP 1 receptor agonist or tirzepatide and still need further control, we should add a sulfonylurea, pioglitazone, or insulin.

For people living with obesity, if weight management is a key issue, we should follow the obesity guidance.

If after at least 3 months of initial therapy further glycaemic control is needed, and they are not already on a GLP 1 receptor agonist or tirzepatide, we should consider adding one.

If these are contraindicated, not tolerated, or ineffective, we should add a DPP 4 inhibitor.

If that is not suitable, we should add a sulfonylurea, pioglitazone, or insulin.

If they are already on a GLP 1 receptor agonist or tirzepatide and still need further control, we should add a sulfonylurea, pioglitazone, or insulin.

For people with chronic kidney disease who need further treatment, we should consider adding a DPP 4 inhibitor.

If they are already on one, or it is not suitable, we should consider adding pioglitazone, or a sulfonylurea if eGFR is above 30, or insulin.

Finally, for people with frailty who need further treatment to control symptoms and reach targets, we should consider adding a DPP 4 inhibitor.

If they are already on one or it is not suitable, we should consider adding pioglitazone, a sulfonylurea, or insulin.

When choosing in frailty, we must remember that sulfonylureas and insulin increase the risk of hypoglycaemia and falls.

So that is it, a review of a section of the NICE guideline on type 2 diabetes.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/-kla7F8yibM

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.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in March 2026 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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

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 February 2026 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2026-03-01&to=2026-03-31&ndt=Guidance&ndt=Quality+standard

The new guideline on Kidney cancer: diagnosis and management [NG256] can be found here:

·      https://www.nice.org.uk/guidance/ng256

The guideline on suspected cancer: recognition and referral can be found here:

·      https://www.nice.org.uk/guidance/ng12/

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. In today’s episode, we’ll look at the NICE updates published in March 2026, focusing on what is relevant in Primary Care only.

This month, none of the updated guidelines were relevant to primary care. Only one new guideline had some relevance: kidney cancer: diagnosis and management.

We will cover this briefly, focusing mainly on diagnosis and referring to the relevant section of the NICE guideline on suspected cancer, recognition and referral.

Right, let’s jump into it.

Before we go into kidney cancer itself, let’s briefly set the scene by looking at the NICE suspected cancer guideline. It is designed to help us recognise when symptoms may represent cancer and when to refer patients urgently.

In urological cancers, we need to be aware that many cancers, including kidney and bladder cancer, may present with relatively non-specific symptoms.

However, one symptom stands out as particularly important: that is, haematuria.

Visible haematuria is the single most important red flag symptom for urological cancers.

NICE recommends that we should make an urgent suspected cancer referral for bladder or renal cancer in adults aged 45 and over with unexplained visible haematuria, either without a urinary tract infection, or if it persists or recurs after treatment of a urinary tract infection.

So, this is an important point. Visible haematuria, especially when unexplained, should always be taken seriously.

At the same time, we should remember that haematuria can also be associated with prostate cancer. NICE advises that we should consider a PSA test and a digital rectal examination in patients with visible haematuria as well as those with lower urinary tract symptoms or erectile dysfunction.

However, prostate cancer assessment follows a separate pathway, so today we will just focus on renal cancer.

Now, what about non-visible haematuria?

This is less specific, but still important in certain groups.

NICE recommends that we should consider an urgent suspected cancer referral in people aged 60 and over with unexplained non visible haematuria if this is associated with symptoms such as dysuria, or abnormal blood results such as a raised white cell count.

So the threshold is higher, but it is still clinically relevant.

However we should note that this relates to suspected bladder cancer rather than kidney cancer, as the urgent criteria for renal cancer are based on visible haematuria.

And while we are here, NICE also advises that we should consider a non urgent referral for bladder cancer, I repeat, a non urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection.

Additionally, the suspected cancer guideline also emphasises safety netting.

If a patient does not meet the referral criteria but symptoms persist or evolve, we should reassess and reconsider referral, always using our clinical judgement alongside the guideline.

Now, with that context in mind, let’s move on to the new kidney cancer guideline itself.

Diagnosing kidney cancer in Primary Care can be challenging. In fact, patients with kidney cancer may present late or with non-specific symptoms which may overlap with other conditions.

So in practice, the diagnosis pathway for kidney cancer in Primary Care relies heavily on the features that trigger referral under the guideline on suspected cancer.

This means that visible haematuria remains central.

In addition, we also need to be aware that kidney cancer may present with more general symptoms, like flank or abdominal pain, weight loss, or fatigue.

However, these are non-specific, and on their own may not meet referral thresholds.

So again, clinical judgement and safety netting are really important.

Another important point is the role of incidental findings.

Some kidney cancers are detected incidentally on imaging performed for other reasons, although, in these cases, the pathway is usually driven by secondary care.

In Primary Care, our role is mainly in recognising the features and making the referral and after that, most of the diagnostic pathway takes place in secondary care. There, once kidney cancer is suspected, the main test used is a CT scan of the abdomen and pelvis, or, if necessary, an MRI scan. On occasions, a contrast-enhanced ultrasound scan can be considered.

So to summarise this section.

Kidney cancer diagnosis in Primary Care is largely based on recognising features that trigger referral under the suspected cancer guideline.

Visible haematuria remains the most important red flag symptom.

Non-visible haematuria can also be relevant for bladder cancer in higher risk groups.

And because symptoms can be vague, safety netting and clinical judgement are essential.

So that is it, a review of the NICE updates relevant to primary care.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/7LiKkriN9tc

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.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, 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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

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 NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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 looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections.

Today, we are focusing on medicines management, including sick day rules and choosing initial medicines.

In recent episodes, we covered the initial sections of the guideline and in future episodes, we will move on to further drug treatment and the management of complications.

Right, let’s jump into it.

When discussing medicines, we should go through the benefits and risks of each option. This includes:

·      The effect on HbA1c and weight.

·      The effect on cardiovascular and renal outcomes.

·      Whether there are contraindications, such as pioglitazone in heart failure or metformin when eGFR is below 30.

·      Practical issues that might affect adherence.

·      And cost. If two medicines from the same class are equally suitable, we should use the least expensive option.

If a person has more than one comorbidity, for example atherosclerotic cardiovascular disease and obesity, we should make a shared decision about which condition to prioritise.

When discussing GLP 1 receptor agonists or tirzepatide we should explain the guidance on use in pregnancy and breastfeeding. We should explain that weight loss may improve fertility and that effective contraception must be used while taking these medicines. And if pregnancy is planned, contraception should continue for a period after stopping treatment.

Now let’s move on to sick day rules.

We should include clear sick day guidance in each person’s individual treatment plan.

Depending on the medicines they are taking, this should cover:

·      Whether medicines need to be adjusted during illness or surgery.

·      Whether medicines such as metformin or SGLT 2 inhibitors should be temporarily stopped if there is a risk of dehydration, vomiting, or diarrhoea.

·      How to adjust insulin doses.

·      And how to restart treatment after recovery.

Before initiating treatment, we should assess cardiovascular and renal status, and the person’s future cardiovascular risk.

If frailty is a concern, we should assess this before starting medicines. Frailty can change the balance between benefits and harms.

Let’s now move on to initial medicines.

This section sets out what we should start at diagnosis, before insulin is needed. The recommendations are grouped by clinical profile.

Let’s go through them one by one.

First, people with no relevant comorbidities.

For them, we should offer dual therapy with modified release metformin and an SGLT 2 inhibitor from the outset.

If metformin is contraindicated or not tolerated, we should offer an SGLT 2 inhibitor alone.

So the default starting point is dual therapy, not metformin alone.

Next, people with heart failure.

For adults with type 2 diabetes and heart failure, regardless of ejection fraction unless otherwise specified, we should again offer modified release metformin and an SGLT 2 inhibitor.

If metformin cannot be used, we should offer an SGLT 2 inhibitor alone.

Now let’s look at people with atherosclerotic cardiovascular disease.

Here, we should offer modified release metformin, an SGLT 2 inhibitor, and subcutaneous semaglutide, up to 1 mg once weekly, for its cardiovascular, renal, and glycaemic benefits.

If metformin is contraindicated or not tolerated, we should offer an SGLT 2 inhibitor plus subcutaneous semaglutide.

So in this group, initial therapy is triple therapy, reflecting the very high cardiovascular risk.

Next, people with early onset type 2 diabetes.

Early onset means diagnosis under the age of 40.

For these adults, we should offer modified release metformin and an SGLT 2 inhibitor, and we should consider adding either a GLP 1 receptor agonist for its cardiovascular, renal, and glycaemic benefits, or tirzepatide for its glycaemic benefits.

If metformin is not suitable, we should offer an SGLT 2 inhibitor and consider adding a GLP 1 receptor agonist or tirzepatide.

This reflects the higher lifetime risk in early onset disease and the need for more intensive early management.

Now, let’s look at people living with obesity.

For adults with type 2 diabetes who are living with obesity, we should offer modified release metformin and an SGLT 2 inhibitor.

If metformin is contraindicated or not tolerated, we should offer an SGLT 2 inhibitor alone.

Obesity itself does not automatically change the initial dual therapy recommendation, but it will influence later choices.

Next, people with chronic kidney disease.

We need to tailor treatment according to eGFR.

If eGFR is above 30, we should offer modified release metformin and an SGLT 2 inhibitor.

If metformin is not suitable, we should offer an SGLT 2 inhibitor alone.

If eGFR is between 20 and 30, we should offer either dapagliflozin or empagliflozin, together with a DPP 4 inhibitor.

If eGFR is below 20, we should consider a DPP 4 inhibitor.

If a DPP 4 inhibitor is contraindicated, not tolerated, or not effective, we should consider pioglitazone or an insulin-based treatment.

So in advanced kidney disease, the pathway shifts away from metformin and SGLT 2 inhibitors, depending on renal function.

Finally, people with frailty.

For adults with type 2 diabetes and frailty, we should offer modified release metformin.

We should only offer an SGLT 2 inhibitor if the person’s level of frailty does not place them at risk of adverse effects, such as volume depletion or hypotension.

If metformin is contraindicated or not tolerated, we should assess frailty carefully.

If frailty does not increase the risk of adverse events, we should consider an SGLT 2 inhibitor alone.

If frailty does increase risk, we should consider a DPP 4 inhibitor instead.

So that is it, a review of a section of the NICE guideline on type 2 diabetes.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/LsB8J96adC0

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.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, 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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

 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 NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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 looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections.

Today, we are focusing on blood glucose management, including HbA1c targets and glucose monitoring.

In the last episode, we covered patient education, dietary advice, and bariatric surgery. In future episodes, we will move on to further drug treatment and the management of complications.

Right, let’s jump into it.

Let’s start with HbA1c measurement and targets.

We should measure HbA1c every 3 to 6 months, tailored to the person, until levels are stable on unchanging therapy. Once HbA1c and treatment are stable, we should measure it every 6 months.

If HbA1c is unreliable, for example because of abnormal haemoglobin or altered red cell turnover, we should use alternative methods. These include quality-controlled plasma glucose profiles, total glycated haemoglobin if abnormal haemoglobins are present, or fructosamine.

If there is a mismatch between HbA1c and other glucose readings, we should investigate and seek specialist advice if needed.

Now let’s talk about targets.

We should agree an individual HbA1c target with each person. This should be a shared decision. We should encourage people to reach and maintain their target, unless doing so causes adverse effects, including hypoglycaemia, or reduces their quality of life.

For people managed with lifestyle alone, or with medicines that do not cause hypoglycaemia, we should support them to aim for an HbA1c of 48 mmol per mol, or 6.5 percent.

For people taking medicines associated with hypoglycaemia, we should support them to aim for 53 mmol per mol, or 7 percent.

If HbA1c rises to 58 mmol per mol, or 7.5 percent or higher, we should reinforce advice about diet, lifestyle and adherence, and intensify treatment, aiming again for 53 mmol per mol or 7 per cent.

We should consider relaxing HbA1c targets on a case-by-case basis. This is particularly important for older or frail adults, people with reduced life expectancy, those at high risk of hypoglycaemia, or those with significant comorbidities.

If someone achieves an HbA1c lower than their agreed target and is not having hypoglycaemia, we should encourage them to maintain it. However, we should remember that a low HbA1c may sometimes be a sign of other issues, such as weight loss or deteriorating kidney function.

Now let’s move to self-monitoring of capillary blood glucose.

We should not routinely offer self-monitoring to everyone with type 2 diabetes.

We should offer it if the person is on insulin, has hypoglycaemic episodes, is taking medicines that increase the risk of hypoglycaemia while driving or operating machinery, or is pregnant or planning pregnancy.

Additionally, we should consider short term self-monitoring when starting corticosteroids, or to confirm suspected hypoglycaemia.

During acute illness, we should review treatment because blood glucose levels can worsen.

If someone is self-monitoring, we should carry out a structured review at least once a year. This should include checking their technique, how often they test, whether they understand the results, the impact on their quality of life, whether it is still beneficial, and the equipment they are using.

Now let’s look at continuous glucose monitoring.

NICE says that we should offer intermittently scanned continuous glucose monitoring, often called flash monitoring, to adults on multiple daily insulin injections if they have recurrent or severe hypoglycaemia, impaired hypoglycaemia awareness, a disability that prevents finger prick testing, or if they would otherwise need to test at least eight times a day.

We should also offer flash monitoring to adults on insulin who would otherwise need help from a care worker or healthcare professional to monitor their glucose.

We should consider real time continuous glucose monitoring instead of flash if it is available at the same or lower cost.

Continuous glucose monitoring should be provided by a team with expertise, and it must be part of a wider self-management plan.

People using continuous glucose monitoring still need to check capillary blood glucose at times. This is to confirm accuracy and as a back up if the device fails or glucose levels are changing quickly. They should be given enough test strips to do this safely.

If someone cannot or does not want to use continuous monitoring, we should offer capillary blood glucose monitoring instead.

We should review the use of continuous monitoring regularly as part of the diabetes care plan. If there are concerns about how it is being used, we should explore any problems and offer further education or support.

Finally, a word on hyperglycaemia.

If an adult with type 2 diabetes develops symptoms of hyperglycaemia, we should consider insulin or a sulfonylurea, and then review treatment once blood glucose returns to target.

So that is it, a review of the first section of the NICE guideline on type 2 diabetes.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/y-hTBUYkInk

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.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the NICE guideline on Type 2 diabetes in adults: management, 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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

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 NICE clinical guideline on Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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 looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The link to the NICE guideline is the episode description.

Right, let’s jump into it.

The diabetes guideline is a comprehensive document, so I am going to break it down into manageable sections.

Today, we will focus on the first part of the NICE guideline, covering tailoring care, structured education, dietary advice, and bariatric surgery.

In future episodes, we will move on to drug treatment and the management of complications.

First, let’s start with tailoring care to the person.

NICE recommends an individualised approach for adults with type 2 diabetes. Care should be tailored to the person’s needs and circumstances. This includes their personal preferences, their other medical conditions, the risks from polypharmacy, and their likelihood of benefiting from long term treatments.

This is especially important for people with multimorbidity. At each review, we should reassess the person’s situation and think about whether any medicines are no longer effective and could be stopped.

When planning care, we should take into account any disabilities, including visual impairment.

For discussions about overweight and obesity, NICE directs us to the guideline on overweight and obesity management, including how to classify overweight and obesity and how to address the drivers behind it. There is also a specific section in the guideline on eating disorders for those who have both type 2 diabetes and an eating disorder, covering advice on collaborative care, blood glucose management, and insulin use.

Next is structured education.

NICE says we should offer structured education to all adults with type 2 diabetes at diagnosis. Family members or carers should also be involved where appropriate. Education should be reinforced and reviewed every year and it should be explained clearly that structured education is a core part of diabetes care.

Education programmes should be evidence based and suitable for the person. They should have clear aims and learning objectives, and support people to develop the knowledge and skills to self-manage their diabetes.

Programmes should follow a structured curriculum, be delivered by trained educators, and outcomes should be regularly monitored.

Group education is the preferred option, but there must be an alternative of equal standard for people who cannot attend or prefer not to take part in group sessions.

Education programmes should meet local cultural, language, cognitive and literacy needs. All members of the diabetes team should know what programmes are available locally, and these programmes should be integrated into the overall care pathway.

Now let’s move on to dietary advice.

Adults with type 2 diabetes should receive individualised and ongoing nutritional advice from a healthcare professional with expertise in nutrition.

Dietary advice should be sensitive to the person’s culture, beliefs, willingness to change, and the impact on quality of life.

In general, people with type 2 diabetes should follow the same healthy eating advice as the general population. This includes choosing high fibre, low glycaemic index carbohydrates such as fruit, vegetables, wholegrains and pulses, choosing low fat dairy products, eating oily fish, and limiting saturated and trans fats.

For low energy or very low energy diets aimed at remission, the guideline directs us to the specific guidance on the NHS Type 2 Diabetes Path to Remission Programme and the overweight and obesity management guideline.

Dietary advice should be integrated into a personalised diabetes management plan, including physical activity and weight management.

Carbohydrate intake, alcohol intake, and meal patterns should be individualised. Reducing the risk of hypoglycaemia is particularly important for people using insulin or insulin secretagogues.

People can substitute a limited amount of sucrose containing foods for other carbohydrates in their meal plan, but they should avoid excess calorie intake.

NICE advises against using foods marketed specifically for people with diabetes.

For people admitted to hospital or another care setting, there should be a meal planning system that provides consistency in carbohydrate content.

Finally, let’s talk about bariatric surgery.

For people with recent onset type 2 diabetes, we should follow the recommendations on surgical interventions in the overweight and obesity management guideline.

This guideline is separate to the diabetes guideline but we will cover it briefly here. It says that we should offer adults a referral for a comprehensive assessment by a specialist multidisciplinary overweight and obesity management service to see whether bariatric surgery is suitable if they have a BMI of 40 or more, or a BMI between 35 and 39.9 with a significant health condition that could improve with weight loss. These conditions include cardiovascular disease, hypertension, fatty liver disease, obstructive sleep apnoea, and type 2 diabetes. The person must also agree to long term follow up after surgery, including lifelong annual reviews.

For people of South Asian, Chinese, other Asian, Middle Eastern, Black African, or African Caribbean background, we should use a BMI threshold that is 2.5 lower than these values, because cardiometabolic risk occurs at lower BMI in these groups.

We should refer for expedited assessment for bariatric surgery to people with a BMI of 30 or more who have recent onset type 2 diabetes, defined as diagnosed within the past 10 years, provided they are also being assessed within a specialist overweight and obesity management service.

For people from South Asian, Chinese, other Asian, Middle Eastern, Black African, or African Caribbean backgrounds, we should use BMI thresholds that are 2.5 lower when deciding on expedited assessment.

So that is it, a review of the first section of the NICE guideline on type 2 diabetes.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/YX_YmP-yRfM

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.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in February 2026 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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

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 February 2026 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2026-02-01&to=2026-02-28&ndt=Guidance&ndt=Quality+standard

The updated guideline on Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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. In today’s episode, we’ll look at the NICE updates published in February 2026, focusing on what is relevant in Primary Care only.

This month there is just one updated guideline relevant to us, but it’s a major one: type 2 diabetes.

A few months ago we reviewed the draft version of the guideline. Now that the final version has been published, over the next few weeks I’ll be creating separate episodes covering the different sections in more depth.

So today, I’ll just give you an overview, highlighting the differences between the draft recommendations and the final version.

Right, let’s jump into it.

Firstly, let’s have a look at the first line treatment in people with no relevant comorbidities.

In the draft guideline, NICE recommended starting metformin plus an SGLT2 inhibitor from the outset, with SGLT2 monotherapy if metformin was not tolerated.

The final guideline confirms this, but now specifies that patients should be started on modified release metformin rather than just metformin.

This change applies throughout the guideline. Wherever standard release metformin was previously recommended, it now says modified release metformin.

Is this the death of the standard release preparation? Possibly in the long term. Anyone starting treatment should be on the modified release version, so numbers on standard release metformin will gradually fall. However, NICE also states that patients already on standard release can continue, or switch if necessary.

Now let’s look at first line treatment in specific clinical groups, starting with heart failure.

In the draft guideline, the recommendation was metformin plus an SGLT2 inhibitor, and it suggested that semaglutide could be added for weight management in selected people with preserved ejection fraction and no frailty.

In the final guideline, it’s still modified release metformin plus an SGLT2 inhibitor, with SGLT2 monotherapy if metformin is not tolerated.

However, for people with heart failure who need further treatment, the guideline moves straight to adding a DPP4 inhibitor first, then a sulfonylurea or insulin if needed. There is no recommendation in this section to add a GLP1 receptor agonist specifically for heart failure.

Next, people with atherosclerotic cardiovascular disease.

The draft guideline recommended early triple therapy with metformin plus an SGLT2 inhibitor plus semaglutide, continuing for cardiorenal benefit even if glycaemic targets were not met.

In the final guideline, this is confirmed but made more specific. Here, we should offer modified release metformin plus an SGLT2 inhibitor plus subcutaneous semaglutide up to 1 milligram once a week for cardiovascular, renal and glycaemic benefits. If metformin is not tolerated, we will use an SGLT2 inhibitor plus semaglutide. It also explicitly recommends starting semaglutide if atherosclerotic cardiovascular disease develops at any stage after initial therapy.

Next is the obesity group.

In the draft guideline, semaglutide was recommended after three months, with additional filters such as preserved ejection fraction and no frailty.

In the final guideline, NICE broadens this. It recommends either a GLP1 receptor agonist or tirzepatide after at least three months of initial therapy if further treatment is needed.

Now let’s look at chronic kidney disease.

There are three eGFR bands here: above 30, 20 to 30, and below 20.

For eGFR above 30, we will use modified release metformin. SGLT2 inhibitors are still prioritised early for kidney and cardiovascular protection, and dapagliflozin and empagliflozin are specifically named because of licensing reasons.

The 20 to 30 eGFR band is where we see a change.

In the draft guideline, if eGFR was between 20 and 30, NICE advised offering dapagliflozin or empagliflozin alone.

In the final guideline, it now says that if eGFR is 20 to 30, we should offer dapagliflozin or empagliflozin plus a DPP4 inhibitor. So, this is now explicit dual therapy rather than SGLT2 monotherapy. The rationale explains why. If the eGFR is below 30, cardiorenal protection of SGLT2 inhibitors remains, but the glucose lowering effect is reduced, so a DPP4 inhibitor is recommended for HbA1c control.

For eGFR below 20, the draft guideline advised using a DPP4 inhibitor first, then considering pioglitazone or insulin, and it stated that sulfonylureas should not be used if eGFR was below 30.

In the final guideline it remains the same, a DPP4 inhibitor first and then pioglitazone or insulin. However, there is no blanket rule about sulfonylureas in the CKD section although we need to know that hypoglycaemia risk increases as renal function falls. .

The draft also recommended not using empagliflozin or dapagliflozin if eGFR was less than 20. The final guideline does not phrase it that way. It simply directs us to DPP4 inhibitors rather than a blanket ban of SGLT2 inhibitors when eGFR is below 20.

And now, the final group is frailty.

The draft guideline recommended metformin alone, effectively deprioritising SGLT2 inhibitors as frailty increases SGLT2 risks.

In the final version, modified release metformin remains first line, but there is no automatic ban of SGLT2 inhibitors at baseline. Instead, the escalation sequence is first a DPP4 inhibitor and then consider pioglitazone, a sulfonylurea or insulin, taking into account hypoglycaemia and falls risk.

Regarding GLP1 receptor agonists and tirzepatide, the draft implied they were generally inappropriate in frailty due to weight loss and gastrointestinal effects.

However, the final guideline is more neutral. It does not specifically recommend them for frailty, but it states there is no inherent safety risk. If another indication exists, they can still be used even in frailty.

Now, let’s look at some other sections of the guideline.

Looking at GLP1 receptor agonists, the draft recommended stopping them if glycaemic or weight goals were not achieved, unless the person had atherosclerotic cardiovascular disease or early onset diabetes.

In the final guideline, NICE recommends stopping GLP1 receptor agonists or tirzepatide if BMI falls below 18.5 or if they do not help with the glycaemic targets as long as they are not being taken for cardiovascular benefit. So, the emphasis shifts from weight thresholds towards glycaemic targets and cardiovascular benefit.

Regarding combining GLP1 receptor agonists and DPP4 inhibitors, both the draft and the final guideline advise against it. The final guideline also extends this to tirzepatide.

In the insulin section, the draft stated that GLP1 receptor agonists could be combined with insulin in Primary Care without specialist approval.

The final guideline does not explicitly restate the specialist approval point. It simply states that when initiating insulin, we should continue metformin, stop other medicines used solely for glycaemic control, and discuss continuing medicines used for cardiovascular protection or weight management.

So that is it, a review of the NICE updates relevant to primary care.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/tdY5bOFmzbg

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.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

This video refers to the clinical guideline by the National Osteoporosis Guideline Group. (details below). 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 review the treatment of osteoporosis, always focusing on what is relevant in Primary Care only. The information is based on the clinical guideline by the National Osteoporosis Guideline Group. The link to it is below.

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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

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 NICE clinical guideline on osteoporosis can be found here:

·      https://www.nice.org.uk/guidance/cg146

The Clinical guideline for the prevention and treatment of osteoporosis by the National Osteoporosis Guideline Group can be found here:

·      https://www.nogg.org.uk/sites/nogg/download/NOGG-Guideline-2024.pdf?v3

The NICE technology appraisal on Bisphosphonates for treating osteoporosis can be found here:

·      https://www.nice.org.uk/guidance/ta464

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 review the treatment of osteoporosis, always focusing on what is relevant in Primary Care only.

I have based this episode on the clinical guideline by the National Osteoporosis Guideline Group. The link to it is the episode description.

Right, let’s jump into it.

We will start by saying that we need a strategy to decide who gets treated, which is what we call “intervention thresholds.”

We need to remember that the NICE guideline on assessing the risk of fragility fracture and Osteoporosis does not itself define fixed treatment thresholds. Instead, we are advised to follow local or national guidance when deciding when to treat. So, for the purpose of this video, I will explain the thresholds given by the National Osteoporosis Guideline Group.

Here the intervention threshold (for people under 70) is set at a fracture risk equivalent to a same-age woman who has already had a fracture. As people age, the threshold for treatment rises, so at the age 70 years and above, fixed thresholds are applied.

When FRAX is calculated we can get a result that shows low risk, intermediate risk, high risk and very high risk of a Major Osteoporotic Fracture.

If the fracture risk is low, we will offer lifestyle advice.

If a person’s calculated risk sits near that intervention threshold, then that is intermediate risk and we should consider a bone mineral density (BMD) measurement with DXA to refine the estimate. If after the bone mineral density result the risk is high, we move forward with treatment otherwise, we will reassess later.

If the fracture risk meets or exceeds the intervention threshold, that person is considered high risk and eligible for treatment.

If the risk is very high, for example if they have multiple risk factors — we may consider referral for more aggressive treatment.

Let’s now focus on the non-drug measures recommended for preventing and managing osteoporosis. They should be recommended for everyone, whether or not we eventually use drugs.

First — diet and nutrition, ensuring adequate calcium intake. Ideally this is achieved through food, but if needed, we can use supplements to reach recommended levels.

We should also make sure vitamin D is addressed. For people at risk of low vitamin D — for example, those with limited sun exposure, people who are housebound, or living in care homes — we should offer vitamin D supplementation.

Next —We should encourage regular weight-bearing and muscle-strengthening exercise, tailored to each person’s ability. This supports bone strength, maintains muscle mass, and helps prevent falls.

Speaking of falls — for those with osteoporosis or fragility fractures, or at risk of fracture, we must assess their fall risk. For patients identified as at risk of falling, we should offer an exercise programme to improve balance and muscle strength.

We must also address lifestyle factors. We should advise smoking cessation in smokers and recommend moderation of alcohol intake.

For all patients we should also screen for and manage other medical conditions that may contribute to bone fragility, such as endocrine problems, malabsorption, chronic illness or immobility.

Now let’s move on to the pharmacological treatment options for osteoporosis, based on the National Osteoporosis Guideline Group recommendations, and the NICE Technology Appraisal on Bisphosphonates for treating osteoporosis

There are several effective drug treatments available, but for most patients, bisphosphonates remain the first-line option. These include oral alendronic acid, risedronate and ibandronate, as well as intravenous zoledronic acid and ibandronate if recommended by a specialist.

How do bisphosphonates work?

Bisphosphonates slow down the rate of bone breakdown by inhibiting osteoclast activity. This helps stabilise bone density and reduces the risk of fractures.

What about risks and how do we minimise them?

Common side effects include gastrointestinal irritation with oral bisphosphonates, and muscle or joint aches. Much rarer risks include atypical femoral fractures and osteonecrosis of the jaw. To minimise these, we ensure correct administration: oral tablets should be taken with a full glass of water on an empty stomach, with the patient remaining upright for at least 30 minutes. We also maintain good dental hygiene, have a dental check-up and complete major dental work before starting treatment where possible, and reassess the need for long-term therapy at appropriate intervals.

Alongside bisphosphonates, denosumab is another established anti-resorptive option. If we use denosumab, we must plan from the start how we will eventually stop or switch treatment, because stopping it abruptly without follow-up therapy can lead to rebound bone loss and an increased risk of vertebral fractures.

For patients at the highest fracture risk, we should seek specialist input. These patients may benefit from anabolic, or bone-forming treatments such as romosozumab, or other anabolic or sequential regimens.

Now let’s look at how we manage osteoporosis treatment over time, that is, the long-term strategy.

First: when we start a drug treatment for osteoporosis — for example a bisphosphonate or denosumab — we need a clear plan for how long that treatment should continue, how we’ll monitor it, and when we’ll reassess risk.

For oral bisphosphonates, we generally treat for at least five years and for intravenous bisphosphonates, at least three years.

In patients at higher risk — for instance people over 70, or those who’ve had hip or vertebral fractures, or patients on high-dose steroids — longer treatment might be needed. Also, if they sustain a further fragility fracture while on treatment, we will also keep going.

In lower-risk patients, after five years of oral bisphosphonates (or three years of IV bisphosphonates), we may consider a treatment pause for 18 to 36 months, depending on individual risk.

Second: we must reassess fracture risk periodically. This means that we should repeat the fracture risk assessment if the patient has a new fracture, regardless of when the treatment started.

If we paused treatment, we should re-assess the fracture risk after 18 months to 3 years — depending on individual circumstances.

Third: some situations require special consideration.

• In people starting long-term glucocorticoids (for example ≥ 7.5 mg prednisolone daily for 3 months or more), we should begin bone-protective therapy immediately — we don’t wait for a DXA scan.
• For patients receiving hormone therapy that impacts bone — for instance androgen-deprivation therapy in men or aromatase inhibitors in women — we should manage fracture risk proactively, often also with bone-protection from the start.

And finally, fourth: after a fragility fracture or in people at high or very high fracture risk, treatment should start promptly, because the risk of re-fracture is often greatest soon after the first event.

So that is it, a review of the treatment of osteoporosis.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/GmCg9TskZNA

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.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

This video refers to a number of medical articles on ADHD published by a number of organisations (details below). 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 any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover ADHD increasing incidence, especially in adults, always focusing on what is relevant in Primary Care only. The information is based on a number of published medical articles. The links to them are below.

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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

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 NICE clinical guideline on osteoporosis can be found here:

·      https://www.nice.org.uk/guidance/cg146

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 looking at the NICE guideline on osteoporosis, specifically how we diagnose it and how we assess the risk of fragility fractures, always focusing on what is relevant in Primary Care only.

The links to the NICE guideline is the episode description.

Right, let’s jump into it.

Let’s start by saying that we should consider assessing fracture risk in all women aged 65 and over, and all men aged 75 and over.

Additionally, we should also consider assessing fracture risk in women under 65 and men under 75 if they have risk factors. Examples of these risk factors include:

• a previous fragility fracture,

• current or frequent recent use of oral or systemic glucocorticoids,

• a history of falls,

• a family history of hip fracture,

• a low BMI, below 18.5,

• smoking,

• drinking more than 14 units of alcohol per week

• and any cause of secondary osteoporosis

Causes of secondary osteoporosis can include endocrine conditions such as hypogonadism in either sex — including untreated premature menopause — and treatment with aromatase inhibitors or androgen-deprivation therapy. They also include hyperthyroidism, hyperparathyroidism, hyperprolactinaemia, Cushing’s disease, and diabetes.

Other causes include gastrointestinal conditions such as coeliac disease, inflammatory bowel disease, chronic liver disease, chronic pancreatitis, and other causes of malabsorption.

Then we have rheumatological conditions like rheumatoid arthritis and other inflammatory arthropathies as well as haematological diseases such as multiple myeloma, and haemoglobinopathies.

And finally we have respiratory conditions like cystic fibrosis and COPD and other conditions like CKD and immobility due to neurological disease or injury.

We should not routinely assess fracture risk in people under the age of 50 unless they have major risk factors — such as current or recent glucocorticoid use, untreated premature menopause, or a previous fragility fracture — because they are unlikely to be at high risk.

Now, how should we actually assess the risk of fracture?

We can use either FRAX — which we can use without a bone mineral density (BMD) value if a DXA scan hasn’t been done — or QFracture, to estimate the ten-year absolute risk. FRAX can be used for people aged 40 to 90, with or without a bone mineral density (BMD) value. QFracture can be used for people aged 30 to 84, but a bone mineral density (BMD) value cannot be added into that tool. If someone is older than the age range covered by these tools, we should assume they are at high risk.

Additionally. we should interpret fracture-risk estimates with caution in people over 80, because a ten-year prediction may underestimate their short-term risk.

We should not routinely measure bone mineral density with a DXA scan before doing a FRAX or QFracture assessment. These tools estimate a ten-year fracture risk using simple clinical information and help us decide whether a scan is actually needed.

Skipping this step can lead to unnecessary DXA scans in people who are clearly low risk. It can also lead to missed scans in those whose risk is borderline, and it is therefore an inefficient use of resources.

We only need to measure bone density when the FRAX or QFracture score is close to the intervention threshold, where a DXA result could change the treatment decision.

So, the NICE guideline recommends using FRAX or QFracture first, and then requesting a DXA scan only if it is likely to influence management. If we do a DXA scan, once we have the bone mineral density result, we should recalculate the absolute risk using FRAX with the bone mineral density value included.

The intervention threshold is the level of risk at which treatment is recommended. The NICE guideline does not define that threshold; instead, we, as clinicians, should follow local protocols or national guidance. I will cover this in a different episode on osteoporosis treatment.

We should also consider measuring BMD before starting treatments that can rapidly reduce bone density, such as sex-hormone deprivation therapy for breast or prostate cancer.

People under 40 should have BMD measured to assess fracture risk only if they have a major risk factor, such as multiple fragility fractures, a major osteoporotic fracture, or current or recent use of high-dose oral or systemic glucocorticoids — meaning more than 7.5 milligrams of prednisolone, or equivalent, per day for three months or longer.

We should consider recalculating fracture risk in the future if the original risk was close to the intervention threshold and only after at least two years, or if the person’s risk factors change. Again, for intervention thresholds we will need to follow local protocols or national guidelines.

We should also remember that risk-assessment tools can underestimate fracture risk in certain situations. This includes people with multiple fractures, previous vertebral fractures, high alcohol intake, high-dose glucocorticoid use, or other causes of secondary osteoporosis.

As mentioned earlier, causes of secondary osteoporosis include endocrine, gastrointestinal, rheumatological, haematological, respiratory, metabolic, renal, and neurological conditions, as well as prolonged immobility.

Finally, we should keep in mind that fracture risk can also be affected by factors not included in the risk tools — for example, living in a care home, or taking drugs that impair bone metabolism, such as anticonvulsants, SSRIs, thiazolidinediones, proton-pump inhibitors, and antiretroviral medications.

So that is it, a review of the NICE guideline on osteoporosis.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/V93jdGfnLIk

This video refers to guidelines produced by a number of organisations (details below). 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 any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do if eosinophilia is found, always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners.

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.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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 

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 of the guidance consulted can be found here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84

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

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 cover what to do when we encounter eosinophilia on a full blood count, always focusing on what is relevant in Primary Care only.

I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description.

Right, let’s jump into it.

Eosinophilia refers to an increased number of eosinophils in the blood. Although thresholds may vary slightly between laboratories, eosinophilia is generally defined as an eosinophil count greater than 0.5 × 10⁹ per litre. Eosinophils are white blood cells involved in allergic responses, parasitic infections, and various inflammatory processes, so an elevated count can indicate a wide range of underlying conditions.

Let’s have a look at some of the possible causes of eosinophilia. They include:

• Asthma: particularly allergic asthma, which commonly has high eosinophil levels because of their role in airway inflammation and hypersensitivity reactions.

• Then we have Skin disease such as eczema, atopic dermatitis, urticaria, and psoriasis: because these conditions involve allergic or immune-mediated inflammation, which often stimulates eosinophils.

• Infections, especially those due to parasites, as well as fungal infections, tuberculosis and malaria. Parasitic infections are a very typical cause, but some fungal and bacterial infections can also trigger eosinophilia through chronic inflammation.

• Another possible cause is Drugs, including penicillin, allopurinol, amitriptyline, and carbamazepine, although virtually any medication can be a possible trigger.

Drug-induced eosinophilia often occurs as part of a hypersensitivity reaction.

• Then we have Connective tissue diseases such as rheumatoid arthritis given that autoimmune and vasculitic conditions can increase eosinophils due to chronic inflammation.

• We also have Solid malignancies, for example breast, renal, stomach, and lung cancer. This is because certain cancers release cytokines that stimulate eosinophil production. In some cases eosinophilia may be a paraneoplastic manifestation.

• Then, Myeloproliferative disorders including leukaemia and lymphoma. Here eosinophilia can happen either because eosinophils are part of the malignant clone or due to cytokine-driven overproduction.

• another cause, Respiratory diseases such as bronchiectasis and cystic fibrosis, again caused by the ongoing inflammatory response.

• Then, Endocrine conditions such as Addison’s disease. This is because cortisol suppresses eosinophils and in Addison’s, the low cortisol will result in a high eosinophil count.

• and finally we have Post-splenectomy. This is because the spleen normally helps regulate and remove eosinophils from circulation, so splenectomy will result in an increased eosinophil count.

If the eosinophil count is greater than 2.5 × 10⁹/L, we will look for signs of organ damage. This is because very high eosinophil levels can lead to direct tissue injury. Activated eosinophils release toxic inflammatory mediators, and cytokines that can cause inflammation and fibrosis in virtually any organ. The heart, lungs, skin, gastrointestinal tract, and nervous system are particularly vulnerable. Damage can progress rapidly and we should consider urgent admission if there are red flags

Red flags include:

• Severe symptoms secondary to organ involvement, such as

• difficulty breathing,

• chest pain,

• abdominal pain, or

• neurological symptoms.

• as well as other complications, including tissue damage, venous thromboembolism, or evidence of end-organ injury such as acute kidney injury or heart failure.

Even in the absence of red flags, criteria for urgent referral to haematology are:

• A leucoerythroblastic blood film, which suggests bone marrow infiltration, haematological malignancy or severe bone marrow stress.

• And absolute eosinophil count greater than 5 × 10⁹/L, as this level significantly increases the risk of hypereosinophilic syndromes and progressive organ damage.

If the urgent criteria are not met and the patient is clinically well, we will check the travel and drug history and assess for any evidence of atopy, such as asthma, eczema, or allergic rhinitis. We will then repeat the blood test within one to two weeks to confirm whether the eosinophilia is persistent and to look for possible underlying causes.

Initial investigations will include:

• As already mentioned, a repeat full blood count, to confirm that the eosinophilia is persistent and to check for other abnormalities which may suggest a bone marrow disorder.

• A blood film, which can reveal abnormal cell morphology, blast cells, or features suggesting reactive versus clonal eosinophilia.

• Inflammatory markers such as ESR and CRP, which help identify underlying infection, inflammation, or autoimmune disease.

• Immunoglobulin E, as a high IgE is common in allergic disease, parasitic infections, and some hypereosinophilic syndromes.

• An autoimmune profile, since eosinophilia can occur in connective tissue diseases and vasculitis.

• Renal and liver function tests, because organ dysfunction can be both a cause and a consequence of eosinophilia.

• A bone profile, as a high calcium may suggest granulomatous disease such as sarcoidosis or certain malignancies. This is because granulomatous conditions and some cancers increase the production of active vitamin D or stimulate bone breakdown, both of which increase calcium levels.

• We will also check for LDH, which can be high in haematological malignancies and in high cell turnover.

• Vitamin B12 and folate, since a raised B12 can be a clue to myeloproliferative disease, while a deficiency can contribute to abnormal blood counts.

• A chest X-ray, particularly if tuberculosis, pulmonary eosinophilia, or sarcoidosis are suspected.

• Stool culture and microscopy for ova, cysts, and parasites, as parasitic infections are a common and important cause of eosinophilia worldwide.

• Serological antibodies for threadworm or other nematode infections, especially if there are suggestive symptoms.

• and finally, Serological antibodies for schistosomiasis, depending on travel history and ideally after discussion with microbiology, as the timing can influence accuracy. Schistosomiasis is a parasitic infection acquired through contact with freshwater in endemic regions in Africa, the Middle East, South America, and parts of Asia, which emphasises why travel history is so important.

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 greater than 1.5 × 10⁹/L for three months or longer, or if it is rising without an obvious cause. These patterns raise concern for hypereosinophilic syndromes or underlying haematological disease.

So that is it, a review of the assessment and management of eosinophilia.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.