Primary Care Guidelines

The video version of this episode can be found here:

·      https://youtu.be/qvrWEoYnznw

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I introduce a new approach to video creation using AI, focusing on what is 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 YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The video version of this podcast can be found here:

·      https://youtu.be/iJKpE3H_Lbk

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 the guideline on CKD, NG203, by the National Institute for Health and Care Excellence (NICE), last updated in November 2021, focusing on what is relevant to Primary Care only.

Given how extensive the guidance is, in this episode I will just focus on diagnosis, and classification of CKD.

In the next two episodes, I will cover investigations, monitoring, referral recommendation and CKD management in Primary care.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

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 guideline chronic kidney disease: assessment and management [NG203] can be found here:

·      https://www.nice.org.uk/guidance/ng203

The links to other relevant guidance covered in this episode can be found here:

The link to the non-visible haematuria video is:

·      https://youtu.be/SaizjWg7Fng?si=McvEYQO9O3chElkj

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are doing a review of the NICE guideline on CKD, or NG203, focusing what is relevant to Primary Care only.

Given how extensive the guidance is, in this episode I will just focus on diagnosis, and classification of CKD.

In the next two episodes, I will cover investigations, monitoring, referral recommendation and CKD management in Primary care, so stay tuned for those.

Right, let’s jump into it.

For this review, I have excluded recommendations related to children and young people with CKD. While their management is often similar to that of adults, most children with CKD are managed by secondary care and this is why I am focusing on adults

Let’s review the investigations recommended in CKD. CKD can be classified depending on the levels of renal function and the presence and degree of proteinuria.

So, let’s have a look at renal function first.

To assess kidney function, path labs should report a creatinine-based estimate of glomerular filtration rate, or eGFRcreatinine, alongside the serum creatinine result. For simplicity, from now on, I’ll refer to eGFRcreatinine simply as eGFR.

Because of how eGFR is calculated, eGFR results may be less reliable in certain situations when we should interpret it with caution. Examples are:

·      AKI because of the acute fluctuations in eGFR,

·      in oedematous states, where eGFR could be both over or underestimated depending on the case

·      pregnancy because it is associated with a physiologically increased kidney filtration rate,

·      muscle wasting disorders, amputation and in malnourishment because reduced muscle mass can lead to an overestimated higher eGFR, and

·      those who have higher muscle mass or use protein supplements because, conversely, they can have an underestimated lower eGFR. It is also for this reason, that we should also advise patients not to eat any meat in the 12 hours before having the blood test.

Although eGFR has not been well validated in certain ethnic groups like black, Asian and other minority ethnic groups in the UK, NICE has removed a previous recommendation of adjusting eGFR for specific ethnicities.

Also, because of lack of evidence, NICE no longer recommends measuring eGFRcystatin-c.

Path labs will report eGFR either as 'greater than 90 ml/min/1.73 m2' or as a whole number if it is 90 ml/min/1.73 m2 or less.

If renal function is suspected to be impaired despite an eGFR greater than 90 ml/min/1.73 m², a significant reduction in kidney function can be inferred if serum creatinine increases by more than 20%.

We also need to remember that eGFR becomes less accurate as the true GFR increases so we should interpret eGFR values of 60 ml/min/1.73 m2 or more with caution

If we have an eGFR less than 60 in someone not previously tested, we will confirm it by repeating the test within 2 weeks.

When interpreting changes in eGFR, we will allow for a natural variability of ±5% in serum creatinine levels. This range reflects both the biological fluctuations and the variability of the test in practice.

Let’s now look at investigations for proteinuria.

For the initial detection of proteinuria:

·      We will not use reagent strips unless they are capable of specifically measuring albumin at low concentrations and expressing the result as an albumin:creatinine ratio (or ACR). 

• If sending the urine to the path lab, we will request urine ACR rather than protein:creatinine ratio (or PCR) because of the greater sensitivity for low levels of proteinuria and
• If the ACR is between 3 mg/mmol and 70 mg/mmol, we will confirm it in a subsequent early morning sample. This is because the concentration of protein in the urine can fluctuate throughout the day due to physical activity, posture, and hydration, which makes early morning samples a more consistent and reliable measure. However, a repeat sample is not needed if the initial ACR is 70 mg/mmol or more. 

We will regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria. 

Should we routinely screen for ACR?

Well, we should check urine ACR in the following groups:

• diabetes (either type 1 or type 2)
• eGFR of less than 60 
• eGFR of 60 more if there is a strong suspicion of CKD and
• children and young people with creatinine above the upper limit of normal.

When ACR is 70 mg/mmol or more, PCR can be used as an alternative to ACR. 

Earlier, we mentioned that reagent strips should not be routinely used to test for proteinuria. However, they are routinely used in practice. So, what should we do if we detect proteinuria or non-visible haematuria on the strip? Let’s have a look at these scenarios:

If unexplained proteinuria is an incidental finding on a reagent strip, we will offer testing for CKD using eGFR and ACR. 

Unlike proteinuria, for haematuria we should use reagent strips and we will investigate further for results of 1+ or higher. But we are specifically advised not to use urine microscopy to confirm a positive result as urine microscopy would not detect haemolysed haematuria. 

How do we manage isolated invisible haematuria?

If you haven’t already, I recommend checking the episode on non-visible haematuria on this channel. The link to it is in the episode description. But, in summary, to differentiate persistent non-visible haematuria without proteinuria from transient haematuria, two positive results out of three reagent strip tests are considered confirmation of persistent invisible haematuria.

Persistent invisible haematuria, with or without proteinuria, should prompt investigation for urinary tract malignancy in appropriate age groups.

For persistent non-visible haematuria without proteinuria, annual follow-up is recommended with repeat testing for haematuria, proteinuria, GFR, and blood pressure monitoring as long as the haematuria persists.

Who should be tested for CKD?

We will check eGFR and ACR if there is:

• diabetes
• hypertension
• previous episode of acute kidney injury
• cardiovascular disease
• structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
• multisystem diseases with potential kidney involvement, for example, SLE
• gout
• family history of end-stage renal disease or hereditary kidney disease and
• incidental detection of haematuria or proteinuria. 

Additionally, we will monitor eGFR at least annually in people on medicines that can affect kidney function, for example lithium or long-term chronic use of NSAIDs.

Also, we should monitor people for CKD for at least 3 years after acute kidney injury (or longer for people with acute kidney injury stage 3) even if eGFR has returned to normal.

Once CKD has been detected, we will need to classify it using a combination of GFR and ACR categories.

The ACR categories are A1, A2 and A3 where:

·      A1: is when the ACR less than 3 mg/mmol

·      A2: is when the ACR 3 to 30 mg/mmol and

·      A3: is when the ACR over 30 mg/mmol

The GFR categories are G1 to G5 where:

·      G1: is when the eGFR 90 or over

·      G2: is when the eGFR 60 to 89

·      G3a: is when the eGFR 45 to 59

·      G3b: is when the eGFR 30 to 44

·      G4: is when the eGFR 15 to 29

·      G5: is when the eGFR under 15

Being aware that an increased ACR and decreased eGFR is associated with increased risk of adverse outcomes and that an increased ACR and decreased GFR in combination multiply this risk even further.

So that is it, a review of the diagnosis and classification of CKD.

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/Od1QDebGbBQ

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 December 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

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 December 2024 can be found here:

·     https://www.nice.org.uk/guidance/published?from=2024-12-01&to=2024-12-31&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered in this episode can be found here:

Tirzepatide for managing overweight and obesity:

·      https://www.nice.org.uk/guidance/ta1026

Urinary tract infection (recurrent): antimicrobial prescribing:

·      https://www.nice.org.uk/guidance/ng112

Meningitis (bacterial) and meningococcal disease:

·      https://www.nice.org.uk/guidance/qs19

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in December 2024, focusing on what is relevant in Primary Care only.

In today’s episode, we’re covering two important clinical topics:

• Tirzepatide for managing overweight and obesity, and
• Antimicrobial prescribing for recurrent UTIs.

But before we jump into the details, let’s take a moment to highlight a game-changing development: the new NICE technology appraisal on Tirzepatide.

For many GPs, the surge in patient requests for Ozempic (or semaglutide) to manage obesity has been a challenging situation, especially as NICE does not recommend its use in primary care for this purpose. Could Tirzepatide mark the end of the GP Ozempic nightmare?

Right, let’s find out!

In the technology appraisal assessing Tirzepatide for overweight and obesity NICE has recommended it as an option for adults, alongside diet and exercise only if they have:

• an initial BMI of at least 35 kg/m2 reduced to 32.5 for people from Asian, Chinese, Middle Eastern, and Black African or African-Caribbean ethnic backgrounds. and
• at least 1 weight-related comorbidity. Examples would be, for example, hypertension, dyslipidaemia, obstructive sleep apnoea, cardiovascular disease, prediabetes, and type 2 diabetes.

If less than 5% of the initial weight has been lost after 6 months on the highest tolerated dose, we will need to decide whether to continue treatment, taking into account the benefits and risks of treatment.

The availability of obesity treatments in primary care has been limited, with semaglutide for obesity currently recommended for use in secondary care only. However, this is an exciting development: NICE has now approved the use of tirzepatide in primary care too. Furthermore, indirect comparisons suggest that tirzepatide may be more effective than semaglutide in managing obesity.

While the manufacturer initially proposed a BMI threshold of 30 kg/m² with at least one weight-related comorbidity, NICE has a stricter criterion. For NICE the acceptable threshold for NHS resource use is a BMI of at least 35 kg/m² and at least one weight-related comorbidity.

Let’s talk a bit more about tirzepatide.

Tirzepatide, marketed as Mounjaro, is available as pre-filled pen devices for subcutaneous injection, with doses ranging from 2.5 mg to 15 mg.

It is a once-weekly injection indicated for:

• Type 2 Diabetes and
• Weight Management

What type of drug is Tirzepatide? Well, it is a dual GIP and GLP-1 receptor agonist.

GIP stands for glucose-dependent insulinotropic polypeptide. By activating the GIP receptor, tirzepatide enhances glucose-dependent insulin secretion from pancreatic beta cells, which improves glycaemic control. And it also modulates lipid metabolism.

GLP-1 stands for glucagon-like peptide-1. By activating the GLP-1 receptors, tirzepatide also enhances insulin secretion, but it also inhibits glucagon release, and slows gastric emptying, leading to a more gradual absorption of glucose and reduced postprandial glucose spikes.

Both GIP and GLP-1 pathways work synergistically to influence the central nervous system, suppressing appetite and promoting satiety, leading to weight loss. This combined mechanism offers unique benefits for managing both glycaemic control and obesity.

Is tirzepatide better than semaglutide?

Tirzepatide is considered potentially better than semaglutide in certain contexts.

For example, the dual pathway of tirzepatide allows multiple metabolic pathways, leading to superior outcomes. Clinical trials have demonstrated that tirzepatide leads to greater weight loss compared to semaglutide. Some studies reported reductions of up to 20% of body weight with tirzepatide versus around 15% with semaglutide.

Tirzepatide has also shown superior glycaemic control, achieving greater reductions in HbA1c levels compared to semaglutide in head-to-head studies.

In addition, GIP receptor activation by tirzepatide may have additional benefits on lipid metabolism, such as reducing triglycerides and improving HDL cholesterol. These benefits are less pronounced with semaglutide.

So, bearing this in mind, would we ever choose semaglutide over tirzepatide? Well, although both drugs share common side effects like nausea and vomiting, tolerability varies and some patients may be intolerant to one drug but not the other, so this may have an effect on the choice of treatment too.

Uncommon side effects of tirzepatide include gallbladder disorders and acute pancreatitis. We will discontinue it if there is persistent, severe abdominal pain and, if pancreatitis is confirmed, we will not restart treatment.

In summary, this is indeed a game changer. With Tirzepatide now approved by NICE for use in primary care, we may finally have another clear, accessible option to treat the pressing issue of obesity and overweight in General Practice.

Let’s now briefly touch on the updates on the prevention and management of recurrent UTIs. The changes include new referral recommendations, advice on oestrogen use, new advice on methenamine Hippurate, and choice of medication. Now, let’s have a look at a summary of the main points:

We will refer to secondary care anyone with:

·      recurrent UTI of unknown cause

·      recurrent UTI and suspected cancer

·      recurrent upper UTI

·      recurrent lower UTI in anyone with a male genitourinary system

·      pregnant people

·      children and young people and

·      anyone who has had gender reassignment surgery that involved structural alteration of the urethra. 

We will consider vaginal oestrogen if:

·      the person is experiencing perimenopause or menopause, or they have already experienced menopause, and

·      behavioural or personal hygiene measures alone are not effective

·      At the moment, this is an off-label use of vaginal oestrogen products.

We will also check the NICE guideline on the menopause, which includes advice on the use of vaginal oestrogen if there is a history of breast cancer.

We will review treatment with vaginal oestrogen within 12 months, or earlier if appropriate. 

But we will not offer systemic HRT specifically to reduce the risk of recurrent UTI. 

We will consider methenamine hippurate as an alternative to daily antibiotic prophylaxis for recurrent UTI in anyone with a female urinary system, if:

• they are not pregnant and
• any current UTI has been adequately treated and
• the recurrent UTI has not improved with behavioural and personal hygiene measures, vaginal oestrogen or single-dose antibiotic prophylaxis if appropriate.

When discussing prophylaxis with methenamine hippurate we will explain that:

• over-the-counter sachets that make urine more alkaline (such as sachets used to relieve UTI symptoms that contain potassium citrate or sodium citrate) should not be used while taking methenamine hippurate because these can make it less effective and that
• medical help should be sought for acute UTI symptoms. 

We will review treatment with methenamine hippurate within 6 months, and then every 12 months, or earlier if appropriate. 

But, what is Methenamine Hippurate?

Methenamine hippurate is a prodrug of methenamine, which means it is inactive in its original form but becomes active after metabolism in the body.

How does Methenamine Hippurate Work?

Methenamine is stable in neutral or alkaline conditions, but in acidic urine it is hydrolyzed into formaldehyde and ammonia. Formaldehyde is toxic to bacteria and has therefore antibacterial properties. So, for Methenamine Hippurate to be effective, it is necessary to maintain an acidic urine. This may be achieved naturally, through dietary measures (for example, cranberry juice or vitamin C) or with urinary acidifiers.

Unlike antibiotics, methenamine hippurate does not target specific bacteria but acts broadly against a wide range, therefore reducing the risk of developing antibiotic resistance.

Methenamine hippurate is used as a prophylactic agent rather than as a treatment for acute UTIs. It is especially helpful in recurrent uncomplicated UTIs for those who may want to avoid regular antibiotics.

And finally, let’s now look at the choice of prophylactic options. We can choose between:

• Antiseptic prophylaxis and
• Antibiotic prophylaxis

For antiseptic prophylaxis:

• Methenamine hippurate is recommended for adults.
• And it may be considered for children over the age of 6, but only with specialist advice.

For antibiotic prophylaxis:

• As a first-line option, we will use trimethoprim or nitrofurantoin.
• As a second-line option, we will use amoxicillin or cefalexin.
• The choice of antibiotic should take into account recent culture results and adhere to local antimicrobial policies.

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/jWp08v7niLs

This channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on diagnosing, monitoring, and managing chronic asthma, NG245, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on asthma monitoring, general treatment principles, and asthma management in special groups

If you haven’t already, I recommend checking out the previous three episodes on this subject covering “initial assessment and diagnosis”, “asthma treatment in patients aged 12 and over” and “asthma treatment in children aged 5 to 11, and those under 5”

The new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you’ll find a link to it in the episode description.

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.  

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 link to the new collaborative NICE guideline on chronic asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245

The table on alternative diagnoses in wheezy children in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/diagnosis/alternative-diagnoses-in-wheezy-children/

The table on alternative diagnoses in adults in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

·      https://rightdecisions.scot.nhs.uk/asthma-pathway-bts-nice-sign-sign-244/diagnosis/alternative-diagnoses-in-adults/

The algorithm A for a summary of objective tests for diagnosing asthma in adults and young people (aged over 16 years) with a history suggesting asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/bts-nice-and-sign-algorithm-a-summary-of-objective-tests-for-diagnosing-asthma-pdf-13556516365

The algorithm B for a summary of objective tests for diagnosing asthma in children aged 5 to 16 with a history suggesting asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-b-objective-tests-for-diagnosing-asthma-in-children-aged-5-to-16-with-a-history-pdf-13556516366

The algorithm C for a summary of the pharmacological management of asthma in people aged 12 years and over can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-c-pharmacological-management-of-asthma-in-people-aged-12-years-and-over-bts-nice-pdf-13556516367

The algorithm D for a summary of the pharmacological management of asthma in children aged 5 to 11 years can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-d-pharmacological-management-of-asthma-in-children-aged-5-to-11-years-bts-nice-sign-pdf-13556516368

The algorithm E for a summary of the pharmacological management of asthma in children under 5 can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-e-pharmacological-management-of-asthma-in-children-under-5-bts-nice-sign-pdf-13556516369

The MHRA safety advice on the risk of neuropsychiatric reactions in people taking montelukast can be found here:

·      https://www.gov.uk/drug-safety-update/montelukast-reminder-of-the-risk-of-neuropsychiatric-reactions

The table of inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/inhaled-corticosteroid-doses-for-the-bts-nice-and-sign-asthma-guideline-pdf-13558148029

The NICE guideline on air pollution: outdoor air quality and health can be found here:

·      https://www.nice.org.uk/guidance/ng70

The NICE guideline on indoor air quality at home can be found here:

·      https://www.nice.org.uk/guidance/ng149

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.

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new guideline on diagnosing, monitoring, and managing chronic asthma, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode we’ll just focus on asthma monitoring, general treatment principles, and management in special groups

If you haven’t already, I recommend checking out the previous three episodes on this subject covering “initial assessment and diagnosis”, “asthma treatment in patients aged 12 and over” and “asthma treatment in children aged 5 to 11, and those under 5”

Right, let’s jump into it.

As you know, the new guideline is a joint initiative by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you’ll find a link to it in the episode description.

And in terms of monitoring asthma control we will review:

·      Symptoms, including daytime, night-time and limitation of activities.

• Significant events such as the Number of asthma attacks, any admissions to hospital, attendance at an emergency department due to asthma and time off work or school due to asthma
• Medication use including possible side effects, the amount of reliever inhaler used, including a check of the prescription record and the number of courses of oral corticosteroids and we will finally review their

·      Lung function, normally FEV1 or peak flow reading

Complete control of asthma is defined as no daytime symptoms, no night-time awakening due to asthma, no asthma attacks, no need for rescue medication, no limitations on activity including exercise, normal lung function (in practical terms FEV1 and/or peak flow more than 80% predicted or best), and minimal side effects from treatment.

On the other hand, uncontrolled asthma can be defined as one or both of the following:

• any asthma exacerbation needing treatment with oral corticosteroids and
• frequent regular symptoms such as:
• needing a reliever inhaler 3 or more days per week, or
• having 1 or more nights per week when asthma causes night-time waking.

If control is suboptimal, we will look at the recommendations on pharmacological treatment, which we have covered separately in episodes 2 and 3.

A significant change is that we will not use regular peak flow (PEF) monitoring to assess asthma control unless there are person-specific reasons for doing so (for example, when PEF measurement is part of the personalised asthma action plan). Instead, we will consider using a validated symptom questionnaire at any asthma review. Examples are the Asthma Control Questionnaire, and the Asthma Control Test including its childhood version.

In addition, for adults we will consider fractional exhaled nitric oxide (FeNO) monitoring:

• at their regular review, and
• before and after changing their asthma therapy. 

Let’s remember that a high FeNO level indicates airway inflammation. Therefore, in terms of asthma control, a high FeNO level means that:

1. there is ongoing inflammation in the airways, which can lead to asthma symptoms.
2. That there is a higher risk of asthma exacerbations and finally
3. FeNO testing can also help determine how well inhaled corticosteroids (ICS) are working. If FeNO levels remain high despite treatment, it may indicate that the current treatment needs to be increased.

Now that we have looked at the monitoring of asthma, let’s now look at some general principles of treatment.

And first of all, we need to remember the new golden rule: 

And the main development is the end of what we used to call step 1 treatment, that is, when intermittent short-acting bronchodilators were used alone on a PRN basis. From now on, the golden rule is clear: no prescribing short-acting beta2 agonists (or SABAs) for asthma at any age without an inhaled corticosteroid (ICS).

Next, we need to be aware that the licensed indications of inhalers vary depending on the type of drug, the dose given and the different devices. Not all asthma inhalers are licensed for every recommendation so we should refer to the summary of product characteristics of each individual product.

Also, before starting or adjusting the treatment, we consider possible reasons for uncontrolled asthma. These may include:

• alternative diagnoses or comorbidities
• suboptimal adherence or inhaler technique
• smoking (both active or passive), including vaping and the use of e-cigarettes
• occupational exposures
• psychosocial factors (for example, anxiety and depression) and finally
• we should also consider seasonal and environmental factors (for example, air pollution, and indoor mould exposure). 

If possible, we will check the fractional exhaled nitric oxide (or FeNO) level when asthma is uncontrolled. If it is raised this may indicate poor adherence to treatment or the need for an increased dose of inhaled corticosteroid (ICS). 

After starting or adjusting the asthma treatment, we will review the response after 8 to 12 weeks before considering further changes.

We will base the choice of inhaler on:

• an assessment of correct technique remembering to check it at every asthma-related consultation
• on the patient’s preference
• the lowest environmental impact among suitable devices
• the presence of an integral dose counter and
• A spacer should usually be prescribed for use with a metered dose inhaler, particularly in children.

If possible, we will prescribe the same type of device to deliver preventer and reliever treatments. In addition, when prescribing dry powder inhalers, we will consider providing an additional metered dose short-acting beta2 agonist inhaler (or SABA) with a spacer for emergency use for children under 12 years who may be unable to activate a dry powder inhaler during an acute asthma attack. 

And finally digital inhalers are not recommended for routine use in people with asthma. 

In terms of self-management, we will:

• Offer an asthma self-management personalised action plan. In adults, they may be based on symptoms or peak expiratory flow (or both). However, symptom-based plans are usually preferred for children. We should consider this even in children under 5 with suspected asthma.
• We will review the content of the personalised action plan at every asthma related consultation and
• We will include in the personalised action plan approaches for minimising exposure to air pollution and any other personal triggers. There are separate guidelines in this respect on air pollution and indoor air quality at home and links to them are in the episode description.
• For those aged 17 and over who are using an inhaled corticosteroid (ICS) in a single inhaler, we will offer an increased dose of ICS for 7 days, within a self-management programme, when asthma control deteriorates. We will clearly outline in the action plan how and when to do this, and what to do if symptoms do not improve, including advice on contacting a healthcare professional if necessary.
• When increasing the inhaled corticosteroid treatment, we will:

·      consider quadrupling the regular ICS dose but

·      we will not exceed the maximum licensed daily dose. 

We will also try to identify at risk patients. People who are at risk of poor outcomes include those with:

• non-adherence to treatment
• over-use of SABA inhalers (that is, more than 2 inhalers per year)
• 2 or more courses of oral corticosteroids per year
• 2 or more visits to an emergency department or
• any hospital admission for asthma. 

Let’s now look as specific recommendations for certain groups of patients.

And in pregnant women, we should make sure that asthma is reviewed during early pregnancy and in the postpartum period, offering smoking cessation support if necessary.

During pregnancy we will recommend the normal use of:

• SABAs
• inhaled corticosteroids and
• oral theophyllines. 

If oral corticosteroids during pregnancy are needed to treat exacerbations, we will explain that the benefits of treatment outweigh the risks. 

Also, if leukotriene receptor antagonists or long-acting muscarinic receptor antagonists or LAMAs are needed to achieve asthma control, they should not be stopped during pregnancy. 

And we will prescribe medicines as normal during breastfeeding in line with recommendations in the BNF. 

When managing asthma in adolescents, we will ask about factors that may affect their inhaler use in real life, such as school and social situations. We will also ask about vaping and smoking and offer support to stop if necessary.

Additionally, we will discuss transitioning to adult services and future career choices highlighting occupations that might increase susceptibility to work-related asthma symptoms. 

And let’s end this episode by touching on organisation and delivery of care.

In primary care, people with asthma should be reviewed at least annually and after any exacerbation and the review should incorporate a written personalised action plan. 

And we will take take into account strategies such as, for example:

• structured protocols for asthma reviews
• mailing or emailing of educational resources and
• telephone calls to provide support

So that is it, a review of asthma monitoring, general principes of treatment, and management in special groups

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/4sbHjioaudI

This channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on diagnosing, monitoring, and managing chronic asthma, NG245, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on treating asthma in children aged 5 to 11, and those under 5

If you haven’t already, I recommend checking out the previous two episodes on this subject covering “initial assessment and diagnosis” and the “asthma treatment in patients aged 12 and over”

In the next episode, we will finish the guideline by covering:

• And finally, Asthma monitoring, general treatment principles, and management in special groups

The new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

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.  

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 link to the new collaborative NICE guideline on chronic asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245

The table on alternative diagnoses in wheezy children in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/diagnosis/alternative-diagnoses-in-wheezy-children/

The table on alternative diagnoses in adults in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

·      https://rightdecisions.scot.nhs.uk/asthma-pathway-bts-nice-sign-sign-244/diagnosis/alternative-diagnoses-in-adults/

The algorithm A for a summary of objective tests for diagnosing asthma in adults and young people (aged over 16 years) with a history suggesting asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/bts-nice-and-sign-algorithm-a-summary-of-objective-tests-for-diagnosing-asthma-pdf-13556516365

The algorithm B for a summary of objective tests for diagnosing asthma in children aged 5 to 16 with a history suggesting asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-b-objective-tests-for-diagnosing-asthma-in-children-aged-5-to-16-with-a-history-pdf-13556516366

The algorithm C for a summary of the pharmacological management of asthma in people aged 12 years and over can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-c-pharmacological-management-of-asthma-in-people-aged-12-years-and-over-bts-nice-pdf-13556516367

The algorithm D for a summary of the pharmacological management of asthma in children aged 5 to 11 years can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-d-pharmacological-management-of-asthma-in-children-aged-5-to-11-years-bts-nice-sign-pdf-13556516368

The algorithm E for a summary of the pharmacological management of asthma in children under 5 can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-e-pharmacological-management-of-asthma-in-children-under-5-bts-nice-sign-pdf-13556516369

The MHRA safety advice on the risk of neuropsychiatric reactions in people taking montelukast can be found here:

·      https://www.gov.uk/drug-safety-update/montelukast-reminder-of-the-risk-of-neuropsychiatric-reactions

The table of inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/inhaled-corticosteroid-doses-for-the-bts-nice-and-sign-asthma-guideline-pdf-13558148029

The NICE guideline on air pollution: outdoor air quality and health can be found here:

·      https://www.nice.org.uk/guidance/ng70

The NICE guideline on indoor air quality at home can be found here:

·      https://www.nice.org.uk/guidance/ng149

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.

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new guideline on diagnosing, monitoring, and managing chronic asthma, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode we’ll just focus on treating asthma in children aged 5 to 11, and those under 5

If you haven’t already, I recommend checking out the previous two episodes on this subject covering “initial assessment and diagnosis” and the “asthma treatment in patients aged 12 and over”

In the next episode, we will finish the guideline by covering:

• And finally, Asthma monitoring, general treatment principles, and management in special groups

So, stay tuned for this!

Right, let’s jump into it.

As you probably know, the new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you’ll find a link to it in the episode description.

As we are going to look at the pharmacological management, it is worthwhile remembering that, from a treatment perspective, there are 3 groups of patients:

·      Those aged 12 and over

·      Those aged 5 to 11 and

·      Those aged under 5

NICE has produced summaries of the pharmacological management in the various age groups and a link to them can be found in the episode description.

And today, we are going to focus on the pharmacological management in children so we will start with those aged 5 to 11.

You may be aware that short acting beta 2 agonists or SABAs have disappeared from the management of patients aged 12 and over. But in children under 12, SABAs have certainly a role to play, so let’s have a look at it.

And, as the initial management in children aged 5 to 11 with newly diagnosed asthma, we will offer a twice-daily paediatric low-dose inhaled corticosteroid (ICS), with a short-acting beta2 agonist (or SABA) as needed. 

By the way, for guidance on what paediatric doses of inhaled corticosteroids are considered low, moderate and high, NICE, SIGN and BTS have produced tables showing the various inhaled corticosteroids and their different doses that you can refer to. You can find a link to them in the episode description.

Now, what do we do after this, that is, if asthma is not controlled with this regimen?

In this age group, there are two pathways: a MART pathway and a conventional pathway. Let’s look at the MART pathway first.

Here, we will consider paediatric low-dose MART when asthma is not controlled on paediatric low-dose ICS plus SABA as needed, as long as they are assessed to have the ability to manage a MART regimen. The current evidence supporting the use of MART in children aged 5 to 11 is based on the use of a dry powder inhaler.

Then, if asthma is not controlled on paediatric low-dose MART, we will consider increasing to paediatric moderate-dose MART. That is also straightforward.

Alternatively, the conventional pathway is needed when children are assessed as being unable to manage the MART regimen. Here, we would consider adding a leukotriene receptor antagonist (LTRA) to twice daily paediatric low-dose ICS plus PRN SABA when asthma symptoms are not controlled. We will give the leukotriene receptor antagonist for a trial period of 8 to 12 weeks, then stop it if it is ineffective. And again, we will follow the MHRA advice on the risk of neuropsychiatric reactions in people taking montelukast

Then, if their asthma symptoms are not controlled on a paediatric low-dose ICS plus PRN SABA (with or without a leukotriene receptor antagonist depending on previous response), we will offer a twice daily paediatric low-dose ICS/LABA combination inhaler plus PRN SABA.

Then, if their asthma symptoms are not controlled on paediatric low-dose ICS/LABA plus PRN SABA, we will offer a twice daily paediatric moderate-dose ICS/LABA inhaler plus PRN SABA (again, with or without a leukotriene receptor antagonist depending on previous response). 

In summary, the conventional pathway recommends that we try both a leukotriene receptor antagonist and a LABA before increasing the inhaled corticosteroid to a moderate dose. In other words, the only time that we will prescribe a moderate dose inhaled corticosteroid to children aged 5 to 11 will be alongside a LABA, either with or without a leukotriene receptor antagonist depending on the case.

But how do we decide whether to use a MART regimen or a conventional pathway?

We need to start by saying that the guideline specifically supports the use of the MART regimen for children under 12 unless assessed as being unable to manage it. This is to address concerns that younger children may have difficulty understanding the MART regimen, which can lead to confusion about when to take the inhaler for maintenance versus symptom relief. This may lead to confusion between maintenance and reliever doses, potentially leading to inconsistent dosing and both overuse or underuse of the inhaler.

But, how do we make this assessment?

Well, the decision to use MART should be based on factors like:

·      The child’s ability to understand the regimen and use the inhaler correctly.

·      The risk of overuse or underuse and

·      The overall safety and suitability for the individual child.

Why do we mention safety? Well, we need to be aware that most of the robust studies on MART have been conducted in adults or adolescents (that is, 12 years and older) and there is limited evidence to support the safety and effectiveness of MART for children under 12. And there is also licensing reality because, at the time of publishing this guideline and releasing this episode, no asthma inhalers were licensed for MART in children under 12, so this use would be off-label. Although off-label prescribing is permissible in the UK when it's based on sound clinical judgement and informed consent, this approach requires careful consideration and clear communication with parents or guardians and we would have to be comfortable with it.

Despite these considerations and in one sentence, the take-home message is that NICE recommends MART for children under 12, provided they are deemed suitable using our clinical judgement.

And regardless of the pathway that we have chosen, if their asthma is not controlled on paediatric moderate-dose MART or paediatric moderate-dose ICS/LABA maintenance treatment (with or without a leukotriene receptor antagonists), we will refer them to a specialist. In other words, we will not prescribe high doses of inhaled corticosteroids to children aged 5 to 11 without seeking specialist advice first.

Let’s now look at the pharmacological management in children under 5

And these recommendations are for children under 5 with both newly suspected or confirmed asthma, or with asthma symptoms that are uncontrolled on their current treatment.

So, if there are:

• symptoms that indicate the need for maintenance therapy (for example, interval symptoms in children with another atopic disorder), or if there are
• severe acute episodes of difficulty breathing and wheeze (for example, requiring hospital admission, or needing 2 or more courses of oral corticosteroids) 

Then the first step is to consider an 8 to12 week trial of twice-daily paediatric low-dose inhaled corticosteroid (ICS) as maintenance therapy (with a short-acting beta2 agonist [or SABA] for reliever therapy).

If symptoms do not resolve during the trial period, we will check:

• the inhaler technique and adherence to treatment
• possible environmental sources of their symptoms (for example mould in the home, cold housing, smokers or indoor air pollution) and
• we will check possible alternative diagnosis.
• 
  
• 
  

And if we cannot explain the poor response to treatment, we will refer to a specialist. This means that we will not increase the inhaled corticosteroid to a moderate dose if there has not been a good initial response to a low dose first.

However, if symptoms are resolved, we will consider stopping treatment after 8 to 12 weeks and then review the symptoms after a further 3 months. 

Then, if symptoms resolve during the trial period, but then:

• symptoms recur by the 3-month review, or
• the child has an acute episode requiring systemic corticosteroids or hospitalisation, we will restart regular inhaler corticosteroids, beginning at a paediatric low dose but here we will be able to titrate up to a paediatric moderate dose if needed, also with a SABA when needed. When symptoms settle, we will consider a further trial without treatment after reviewing the child within 12 months. 

If symptoms are not controlled on a paediatric moderate dose of an inhaled corticosteroids as maintenance (with SABA as needed), we will consider a leukotriene receptor antagonist (LTRA) in addition to the inhaled corticosteroids. We will give the leukotriene receptor antagonist for a trial period of 8 to 12 weeks, and we will then stop it if it is ineffective. 

If symptoms remain uncontrolled on a paediatric moderate dose of inhaled corticosteroids as maintenance and a trial of a leukotriene receptor antagonist has been unsuccessful or not tolerated, we will stop the leukotriene receptor antagonist and refer the child to a specialist for further investigation and management. 

On the other hand, if asthma symptoms are completely controlled and we may want to consider decreasing maintenance therapy.

In this case, at annual review, we will discuss the risks and benefits of decreasing their maintenance therapy and we will update their asthma action plan and arrange self-monitoring and follow up. 

When decreasing maintenance therapy, we will:

• Stop or reduce the dose of medicines in an order that takes into account the clinical effectiveness when they were first introduced, as well as their side effects and the patient’s preference.
• We will allow at least 8 to 12 weeks before considering a further treatment reduction and
• If we are considering step-down treatment for people aged 12 and over on a low-dose maintenance inhaled corticosteroid (ICS) plus a SABA as needed or a low-dose MART, we will step down to on demand AIR therapy with a low-dose ICS/formoterol combination inhaler

So that is it, a review of the treatment of asthma in patients aged under 12.

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/Mef3NziRsME

This channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on diagnosing, monitoring, and managing chronic asthma, NG245, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on treating asthma in patients aged 12 and over.

If you haven’t already, I recommend checking out the previous episode on initial assessment and diagnosis.

In the next two episodes, I will finish the guideline by covering:

·      Treating asthma in children aged 5 to 11, and those under 5

·      Asthma monitoring, general treatment principles, and management in special groups

The new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

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.  

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 link to the new collaborative NICE guideline on chronic asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245

The table on alternative diagnoses in wheezy children in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/diagnosis/alternative-diagnoses-in-wheezy-children/

The table on alternative diagnoses in adults in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

·      https://rightdecisions.scot.nhs.uk/asthma-pathway-bts-nice-sign-sign-244/diagnosis/alternative-diagnoses-in-adults/

The algorithm A for a summary of objective tests for diagnosing asthma in adults and young people (aged over 16 years) with a history suggesting asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/bts-nice-and-sign-algorithm-a-summary-of-objective-tests-for-diagnosing-asthma-pdf-13556516365

The algorithm B for a summary of objective tests for diagnosing asthma in children aged 5 to 16 with a history suggesting asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-b-objective-tests-for-diagnosing-asthma-in-children-aged-5-to-16-with-a-history-pdf-13556516366

The algorithm C for a summary of the pharmacological management of asthma in people aged 12 years and over can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-c-pharmacological-management-of-asthma-in-people-aged-12-years-and-over-bts-nice-pdf-13556516367

The algorithm D for a summary of the pharmacological management of asthma in children aged 5 to 11 years can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-d-pharmacological-management-of-asthma-in-children-aged-5-to-11-years-bts-nice-sign-pdf-13556516368

The algorithm E for a summary of the pharmacological management of asthma in children under 5 can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-e-pharmacological-management-of-asthma-in-children-under-5-bts-nice-sign-pdf-13556516369

The MHRA safety advice on the risk of neuropsychiatric reactions in people taking montelukast can be found here:

·      https://www.gov.uk/drug-safety-update/montelukast-reminder-of-the-risk-of-neuropsychiatric-reactions

The table of inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/inhaled-corticosteroid-doses-for-the-bts-nice-and-sign-asthma-guideline-pdf-13558148029

The NICE guideline on air pollution: outdoor air quality and health can be found here:

·      https://www.nice.org.uk/guidance/ng70

The NICE guideline on indoor air quality at home can be found here:

·      https://www.nice.org.uk/guidance/ng149

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.

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new guideline on diagnosing, monitoring, and managing chronic asthma, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode we’ll just focus on treating asthma in patients aged 12 and over.

If you haven’t already, I recommend checking out the previous episode on initial assessment and diagnosis.

In the next two episodes, we will finish the guideline by covering:

·      Treating asthma in children aged 5 to 11, and those under 5

·      And then, Asthma monitoring, general treatment principles, and management in special groups

So, stay tuned for those!

Right, let’s jump into it.

And let’s remember that the new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you’ll find a link to the new guideline in the episode description.

Before we start, we need to be aware that from a treatment perspective, there are 3 groups of patients:

·      Those aged 12 and over

·      Those aged 5 to 11 and

·      Those aged under 5

NICE has produced summaries of pharmacological management in the various age groups and a link to them can be found in the episode description.

And today we are going to focus on the pharmacological management in people aged 12 and over.

And we are going to look at two areas: the management of newly diagnosed asthma and how to transfer existing asthma patients from the previous guideline to the new one.

Let’s start with newly diagnosed asthma.

As the initial management, we will offer a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief. This is what is called as-needed AIR therapy.

So, what is air therapy?

It stands for Anti-inflammatory Reliever therapy, where formoterol is used as a reliever in an inhaler that also contains an anti-inflammatory corticosteroid. While many of us are familiar with the MART regimen (that is, Maintenance and Reliever Therapy), AIR therapy is different: it involves using a formoterol/corticosteroid inhaler only in response to symptoms, without regular maintenance dosing. Currently, only specific budesonide/formoterol inhalers are licensed for this, with a low-dose budesonide/formoterol combination recommended as on-demand AIR therapy. The use of any other ICS/formoterol inhalers would therefore be off-label.

If the patient presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation, we will start treatment with low-dose MART (maintenance and reliever therapy) instead, in addition to treating the acute symptoms as necessary (for example, a course of oral corticosteroids if needed). We will then consider stepping down to as-needed AIR therapy using a low-dose ICS/formoterol inhaler at a later date if their asthma is controlled. 

By the way, for guidance on what doses of inhaled corticosteroids are considered low, moderate and high, NICE, SIGN and BTS have produced tables showing the various inhaled corticosteroids and their different doses that you can refer to. You can find a link to them in the episode description.

And what comes after the initial on demand AIR therapy?

(do not read: Medicine combination and sequencing in people aged 12 and over)

Well, if symptoms are not controlled on a low-dose ICS/formoterol combination inhaler used as on demand AIR therapy, we will offer low-dose MART.

And let’s remember that MART or maintenance and reliever therapy is when a single inhaler containing ICS and formoterol is used for daily maintenance therapy and the relief of symptoms as needed. The terms low-dose MART and moderate-dose MART refer to the dosage of the maintenance component of MART. People using MART do not normally need a SABA.

And obviously, if symptoms are not controlled on low-dose MART, we will offer moderate-dose MART instead.

For those whose asthma is not controlled on moderate-dose MART despite good adherence:

• We will check the fractional exhaled nitric oxide (or FeNO) level if available, and the blood eosinophil count. If either of these is raised, we will refer to secondary care.
• If neither FeNO or eosinophil count is raised, we will consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (or LAMA) used in addition to moderate-dose MART. We will give them for a trial period of 8 to 12 weeks and, at the end of the trial:
• if asthma is controlled, we will continue the treatment
• if control has improved but is still inadequate, we will continue the treatment and start a trial of the other medicine (either leukotriene receptor antagonist or LAMA depending on what was given first)
• However, if control has not improved, we will stop the first drug that we chose, either the leukotriene receptor antagonist or LAMA and then start a trial of the alternative medicine.
• 
  
• 
  

When prescribing leukotriene receptor antagonists, we should be aware of the MHRA safety advice on the risk of neuropsychiatric reactions in people taking montelukast, including children and adolescents. Reported neuropsychiatric reactions include sleep disorders, hallucinations, anxiety and depression, as well as changes in behaviour and mood. We should advise patients to be alert to these risks and report any concerns.

If asthma is not controlled despite treatment with moderate-dose MART, and trials of a leukotriene receptor antagonist and a LAMA, we will refer to a specialist.

Let’s now look at how to transfer existing asthma patients from the previous guideline to the new one.

So, what do we do with them?

Well, those currently using only a short-acting beta2 agonist (or SABA) should be changed to a low-dose as-needed AIR therapy using an ICS/formoterol combination.

For those whose asthma is not controlled on:

• regular low-dose ICS plus PRN SABA, both with and without supplementary therapy (that is, a leukotriene receptor antagonist) and
• regular low-dose ICS/ long-acting beta2 agonist (or LABA) combination inhaler plus PRN SABA, also both with and without supplementary therapy (that is, a leukotriene receptor antagonist)

We will consider changing them to a low-dose MART

For those whose asthma is not controlled on:

• regular moderate-dose ICS plus PRN SABA, both with and without supplementary therapy, that is, with or without leukotriene receptor antagonist or LAMA, or both and
• regular moderate-dose ICS/LABA combination inhaler plus PRN SABA, both with and without supplementary therapy, that is, with or without leukotriene receptor antagonist or LAMA, or both

We will consider changing treatment to a moderate-dose MART

When changing from low- or moderate-dose ICS (or ICS/LABA combination inhaler) plus supplementary therapy to MART, we will consider whether to stop or continue the supplementary therapy, that is, a leukotriene receptor antagonist or LAMA, based on the degree of benefit achieved when first introduced. 

Those whose asthma is not controlled on treatment containing a high dose of ICS should be referred.

On the other hand, if asthma symptoms are completely controlled and we may want to consider decreasing maintenance therapy.

In this case, at annual review, we will discuss the risks and benefits of decreasing their maintenance therapy and we will update their asthma action plan and arrange self-monitoring and follow up. 

When decreasing maintenance therapy, we will:

• Stop or reduce the dose of medicines in an order that takes into account the clinical effectiveness when they were first introduced, as well as their side effects and the patient’s preference.
• We will allow at least 8 to 12 weeks before considering a further treatment reduction and
• If we are considering step-down treatment for those on a low-dose maintenance inhaled corticosteroid (ICS) plus a SABA as needed or a low-dose MART, we will step down to on demand AIR therapy with a low-dose ICS/formoterol combination inhaler

So that is it, a review of the treatment of asthma in patients aged 12 and over.

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/-64tUk-zkWk

This channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on diagnosing, monitoring, and managing chronic asthma, NG245, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on initial assessment and diagnosis.

In the next three episodes, I will cover:

·      Treating asthma in patients aged 12 and over

·      Treating asthma in children aged 5 to 11, and those under 5

·      And finally, Asthma monitoring, general treatment principles, and management in special groups

The new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

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.  

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 link to the new collaborative NICE guideline on chronic asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245

The table on alternative diagnoses in wheezy children in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/diagnosis/alternative-diagnoses-in-wheezy-children/

The table on alternative diagnoses in adults in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

·      https://rightdecisions.scot.nhs.uk/asthma-pathway-bts-nice-sign-sign-244/diagnosis/alternative-diagnoses-in-adults/

The algorithm A for a summary of objective tests for diagnosing asthma in adults and young people (aged over 16 years) with a history suggesting asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/bts-nice-and-sign-algorithm-a-summary-of-objective-tests-for-diagnosing-asthma-pdf-13556516365

The algorithm B for a summary of objective tests for diagnosing asthma in children aged 5 to 16 with a history suggesting asthma can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-b-objective-tests-for-diagnosing-asthma-in-children-aged-5-to-16-with-a-history-pdf-13556516366

The algorithm C for a summary of the pharmacological management of asthma in people aged 12 years and over can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-c-pharmacological-management-of-asthma-in-people-aged-12-years-and-over-bts-nice-pdf-13556516367

The algorithm D for a summary of the pharmacological management of asthma in children aged 5 to 11 years can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-d-pharmacological-management-of-asthma-in-children-aged-5-to-11-years-bts-nice-sign-pdf-13556516368

The algorithm E for a summary of the pharmacological management of asthma in children under 5 can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/algorithm-e-pharmacological-management-of-asthma-in-children-under-5-bts-nice-sign-pdf-13556516369

The MHRA safety advice on the risk of neuropsychiatric reactions in people taking montelukast can be found here:

·      https://www.gov.uk/drug-safety-update/montelukast-reminder-of-the-risk-of-neuropsychiatric-reactions

The table of inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline can be found here:

·      https://www.nice.org.uk/guidance/ng245/resources/inhaled-corticosteroid-doses-for-the-bts-nice-and-sign-asthma-guideline-pdf-13558148029

The NICE guideline on air pollution: outdoor air quality and health can be found here:

·      https://www.nice.org.uk/guidance/ng70

The NICE guideline on indoor air quality at home can be found here:

·      https://www.nice.org.uk/guidance/ng149

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.

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through

the new NICE guideline on diagnosing, monitoring, and managing chronic asthma, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode we’ll just focus on initial assessment and diagnosis.

In the next three episodes, we will cover:

·      Treating asthma in patients aged 12 and over

·      Treating asthma in children aged 5 to 11, and those under 5

·      And finally, Asthma monitoring, general treatment principles, and management in special groups

So, stay tuned for those!

Right, let’s jump into it.

The new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you’ll find a link to it in the episode description.

As the initial clinical assessment we will get the history, checking for symptoms such as wheezing, a cough, shortness of breath, chest tightness and any triggers that make symptoms worse as well as a personal or family history of asthma or allergic rhinitis. And we will consider alternative diagnoses depending on the symptoms and presentation. There are tables produced in the previous BTS/SIGN guideline on alternative diagnoses in wheezy children and adults that you can have a look at, and I have put a link to them in the episode description.

We will then do a physical examination to check for expiratory polyphonic wheeze and signs of other possible causes, being aware that asthma can present with a normal examination.

However, we will not confirm the diagnosis of asthma without a suggestive clinical history and a supporting objective test.

What should be our approach if there are acute symptoms at presentation?

Well, we will start treatment immediately if they are acutely unwell or highly symptomatic, and perform objective tests to confirm a diagnosis of asthma if the equipment is available. 

However, if objective tests for asthma cannot be done immediately, we will carry them out when acute symptoms have been controlled, even though we need to be aware that the results of spirometry and FeNO tests may be affected with inhaled corticosteroids, as the test results are more likely to be normal. 

So, let’s look at the objective diagnostic tests that we will need to organise.

But before, we need to know that, from a diagnosis perspective, there are three groups of patients:

·      Those aged over 16

·      Those aged 5 to 16 and

·      Those aged under 5

NICE has produced summaries of objective tests in the various age groups and a link to them can be found in the episode description.

Let’s start with those over the age of 16. For them, as the initial tests we will measure the blood eosinophil count or fractional exhaled nitric oxide (FeNO) level.

We will then diagnose asthma if the eosinophil count is above the reference range or the FeNO level is 50 ppb or more. 

If asthma is not confirmed by eosinophil count or FeNO level, we will then measure bronchodilator reversibility with spirometry and we will diagnose asthma if the FEV1 increase is 12% or more AND 200 ml or more from the pre-bronchodilator measurement or, also, and this is new, if the FEV1 increase is 10% or more of the predicted normal FEV1. 

Let’s look at this in a bit more detail. NICE has argued that the change in FEV1 is best given as the percentage change compared with, not the person’s baseline, but the person's predicted FEV1. Using this calculation, a change of 10% or more is abnormal and therefore diagnostic. If we use the more traditional way as a percentage from the baseline FEV1, then a positive reversibility should be slightly higher, 12% for both adults and children. In adults, the change should also be 200 ml or more. So NICE decided to include both ways of measuring reversibility in their recommendations, that is 10% or more of predicted or 12% or more from baseline FEV1.

If spirometry is not available or it is delayed, we will measure peak expiratory flow (PEF) twice daily for 2 weeks and we will diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more. This is calculated by subtracting the lowest value measured each day from the highest value on the same day, and averaging this over the number of days on which PEF is measured

If asthma is not confirmed by eosinophil count, FeNO, BDR or PEF variability, but it’s still suspected on clinical grounds, we will refer for consideration of a bronchial challenge test. Then, asthma we will be diagnosed if bronchial hyper-responsiveness is present. And let’s remember that bronchial hyper-responsiveness is a measure of how easily bronchospasm can be induced in the airways. 

Let’s now look at the second group of patients, those aged 5 to 16.

In this age group, as the initial test we will measure the FeNO level and diagnose asthma if the FeNO level is 35 ppb or more. This is a change in practice because before in the old guideline, FeNO testing was not recommended as an initial test in this age group. Also, please note that we will not use eosinophil count as an initial test here, although it can play a part at a later stage. But we will come to that a little later.

So, if the FeNO level is not raised, or if FeNO testing is not available, we will measure BDR with spirometry and diagnose asthma if the FEV1 increase is 10% or more of the predicted normal FEV1or 12% or more from baseline FEV1. Please note that it does not need to be more than 200ml in this age group. 

If spirometry is not available or it is delayed, we will measure PEF twice daily for 2 weeks and diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more, that is, exactly the same as for adults. 

If asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds, we will either perform skin prick testing to house dust mite or measure total IgE level and blood eosinophil count.

We will then:

• Diagnose asthma if there is evidence of sensitisation or if there is a raised total IgE level and the eosinophil count is more than 0.5 x 109 per litre. 

If there is still doubt about the diagnosis, we will refer to a paediatrician for a second opinion, which will include consideration of a bronchial challenge test. 

What about diagnosing asthma in children under 5

Diagnosis in children under 5 is hard because it is difficult to do the tests and there are no good reference standards.

So, for children under 5 with suspected asthma, we should treat with inhaled corticosteroids in line with NICE recommendations and review them on a regular basis. If they still have symptoms when they reach 5 years, we will attempt objective tests.

If a child is unable to perform objective tests when they are aged 5:

• We will try doing the tests again every 6 to 12 months until satisfactory results are obtained or
• We will refer for specialist assessment if the symptoms are not responding to treatment. 

On a separate basis, we will refer to a specialist respiratory paediatrician any preschool child with an admission to hospital, or 2 or more admissions to an emergency department, with wheeze in a 12-month period. 

Before ending this episode, let’s touch on the subject of diagnosing occupational asthma.

And for this, in adult-onset asthma, poorly controlled established asthma, or reappearance of childhood asthma, we should check for a possible occupational component by asking the following questions:

• Are symptoms the same, better or worse on days away from work? and
• Are symptoms the same, better or worse when on holiday (or time away from work, longer than usual breaks, at weekends or between shifts)?
• 
  
• 
  

If the answer is yes to any of those questions, we will suspect occupational asthma and we will refer them to a specialist. 

So that is it, a review of the initial assessment and diagnosis of asthma.

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/MxR8AMtBkDY

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in November 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

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 October 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-11-01&to=2024-11-30&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered in this episode can be found here:

Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) can be found here:

·      https://www.nice.org.uk/guidance/ng245

Asthma pathway (BTS, NICE, SIGN) can be found here:

·      https://www.nice.org.uk/guidance/ng244

Endometriosis: diagnosis and management can be found here:

·      https://www.nice.org.uk/guidance/ng73

Menopause: identification and management can be found here:

·      https://www.nice.org.uk/guidance/ng23

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in November 2024, focusing on what is relevant in Primary Care only.

In today’s episode we’re covering 3 really important clinical areas. We’ll look at the updates on endometriosis, the all-important menopause, and, of course, the wow factor, the one guideline that we’ve all been waiting for: the new collaborative guideline on asthma! Yes, it’s finally here!

Right, let’s jump into it

And, of course, we have to start with the star of the show, the new guideline on the diagnosis, monitoring and management of chronic asthma.

This is a new collaborative guideline developed jointly by NICE, the British Thoracic Society (or BTS), and the Scottish Intercollegiate Guidelines Network (or SIGN).

It updates and replaces parts of the BTS/SIGN guideline as well as previous NICE guidance. There’s also an updated asthma pathway, which presents the same recommendations in a different format.

This is a major development, so today I’ll just focus on the highlights. But I will dedicate the next episodes to cover this guideline in detail, so stay tuned.

When someone presents with a history suggestive of asthma, we need to confirm the diagnosis with objective tests.

And from a diagnosis perspective, there are 3 groups of patients:

·      Those aged over 16

·      Those aged 5 to 16 and

·      Those aged under 5

So, to confirm the diagnosis in anyone over the age of 16 with suggestive asthma symptoms we will start by measuring the blood eosinophil count or FeNO level.

And we will diagnose asthma if:

• The Eosinophil count is high, or
• FeNO level is 50 ppb or more.

Then, if these tests are negative and we still suspect asthma, we will do a spirometry with reversibility and diagnose asthma:

·      if FEV1 increases by ≥ 12% from baseline and by ≥ 200 ml or, and this is new,

• if the FEV1 increase is 10% or more of the predicted normal FEV1(that is, not the baseline)

If spirometry is unavailable or it is delayed, we will use peak flow (PEF) variability checking readings twice daily over 2 weeks and diagnose asthma if variability ≥ 20%.

If all tests are negative and there are still diagnostic doubts, we will refer for a bronchial challenge test.

The process is slightly different in children aged 5 to 16, because, as the initial test we will just:

• measure FeNO levels and diagnose asthma if level ≥ 35 ppb.
• This is also new because before FeNO testing was not recommended as an initial test in this age group. And please also note that we will not use eosinophil count as an initial test here, although it can play a part at a later stage. But we will come to that a little later.

If FeNO is not raised or is unavailable and asthma is still suspected in this group of children:

• We will check spirometry with reversibility and diagnose asthma if FEV1 increases ≥ 12%. But it does not need to be more than 200ml

If spirometry with reversibility is not raised or is unavailable:

• We will check peak flow readings twice daily for two weeks and diagnose asthma if variability ≥ 20%.

And finally, if asthma is not diagnosed with any of the above tests, we will move to Sensitisation Tests by:

·      Doing skin prick testing for house dust mite or measuring total IgE and eosinophil count.

And then we will diagnose asthma if:

• Sensitisation is present on skin prick testing, or
• Total IgE is raised and eosinophil count > 0.5 × 10⁹/L.

If all tests are negative and there are still diagnostic doubts, we will refer to paediatrics.

Diagnosing asthma in the under 5s is more complex and requires clinical judgement, so we will not cover this today.

Now that we have looked at the diagnosis, let’s look at what monitoring is recommended.

And a significant change is that we are now advised to avoid regular peak flow monitoring unless it's part of a personalised asthma action plan. Instead, we are advised to monitor symptoms and use validated symptom questionnaires for both adults and children. Additionally, for adults, we can also consider monitoring FeNO levels at regular reviews and before or after treatment changes.

And finally, let’s touch on a few new treatment recommendations.

And the main development is the end of step 1 treatment, where intermittent short-acting bronchodilators were used alone. From now on, the golden rule is clear: no prescribing short-acting beta2 agonists (or SABAs) for asthma at any age without an inhaled corticosteroid (ICS).

Let’s look at the management in a little more detail. And from a treatment perspective, there are three groups:

·      Those aged 12 and over

·      Those aged 5 to 11 and

·      Those aged under 5

For those aged 12 and over, the first step is to offer on-demand AIR therapy. So, what is AIR therapy? It stands for Anti-inflammatory Reliever therapy, where formoterol is used as a reliever in an inhaler that also contains an anti-inflammatory corticosteroid. While many of us are familiar with the MART regimen (that is, Maintenance and Reliever Therapy), AIR therapy is different: it involves using a formoterol/corticosteroid inhaler only in response to symptoms, without regular maintenance dosing. Currently, only specific budesonide/formoterol inhalers are licensed for this, with a low-dose budesonide/formoterol combination recommended as on-demand AIR therapy. So, anyone in this age group who is currently on PRN salbutamol only should now be switched to AIR therapy instead.

However, whilst this is really the death of the salbutamol inhaler for anyone aged 12 and over, there is still a role for it in children under 12, for whom a SABA may be prescribed, although always alongside an inhaled corticosteroid.

There are a few more changes but, as a taster, we will stop it here today, as we will be covering the full guideline more extensively in future episodes.

But, in summary, for me, the highlights are that:

·      New diagnostic criteria for adults include a high eosinophil count and a post bronchodilator increase in FEV1 of the predicted normal FEV1by 10% or more.

·      FeNO testing is the main initial test for children aged 5 to 16.

·      Skin prick testing, serum IgE, and eosinophil count now have a role in diagnosing asthma.

·      Peak flow readings are no longer recommended for routine monitoring.

·      And in a notable shift, SABAs have vanished from the management of patients aged 12 and over but remain in use for those under 12.

Let’s now move to the updates of endometriosis:

And now we are advised to ask if there are any first-degree relatives with a history of endometriosis, as this increases the likelihood of developing it.

We should offer an abdominal and an internal vaginal examination as part of the initial assessment, but only an abdominal examination if a vaginal examination is declined, or not suitable.

We will offer a transvaginal ultrasound scan even if the examination is normal. If it is declined or not suitable, we will organise a transabdominal pelvic ultrasound instead.

But we should not exclude the possibility of endometriosis if the examination and ultrasound scans are normal, so referral may still be necessary for consideration of pelvic MRI scan and laparoscopy.

And finally, we will not offer hormonal treatment if they are trying to conceive, because this management does not improve spontaneous pregnancy rates. 

And now, let’s look at the updated Menopause guideline

There are new recommendations on CBT to manage menopausal symptoms and we are advised to consider menopause-specific CBT as a treatment option.

There are also new recommendations on managing genitourinary symptoms.

If there is no history of breast cancer, we will offer vaginal oestrogen (including to those using systemic HRT), explaining that vaginal oestrogen is absorbed locally and only a minimal amount is absorbed into the bloodstream which is unlikely to have a significant systemic effect.

We should also give advice on the use of non-hormonal moisturisers or lubricants, which can be used either alone or in combination with vaginal oestrogens.

In resistant or difficult to treat cases, we can consider vaginal prasterone and oral ospemifene.

However, if there is a personal history of breast cancer, we will offer non-hormonal moisturisers or lubricants instead. Vaginal oestrogens can still be considered in certain circumstances by a menopause specialist, although this would be an off-label use and the individual safety should be assessed carefully.

For example, in oestrogen receptor negative breast cancer, vaginal oestrogen is unlikely to increase the risk, and so it is likely to be safe. 

On the other hand, in oestrogen receptor positive breast cancer, the risk of vaginal oestrogens is unknown but there is a potential risk. 

And finally, there are also new recommendations on the effects of HRT on specific health outcomes. There are tables in the guideline that you can use to explain the risks and benefits to patients, so I will only touch briefly on some key aspects.

For example, if there is a history of coronary heart disease or stroke, HRT should be discussed with a menopause specialist. This also applies to anyone with a history of breast cancer or at high risk of breast cancer.

The Breast cancer risk increases with combined HRT but there is little or no increase in the risk of breast cancer mortality with oestrogen-only HRT.

And Stroke risk is unlikely to increase with transdermal combined HRT but it increases with oral combined HRT.

And finally, we should not offer HRT for primary or secondary prevention of cardiovascular disease or for the purpose of dementia prevention.

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/_QJQ6ht8v2s

This channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE 

My name is Fernando Florido (also known as Juan Fernando Florido Santana) and I am a General Practitioner in the United Kingdom. In this episode I go through a variety of guidelines and publications on hepatitis B serology in order to clarify the concept and understand the interpretation of the results. You can find links to the resources consulted in the description 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.   

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 links to the guidance covered in this episode can be found here: 

NICE guideline on hepatitis B:  

https://www.nice.org.uk/guidance/cg165/chapter/Recommendations#assessment-and-referral-in-primary-care 

Hepatitis B Foundation:  

https://www.hepb.org/prevention-and-diagnosis/diagnosis/understanding-your-test-results/

BMJ article:  

https://www.bmj.com/bmj/section-pdf/756691?path=/bmj/348/7957/Practice.full.pdf 

Hepatitis B online guidance for Primary Care (PDF):

https://www.hepatitisb.uw.edu/page/primary-care-workgroup/guidance

Hepatitis B online module:  

https://www.hepatitisb.uw.edu/go/screening-diagnosis/diagnosis-hbv/core-concept/all 

GP notebook:

https://gpnotebook.com/en-GB/pages/trauma-medicine/hepatitis-b-serology-summary 

NICE guidance:  

https://www.nice.org.uk/guidance/ph43/chapter/Recommendations#recommendation-4-testing-for-hepatitis-b-and-c-in-primary-care 

WHO hepatitis recommendations (PDF):  

https://iris.who.int/bitstream/handle/10665/254621/9789241549981-eng.pdf 

Public Health England:  

https://www.gov.uk/government/publications/infectious-diseases-in-pregnancy-screening-programme-laboratory-handbook/results-table-and-reporting-comments-for-hepatitis-b

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, it’s employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the interpretation of hepatitis B serology. For this, I have consulted a variety of guidelines and publications in order to clarify the concepts. You can find links to the resources consulted in the episode description. 

Right, let’s jump into it. 

To interpret hepatitis B serology, first we have to understand the viral antigens and then their corresponding antibodies. So, let’s break them down one by one.

Let’s look at the antigens first. There are three antigens in the hepatitis B virus. 

The Hepatitis B Surface Antigen is found on, well, the surface of the hepatitis B virus. This antigen is produced during active viral replication and indicates the presence of infection, appearing in the blood both during acute and chronic infections.

Then we have the Hepatitis B e Antigen, which is found between the core and the viral membrane and it is released into the bloodstream during the replication of the virus.

And then, the third antigen is the Hepatitis B Core Antigen, which is located within the nucleus of the virus and is not directly detectable in the blood. So, it plays no part in the serology testing but it is important because of the antibodies that it can produce.  

So, let us look at the antibodies now. We have three antigens, so we also have three antibodies,  

The surface antibodies

The e antibodies and

The core antibodies. 

So let us have a look at the clinical implications of both antigens and antibodies.  

As we said earlier, the hepatitis B surface antigen is the main marker of hepatitis B infection. So, a negative result means that there is no active infection. This could be because the person has never been infected or because the infection has cleared.

On the other hand, a Positive result confirms an active infection (either acute or chronic). In an acute Infection, the surface antigen is detectable 1-10 weeks after exposure, with an average of one month, and it generally clears within 6 months if the infection resolves. However, if the surface antigen persists for more than 6 months, it indicates chronic hepatitis B.

It may be worthwhile mentioning that during Hepatitis B vaccination, the person is injected with surface antigen and, as a result, after receiving the vaccine, this antigen can sometimes be briefly detected in the blood, usually within 14 days post-vaccination and does not persist beyond this period. In this case, this transient positivity is not indicative of an actual infection but it is rather connected to the administration of the vaccine.

And what about the hepatitis B surface antibody?

Well, the surface antibody is produced by the immune system and if it is positive, then this usually indicates that the person has developed immunity either by:

·      Successfully clearing a previous Hepatitis B infection or by

·      Being successfully vaccinated.

Therefore, the surface antibodies, provide immunity against future infections and neutralise the surface antigen. Consequently, it is not possible to test positive for both surface antigen and surface antibodies at the same time. 

On the other hand, a negative surface antibody indicates that the person has no immunity to the hepatitis B virus and is susceptible to infection. 

Next, let’s look at the e Antigen. It is associated with viral replication and:

·      In an acute Infection, it appears shortly after the surface antigen during the acute phase, indicating active viral replication and

·      In chronic hepatitis B, its presence also suggests high levels of viral replication and infectivity. However, some patients transition to an e antigen-negative chronic phase due to viral mutations.

So, in summary:

·      A Positive e antigen test indicates a high viral load, high infectivity, and it is often seen in acute infections or poorly controlled chronic infections.

·      A Negative result may indicate lower replication or mutant forms of the virus that do not produce the e antigen.

What about the e antibodies? Well, e antibodies are also produced as the immune system suppresses viral replication. So, if the e antibodies are positive, then this usually indicates a suppressed low viral replication and reduced infectivity, whereas a negative result suggests active viral replication in an infected person. 

Finally, let’s look at the core antigen and core antibodies.

As explained, earlier, the core antigen is not detectable in the blood, so, it plays no part in the serology. On the other hand, the core antibodies have got much more clinical significance because they work as key markers of infection history.  

There are two types of core antibodies:

• IgM antibodies, which indicate recent or acute infection and remains detectable during the acute phase only, becoming negative in chronic or resolved infection. And then we have
• IgG antibodies, which suggest previous exposure to the hepatitis B virus and these IgG antibodies persist for life as a marker of past infection.

Please note one difference between the surface antibodies and the core antibodies. The surface antibodies confer immunity whereas the core antibodies do not. So, a positive surface antibody means that there is no active disease, whereas positive Ig G core antibodies may suggest either a previous resolved infection, or also active chronic disease. 

So how do we interpret hepatitis B serology results?  

Well, Most path labs will use the 3-part “Hepatitis B Panel”, testing for: 

·      The surface antigen to check for active infection

·      The surface antibody to check for immunity

·      And the core antibody to check for past or current infection.

·      Additionally, and in certain circumstances, generally when some of the previous tests are positive, the path lab will test for the e antigen and the e antibodies. This is to check for levels of viral replication and infectivity.

Right, to finalise, let’s look at common scenarios: 

1.   A:

·      Negative surface antigen

·      A Negative surface antibody and

·      A negative core antibody

Would correspond to someone who has not been infected and who is not immune and therefore not protected, so these people should be advised vaccination if at risk of infection. 

2.   A:

·      Negative surface antigen

·      A positive surface antibody and

·      A positive core antibody

Would correspond to someone who has been infected but has successfully cleared the infection. These people are immune and do not need vaccination. 

3.   A:

·      Negative surface antigen

·      A positive surface antibody and

·      A negative core antibody

Would correspond to someone who has never been infected but that has been successfully vaccinated. 

4.   A:

·      Positive surface antigen

·      A Negative surface antibody and

·      A positive core antibody

Would correspond to someone who has been infected. These people should have more testing, for example, to determine IgM and IgG core antibodies and possible e antigen and e antibodies 

5.   A:

·      Positive surface antigen

·      A negative surface antibody

·      A Positive IgM core antibody

·      A Positive e antigen

Would correspond to someone with an acute hepatitis B infection with high levels of viral replication and infectivity.

6.   A:

• Positive surface antigen (for more than 6 months)
• A negative surface antibody
• A Positive total core antibody
• A Negative IgM core antibody and
• A Positive or Negative e antigen

Would correspond to someone with a chronic Infection, with the e antigen simply determining whether the person is highly infectious because of high viral replication or not.

7.   A:

• Negative surface antigen
• A negative surface antibody and
• A Positive IgM core antibody

Would correspond to someone in a Window Period. The surface antigen is negative in the window period because it has been cleared from the bloodstream by the immune system, which has not yet produced enough surface antibodies to be detected. In this case, the presence of positive IgM core antibody is crucial for the diagnosis during this transitional phase.

And finally

8.   A:

·      Negative surface antigen

·      A negative surface antibody and

·      A Positive IgG core antibody

Is probably the trickiest scenario. An isolated positive IgG core antibody, that is, with a negative surface antigen and a negative surface antibody, has 4 possible causes:

1) It may be the "window phase" between disappearance of the surface antigen and appearance of surface antibodies

2) It may represent a remote resolved infection with the decline of surface antibodies to undetectable levels

3) It could also indicate ongoing chronic infection with low levels of surface antigen which are undetectable, or

4) It may represent a false-positive test (rare)

So that is it, a review of hepatitis serology and its interpretation.

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/vETTV_AmatY

The previous episode on AKI covering the diagnosis, investigations and recommendations on the use of contrast media can be found here:

·      https://youtu.be/k6amIFy84Bc

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on acute kidney injury, NG148, focusing on what is relevant to Primary Care only, covering the management recommendations by NICE, and the Primary Care flowchart on AKI by Barnsley Hospital NHS Trust and King’s College Hospital NHS Trust. You can find links to them in the description below.

If you have not already done so, I recommend that you check the previous episode on AKI covering the diagnosis, investigations and recommendations on the use of contrast media.

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.  

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 links to the guidance covered in this episode can be found here:

Acute kidney injury: prevention, detection and management (NG148):

·      https://www.nice.org.uk/guidance/ng148

The 1-page visual summary on assessing the risk of acute kidney injury in adults having iodine-based contrast media: outpatient, non-urgent inpatient and community settings:

·      https://www.nice.org.uk/guidance/ng148/resources/visual-summary-pdf-13551376429

The algorithm for early identification of acute kidney injury, endorsed by NHS England:

·      https://www.england.nhs.uk/akiprogramme/aki-algorithm/

The Management of acute kidney injury in adults in Primary Care by Barnsley Hospital NHS Trust:

·      https://best.barnsleyccg.nhs.uk/media/hruaaymn/best-december-2015-barnsley-aki-primary-careguidance-pathway.pdf?form=MG0AV3

The Adult Acute Kidney Injury Care Pathway for Primary Care by King’s College Hospital NHS Trust:

·      https://www.kch.nhs.uk/wp-content/uploads/2023/01/mi-169.2-adult-acute-kidney-injury-care-pathway.pdf

A calculator for the National Early Warning Score (NEWS):

·      https://www.mdcalc.com/calc/1873/national-early-warning-score-news

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE recommendations on the management of acute kidney injury, focusing on what is relevant in Primary Care only. We will also cover the Primary Care flowchart on AKI by Barnsley Hospital NHS Trust and King’s College Hospital NHS Trust. You can find links to them in the episode description. If you have not already done so, I recommend that you check the previous episode on AKI covering the diagnosis, investigations and recommendations on the use of contrast media.

Right, let’s jump into it.

What management does NICE recommend?

Well, managing acute kidney injury in primary care settings is generally limited, as it often requires specialised hospital monitoring and treatment. We are also likely to feel apprehensive keeping these patients in Primary Care, given the severity of some causes of AKI, such as sepsis, or some of its complications, such as acidosis and hyperkalaemia. Although NICE does not spell out which cases can potentially be managed in Primary Care, some other guidelines do provide us with some guidance, stating that primary care management can be justified, particularly for lower-risk cases. I have looked at the guidelines on the management of AKI by Barnsley Hospital and King’s College Hospital and we will go through them a little later.

But for now, let’s stick to the NICE guideline.

In terms of pharmacological management:

·      We will not offer low-dose dopamine

·      We will not routinely offer loop diuretics but 

·      We will consider loop diuretics for treating fluid overload or oedema while:

• awaiting renal replacement therapy or
• while renal function is recovering and the patient is not receiving renal replacement therapy 

In terms of relieving urological obstruction, we will refer these patients to a urologist. We will do so as an emergency if there is:

• pyonephrosis
• an obstructed solitary kidney
• bilateral upper urinary tract obstruction or
• complications of acute kidney injury caused by urological obstruction. 

We will refer to nephrology those who need dialysis, but we will not refer those with a clear cause for the acute kidney injury if the condition is responding to medical management, unless they have a renal transplant. 

We will monitor creatinine after AKI, basing the frequency of monitoring on the renal function at the time of discharge. We will refer to a nephrologist if eGFR is 30 or less post AKI recovery. 

We will refer to a paediatric nephrologist anyone under 18 years who, after AKI, have hypertension, impaired renal function or 1+ or greater proteinuria on dipstick testing. 

Right, that is the end of the NICE guideline summary.

Let’s now review the guidance provided by King’s College Hospital and Barnsley Hospital. Since both pathways are quite similar, I’ll primarily focus on the flowchart from Barnsley Hospital NHS Trust, because it is better to navigate clinical cases but I’ll be sure to highlight any supplementary details from King’s College Hospital along the way.

Right, so, we start with the flowchart by Barnsley Hospital.

And, if we get an AKI Alert

Then we have to look at the stage of the AKI that we are dealing with, so, as promised, let’s look at them. We have:

Stage 1: which is when creatinine rises by between 1.5 and 1.9 times from normal baseline. King’s College hospital also includes here a rise of creatinine by 26µmol/L within 48 hours, which is in keeping with NICE recommendations.

Stage 2: is when creatinine rises by between 2 and 2.9 times from normal baseline and

Stage 3: is when creatinine rises by 3 or more times from normal baseline. King’s College hospital also includes here when creatinine rises to 354µmol/L or more.

Then we see that Stage 3 AKI will require admission to hospital,

But admission to hospital will also be needed in a number of other cases. Let’s go through the list:

So, not only stage 3 AKI but also

If the patient is Clinically Unwell, with suspected sepsis and/or has a high NEWS score. Remember that NEWS stands for National Early Warning Score, which is used to assess the severity of a patient's condition, especially in cases of sepsis or other acute illnesses. If you are not familiar with it, I have put the link for a NEWS calculator in the episode description.

We will also admit to hospital patients with any AKI stage with no clear cause

Or if there is inadequate response to initial treatment

A possible diagnosis that may need specialist treatment:

For example, AKI with suspicion of urinary tract obstruction or intrinsic renal disease,

Pregnancy

Urinalysis shows both ≥2+ Blood AND Protein, although here King’s College recommends admission if urinalysis shows either ≥2+ Blood or Protein in absence of UTI.

Systemic symptoms (for example arthralgia, rash, epistaxis, haemoptysis) (when we will think of glomerulonephritis, vasculitis, interstitial nephritis, and myeloma)

We will also admit if there are AKI Complications: like hyperkalaemia (with a K>6.0mmol/L), fluid overload, or uraemia

Also, if there is prior CKD stage 4 or 5, that is, an eGFR of below 30

And a renal transplant with any AKI

And so, in all these cases, we will refer to the medical team, considering discussion with nephrology or urology depending on the clinical presentation.

And therefore, the implication is that AKI stages 1 and 2 can potentially be managed in Primary Care.

So, in these cases, we will ask ourselves: Is the patient ACUTELY UNWELL? Are there AKI Complications? Is there a need for IV Fluids? Or worsening AKI? Or any other on-going Concerns?

And if the answer is yes, we will admit them to hospital.

But if the answer is no,

Then we should be able to manage them in the community.

For this, we will need Close follow-up, Early repeat of Creatinine and monitoring of Potassium (K+), carry out the process of STOP-AKI, which we will look at in a minute, and Review the patient Clinically within 24 to 48hrs (using the rapid response team if necessary), Discussing with the Medical Team if there are On-going Concerns.

So, what do we need to do in respect of the STOP AKI process? Well, STOP AKI is a systematic approach where each letter in "STOP" represents a critical component of AKI management, aiming to reduce complications and support kidney recovery:

So, S is for SEPSIS: where we should Recognise and treat infection.

We will Do Urinalysis and if there is protein / leucocytes or nitrites we will send an MSU and start Antibiotics. King’s College Hospital recommends that if there is infection, we should not prescribe trimethoprim or nitrofurantoin because of increased risk of toxicity and, in the case of nitrofurantoin, reduced efficacy in AKI.

We should also Check FBC and, U&E at least every 48-72hrs until the patient is clinically stable

T is for TOXINS: we should hold nephrotoxic drugs like for example NSAIDS, ACE inhibitors, ARBs, Nitrofurantoin and Allopurinol

O is for OPTIMISE BP and Fluid state

-If the patient is dehydrated, we will encourage oral fluid intake

-If there is fluid overload we will refer to the medics

-If the patient is HYPOTENSIVE, we will obviously stop anti hypertensives and diuretics until the situation is stable

P is for PREVENT Harm: We will do a Drug Review and apply Sick day Rules, like, for example, Stop or Adjust the dose of

- Metformin (because of the risk of lactic acidosis)

- Proton pump inhibitors, which can worsen electrolyte imbalances

- Opiates (because they can accumulate during AKI)

- And in the cases of specialist drugs such as Sulphasalazine or Lithium, we will Discuss it with the relevant specialist.

Obviously, we will always aim to identify the AKI Cause, Thinking of Pre-renal causes, Intrinsic Renal disease and Obstructive causes. In this respect, King’s College emphasises the need to exclude a palpable bladder during examination and requesting an USS of the urinary tract in patients with Stage 2 AKI.

So that is it, a review of the management recommendations on AKI. If you have not already done so, please check the previous episode covering the diagnosis, and initial investigations of AKI.

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.