Primary Care Guidelines

The video version of this episode can be found here:

• https://youtu.be/t-wXLOAr8ik?si=TR3eNXpNPlBP3NCs

My summary of the guidance consulted can be found here:

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

This episode refers to guidelines produced by a number of organisations. Please note that the content reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the interpretation of an abnormal full blood count, always focusing on what is relevant in Primary Care only.

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

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

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

The resources consulted can be found here:

·      Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage

·      Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0

·      Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf

·      King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdf

·      Medscape / Kevin Fernando- management of abnormal blood tests: https://1drv.ms/b/s!AiVFJ_Uoigq0mQPPwvFNZtsUSpIr?e=xYthDn

·      Oxford hospital referral pathway: https://nssg.oxford-haematology.org.uk/general-haematology/documents/general-haematology/raised-haematocrit.pdf

·      GP notebook: https://gpnotebook.com/en-GB/pages/general-information/abnormal-fbc-in-adults

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

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

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to go through the interpretation of full blood counts, including follow up management, always focusing on what is relevant in Primary Care only.

I will be covering several areas:

1.   Review of haematological indices

2.   Polycythaemia

3.   Anaemia

4.   Thrombocytosis

5.   Thrombocytopenia

6.   Neutrophilia

7.   Neutropenia

8.   Lymphocytosis

9.   Lymphopenia

10. Eosinophilia

11. Monocytosis

I have put time stamps throughout the video so that you can skip to the section that you are interested in.

I have based this episode on a variety of sources, primarily Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners, although other sources like Medscape and GP notebook were also reviewed. I have put links to them in the episode description. They are worth having a look as they have flowcharts and other information that you may find useful.

Make sure to stay for the entire episode because at the end, I will tell you how to access my summary of the recommendations, which I hope that you will find helpful. 

Right, there is a lot of information to cover, so let’s jump into it.

I will now go through the blood indices on the full blood count and I will also touch on iron investigations such as ferritin and total iron binding capacity. So, let’s look at them one at a time:

·      The Platelet Count gives us the absolute number of platelets

·      The Mean Platelet Volume or MPV gives us the average size of platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced, for example during infection or inflammation.

·      The White Blood Cell Count or WBC, gives the absolute number of white blood cells present. Leucocytosis is when the White Blood Cell Count is raised and leucopenia when it is low. In these situations, we need to look at the subtypes of the white blood cells, that is, we need to look at the:

·      WBC Differential, which looks at the number and proportion of the different types of WBC. We have five types: neutrophils, lymphocytes, monocytes, eosinophils, and basophils.

·      The Red Blood Cell Count or RBC is the absolute number of red cells. It is an important value but we often rely on other red blood cell indices to interpret the results correctly

·      Haemoglobin or Hb is crucial for the diagnosis of anaemia but, again, other indices are needed for the final interpretation.

·      The Haematocrit or HCT measures how much volume is taken up by red blood cells and it is expressed either as a percentage (that is from 0 to 100) or a proportion (that is, from 0 to 1). The haematocrit is therefore influenced not only by the number of red blood cells but also the amount of plasma present.

·      The Mean Corpuscular Volume or MCV refers to the average size of each RBC. An elevated MCV or macrocytosis is when the RBCs are larger than normal, for example in vitamin B12 or folic acid deficiency. A low MCV or microcytosis is when the RBCs are smaller than normal which may indicate, for example, iron deficiency anaemia.

·      The Mean Corpuscular Haemoglobin or MCH measures the average haemoglobin per red cell. Since macrocytic or larger RBCs tend to carry more haemoglobin that normal, they would normally have higher MCH values. 

·      The Mean Corpuscular Haemoglobin Concentration or MCHC is about concentration, that is, the amount of haemoglobin relative to the size of the cell. A decreased MCHC or hypochromia is seen in conditions such as in iron deficiency anaemia, chronic inflammation or thalassaemia. An increased MCHC or hyperchromia is seen when the haemoglobin is abnormally concentrated in the cells, such as in spherocytosis.

·      The Red Cell Distribution Width or RDW measures how uniform the red cells are in size. A high RDW indicates a mix of small and large cells, which can happen in some anaemias, such as iron deficiency or vitamin B12 deficiency. An increase in RDW happens when red blood cells have different sizes also called anisocytosis, or different shapes also called poikilocytosis.

·      Ferritin is the most useful indicator of iron deficiency, as it can drops before any decrease in levels of iron in the blood occurs. Ferritin is the main form of iron storage and is present mostly in the liver. Ferritin levels are low in long-term iron deficiency. Ferritin may also be decreased if protein levels are very low, like in malnutrition. Ferritin is high in states of iron overload, especially in haemochromatosis. However, ferritin can be high for a number of other reasons including inflammatory conditions, infection and liver disease. 

·      Total Iron Binding Capacity, or TIBC, measures the total capacity to bind iron in the blood. TIBC correlates with the amount of transferrin, and while both tests (TIBC and transferrin) are different, they measure essentially the same thing and most laboratories only measure one or the other. The amount of transferrin transporting iron is called transferrin saturation. Iron deficiency results in a low transferrin saturation, but an increased TIBC. In iron overload, such as in haemochromatosis, iron and transferrin saturation will be high and TIBC will be low or normal. Because transferrin is made in the liver, TIBC and transferrin will also be low in liver disease.

Now let’s start looking at the different haematological conditions. And the first section refers to polycythaemia.

Polycythaemia is judged on basis of HCT and it can be diagnosed if the HCT > 0.52 in men and > 0.48 in women.

Polycythaemia is also sometimes referred to as Erythrocytosis but this is not always correct. Why? Well, erythrocytosis indicates an excess number of erythrocytes or red blood cells and, as we have said, polycythaemia is judged on haematocrit, not red blood cells.

And this is because there are two types of polycythaemia, absolute polycythaemia, that is, when erythrocytosis is present, and relative or apparent polycythaemia, when this is not the case.  

For example, in apparent or relative polycythaemia, the HCT increases as a result of a reduced plasma volume rather than an increased red blood cell mass. It is common in obese men, and it is also associated with smoking, diuretics, alcohol, hypertension, stress, and dehydration. Despite the potentially reversible causes, these patients are also at risk of occlusive vascular episodes.

On the other hand, we have absolute polycythaemia, which can be primary or secondary. The primary cause is Polycythaemia Vera. Well over 90% of PV patients have an acquired mutation in a gene called JAK2 that regulates erythropoiesis. These patients do not need as much erythropoietin or EPO to drive red cell production. So, the features of PV are a positive test to the JAK2 mutation, and a low serum EPO level. It also has a low ferritin secondary to the excess production of red cells, which consumes a significant amount of iron. Being a myeloproliferative disorder, it can also sometimes be associated with raised WBC and / or platelets.

Secondary Polycythaemia is due to the physiological response to increased EPO levels. It can be an appropriate response to hypoxia like in COPD, heart disease and smoking or to an inappropriate response due to an EPO producing tumour like in some Renal & liver tumours or fibroids. Other possible causes are anabolic steroids and testosterone therapy, as androgens can also stimulate EPO production. In cases of secondary polycythaemia, the JAK2 mutation is negative, EPO levels are high and ferritin, WBC and platelets are normal.

Criteria for urgent referral are a HCT >0.60 in men or >0.56 in women or also if there is recent thrombosis, abnormal bleeding, or neurological or visual symptoms.

If the criteria for urgent referral are not met, we should confirm the results by repeating the blood test. In order to differentiate between apparent and absolute polycythaemia, the blood sample should be uncuffed and we should ensure that the patient has not fasted, is well hydrated, and has been advised about alcohol and smoking.  

In this blood test, we should request a:

·      Repeat FBC

·      A blood film and screen for diabetes, hyperlipidaemia and hypertension, checking

·      HbA1c

·      Lipids

·      Ferritin

·      Renal and liver function tests. Additionally, if we suspect absolute polycythaemia, we should also request

·      Genetic testing for the JAK2 mutation and do

·      EPO levels.

Criteria for routine referral are unexplained persistently elevated HCT >0.52 in men or >0.48 in women, taking into account that we should refer at lower limits if there is associated iron deficiency. “Persistently” means at least two readings above these levels 4 weeks apart.  

Alternatively, routine referral is also justified if the HCT >0.52 in men or >0.48 in women without waiting for a second test if there are associated symptoms of concern like pruritus, raised WBC and / or platelets or splenomegaly, or if there is a past (not recent) history of arterial or venous thrombosis. 

Right, let’s move on to the next chapter, which is a very important and common one, anaemia.  

Anaemia presents as a low haemoglobin and is not a disease in itself, but may reflect an underlying disease process. It may also result from an increase in plasma volume and a dilutional effect, like in pregnancy. There may be local variations in the thresholds for diagnosis but the WHO uses the following haemoglobin thresholds to define anaemia at sea level in adults:

·      women - 12 g/dl (reduced to 11 g/dl in pregnancy)

·      men - 13 g/dl 

So, I will be using these thresholds in this episode. 

Also, I will be focusing on what we normally see in Primary Care, that is, chronic anaemia rather than anaemia secondary to acute bleeding requiring admission. Hospital admission will also be required with very severe anaemias, for example when the Hb <50 or even at higher levels if the patient is very symptomatic 

The first thing to look after a low haemoglobin is the mean corpuscular volume or MCV. Depending on this value, the anaemia can be described as: 

·      Microcytic if the MCV is below 80

·      Macrocytic if it is over 100 and

·      Normocytic if it is between 80 and 100

·      Bearing in mind that there may be mixed deficiencies, so we should look at the whole picture. 

So, let’s look at the microcytic anaemias first. The most common cause of microcytosis is iron deficiency, so we will repeat the full blood count and check the patient’s iron status.  

As we said earlier, ferritin can be an acute phase reactant so it can be raised in cases like, for example, inflammation, malignancy, alcohol excess, liver or renal disease and infection. If we suspect any of this, we should check ferritin together with iron studies or transferrin saturation to get a clearer picture. If the ferritin is >50mcg/L and transferrin saturation is >20%, then iron deficiency can be excluded. In that situation, we will consider haemoglobinopathy screening in order to exclude thalassaemia or other haemoglobin variants and, if positive, we will refer to haematology as necessary. 

If the haemoglobinopathy screen is normal or if testing is not considered necessary , then we will think about the following conditions: 

·      One, Anaemia of chronic disease and we will look for causes of:

o  Chronic inflammation: for example, autoimmune diseases, malignancy or tuberculosis

o  Endocrine problems: for example, hypothyroidism, hypopituitarism or Addison’s and

o  Other conditions such as CKD, liver disease or malnutrition

·      Two, Myelodysplastic syndrome, usually presenting as lone unexplained and persistent anaemia and

·      Three, We will also consider haemochromatosis where ferritin is raised. 

And we will refer to the appropriate service if necessary. 

On the other hand, if ferritin is:

·      <30 mcg/L or

·      <100 mcg/L with transferrin saturation less than 20%  

We will regard it as iron deficiency anaemia. We will then enquire about upper and lower GI symptoms and we will consider an urgent cancer referral for upper and lower GI endoscopy after requesting a FIT test if:

·      There are red flag symptoms

·      There is an unexplained drop in Hb to below 110 in men and below 100 in non-menstruating women or if

·      There is a strong family history of colorectal cancer, that is, two first degree relatives with the diagnosis or one first degree relative with a diagnosis before the age of 50. 

If there are no criteria for urgent referral, and the cause of the iron deficiency is unknown, we will look for other possible causes, for example: 

·      Testing for coeliac serology and refer to gastroenterology if it is positive.

·      Enquire about Heavy menstrual bleeding

·      Consider Dietary causes

·      Do Urinalysis to test for haematuria (as 1% of IDA have a renal malignancy)

·      Do Stool testing for parasitology and we will also

·      Consider aspirin, NSAIDs and anticoagulants as an aggravating factor but we will still investigate these patients fully. 

When the cause of the iron deficiency anaemia is known, we will give iron therapy and treat the underlying cause accordingly and then recheck the Hb and ferritin within 3 months. If the deficiency has not resolved and it is not due to menstrual loss, we will refer to gastroenterology or other specialist services depending on the presentation and our clinical judgement.  

Let’s now look at macrocytic anaemias, that is, when the MCV is >100.

If there is macrocytosis, with or without anaemia we should consider some of the possible causes and: 

·      Check alcohol intake

·      Enquire about family history

·      Review medication that could cause it, for example methotrexate, metformin, and some anticonvulsants, amongst others and

·      remember that a high MCV can be a normal physiological finding in pregnancy. 

Initial investigations will include: 

·      A Repeat FBC

·      A Blood Film

·      Vitamin B12 and folate levels

·      Renal and liver function tests, including GGT

·      TFTs

·      Ferritin, iron studies

·      Myeloma screen, including bone profile, serum immunoglobulins, serum Free Light Chains and Urinary Bence Jones protein

·      And finally, we will also check the Reticulocyte count and LDH levels, looking for evidence of haemolysis, bearing in mind that markers of haemolysis include a raised reticulocyte count, a high bilirubin and a high LDH  

Criteria for urgent referral to haematology are: 

·      Leucoerythroblastic features or blasts seen on blood film

·      Unexplained symptomatic and progressive anaemia and if there is

·      Associated splenomegaly, lymphadenopathy or other significant cytopenias 

If the urgent criteria are not met, we will then act on the results and refer the patient accordingly. That is:

·      If the reticulocyte count is high: we will look for evidence of bleeding or haemolysis and refer to the appropriate department.

·      If there is CKD related anaemia: we will refer to the renal team

·      If the TFTs are abnormal, we will treat the dysfunction and repeat the FBC 4-6 weeks later

·      If vitamin B12 and / or folate levels are low: we treat the deficiencies and assess for the underlying cause. For example:

o  In vitamin B12 deficiency, we will check for intrinsic factor Antibodies and Parietal Cell Antibodies and treat as pernicious anaemia if positive and

o  In both vitamin B12 and folate deficiencies we will do a coeliac screen.  

Criteria for routine haematology referral are: 

·      If paraprotein is detected

·      If all results are normal, but there is persistent unexplained anaemia

·      If there is persistent unexplained macrocytosis with an MCV >100 as this can be a feature of myelodysplasia

·      If there is persistent unexplained vitamin B12 deficiency because persistent unexplained vitamin B12 deficiency can also occur in myelodysplastic syndromes

·      If there is anaemia with associated abnormalities in other blood cells

·      If the reticulocyte count is low or the picture is unclear and

·      If there is an abnormal blood film

Finally, let’s now look at normocytic anaemias, that is, when the MCV is between 80 and 100.  

Possible causes of normocytic anaemias are: 

·      A mixed haematinic deficiency

·      Myelodysplastic syndrome

·      Recent blood loss

·      Anaemia of chronic disease like in:

o  Chronic inflammation

o  Endocrine problems or

o  Other conditions such as CKD, liver disease or malnutrition

·      And haemochromatosis if ferritin is raised. 

In these cases, we will investigate similarly to macrocytic anaemias, that is, we will check the following: 

·      A repeat FBC with a Blood Film

·      Vitamin B12 and folate levels

·      Renal and liver function tests, including GGT

·      TFTs

·      Ferritin, iron studies

·      Myeloma screen

·      And finally, we will also check the Reticulocyte count and LDH levels, looking for evidence of haemolysis  

And we will act on the results and refer the patient accordingly.

The next section refers to thrombocytosis or a raised platelet count above 450 x 109/L.

Possible causes of thrombocytosis are:

·      Iron Deficiency Anaemia

·      Malignancies especially the LEGO cancers, that is:

o  Lung

o  Endometrium

o  Gastric

o  Oesophageal

·      Inflammation

·      Infection

·      Post-Splenectony and Hyposplenism like in Coeliac Disease

·      Post-Operatively situations and finally a

·      primary Myeloproliferative Disorder

But before moving on, let’s clarify a concept: should we call it thrombocytosis or thrombocythemia? Well, in fact, there is a difference. In summary, thrombocytosis is more common and arises as a secondary response, and therefore it is also referred to as reactive thrombocytosis. On the other hand, thrombocythemia, also referred to as primary or essential thrombocythemia, is less common and is a form of myeloproliferative disorder. Another key difference if that people with reactive thrombocytosis have normal platelets and therefore, also have a lower risk of blood clots and bleeding whereas those with thrombocythemia have abnormal platelets and also a higher risk of clots and bleeding. Thrombocythemia often presents with splenomegaly and a platelet count >1000.

Therefore, criteria for urgent haematology referral are if:

·      The PLT count exceeds 1000 x 109 / L

·      There is splenomegaly

·      There is a recent history of thromboembolism

·      The PLT count is >600 x109/L and the patient is at high risk of thromboembolism or CVD

·      There are neurological symptoms

·      There is abnormal bleeding

·      There are any signs of malignancy or

·      There are any other significant abnormal FBC indices 

If the urgent referral criteria are not present, we will then look for causes by doing the following initial investigations: 

·      A repeat FBC

·      A blood film

·      Inflammatory markers like ESR and CRP

·      Ferritin and iron studies and we will also

·      consider doing a coeliac screen as it can be associated with thrombocytosis 

If the patient is asymptomatic and there is no obvious cause, we will repeat the FBC 4-6 weeks later. If the thrombocytosis persists >450, we will refer to haematology routinely. 

The next section is thrombocytopenia, which is defined as a low platelet count below 150 x 109/L. We need to remember that thrombocytopenia can frequently be an artefact, stemming from platelet clumping, rather than reflecting an actual decrease in platelet count. We should always confirm it with a second FBC and a blood film report. 

We will enquire about travel, drugs and alcohol because possible causes of thrombocytopenia include:

·      Alcohol excess

·      Recreational drugs

·      Malaria

·      TB

·      Liver & Renal disease

·      Medications, for example, NSAIDs, Heparin, Digoxin, Quinine, anti-epileptics, antipsychotics, and PPIs

·      B12 and folate deficiency

·      Viral infection including:

o  EBV (it usually resolves within few weeks in this case)

o  HIV and

o  Hepatitis B and C

·      Malignancy

·      Bone marrow failure like in aplastic anaemias

·      Immune thrombocytopenic purpura or ITP and

·      Autoimmune diseases, like SLE 

Baseline investigations will include: 

·      Repeat FBC and blood film

·      Vit B12 and folate

·      Ferritin and iron studies

·      Inflammatory markers such as ESR and CRP

·      Autoimmune profile

·      Renal, liver and thyroid function tests

·      HIV, hepatitis B and C serology and

·      Any other test suggested by the clinical history or examination findings 

We should arrange a hospital urgent same day assessment if the platelet count is <20 with: 

·      Active Bleeding

·      An abnormal blood film like Blasts or Fragments on the blood film or an

·      Altered Conscious Level Or Confusion 

We should make an urgent referral to haematology if: 

·      The platelet count is 50-100 and there is splenomegaly, lymphadenopathy, other cytopenias, the patient is pregnant or there is upcoming surgery or if

·      The platelet count is <50. In this case, we will stop all antiplatelet agents and anticoagulants as it would be unsafe to continue. 

If the platelet count is over 50 and the urgent referral criteria are not present, we will repeat the FBC after 4-6 weeks and refer to haematology routinely if the thrombocytopenia persists and remains unexplained.

 Now, next, let’s have a look at neutrophilia, which is when the neutrophil count is raised, that is, over 7.5. 

Infection is the most common cause but other possible causes are: 

·      Infection

·      Inflammation

·      Steroids

·      Pregnancy

·      Smoking

·      Underlying Malignancy including Lymphoma and Leukaemia

·      Connective tissue disease like RA

·      Haemorrhage

·      Haemolysis

·      Hypoxia and

·      Tissue damage including infarction 

If the cause is unclear, we will investigate further by doing: 

·      A repeat FBC

·      A Blood Film

·      Inflammatory markers such as ESR and CRP

·      Renal and liver function tests

·      Autoimmune screen and

·      Any other tests led by history 

Criteria for urgent haematology referral will include a high suspicion of leukaemia because of: 

·      A leucoerythroblastic film or an

·      Absolute Neutrophil count, ANC > 50 x109/L  

We will make an early routine haematology referral, that is, without waiting for a repeat FBC, if the neutrophil count is >15 and: 

·      There is splenomegaly or

·      There are other FBC abnormalities.

Otherwise, we will repeat the FBC 6 weeks later and we will refer to haematology routinely if: 

·      The neutrophilia persists and remains unexplained 

Let’s now look at neutropenia, which is when the neutrophil count is low. A normal neutrophil count in adults is from 2.0 to 7.5. However, an isolated low neutrophil count is very common and a neutrophil count of between 1-5 -2.0 x 109/l, whilst below the normal range, is unlikely to be of any clinical significance. Also, people of Afro-Caribbean or Middle Eastern ethnicity have a lower normal range between 1 and 1.8 x 109/l, which is also referred to as constitutional or ethnic neutropenia. This is of no clinical consequence and we should only refer them if their neutrophils are <1.0 x 109/l on repeat testing. 

For everybody else and for the purpose of this episode, we will say that neutropenia is when the neutrophil count is below 1.5. 

Possible causes of neutropenia are: 

·      Drugs e.g. Phenytoin, Carbimazole, Antipsychotics and Clotrimoxazole

·      Malignancy, like myeloma, bone marrow infiltration and chemo or radiotherapy

·      Vitamin B12 and / or folate deficiency

·      Iron deficiency

·      Autoimmune diseases

·      Any viral infection including EBV, HIV and Hepatitis B and C

·      Excess alcohol

·      Liver disease and cirrhosis and, as already mentioned, the

·      Ethnic variation in people of Afro-Caribbean and Middle Eastern descent  

We should send the patient to hospital as an emergency if: 

·      There is any evidence of sepsis

·      The neutrophil count is <1 and:

o  The patient is on chemotherapy

o  There is lymphadenopathy

o  There is splenomegaly or

o  There is other cytopenia 

We should make an urgent haematological referral on a cancer pathway if: 

·      The neutrophil count is <0.5 and the patient is otherwise well

If the neutrophil count is >0.5 and the patient is well, we will repeat the blood test within 1 week and investigate the cause by doing:  

·      A repeat FBC

·      A blood film

·      Vitamin B12

·      Folate

·      Ferritin and iron studies

·      Autoimmune screen

·      HIV and

·      Hepatitis B and C serology 

If the patient is well and the cause remains unknown, we will:

·      Refer to haematology urgently if the neutrophil count remains <1 but

·      If the neutrophil count is between 1 and 1.5, we will monitor the FBC for 4-6 weeks and refer to haematology routinely if: 

o  The neutrophil count remains below 1.5 (or 1 in African-Caribbean patients)

o  There are other FBC abnormalities or

o  There is a history of infections or ulcers 

The next section refers to lymphocytosis, which is when the lymphocyte count is high that is, more than 3.5 x109 / L. 

Possible causes of lymphocytosis are: 

·      Viral infections especially

o  Glandular fever but also others such as:

o  Measles, mumps, rubella

o  EBV and

o  CMV

·      Bacterial infections, e.g. pertussis infection or whooping cough

·      Lymphoproliferative disorders (such as Acute or Chronic Lymphatic Leukaemia or non-Hodgkins lymphoma)

·      Post-splenectomy

·      Rheumatoid arthritis

·      Smoking

·      Stress and

·      Vigorous exercise

If there are features of acute or recent viral illness and the patient is otherwise well, we will repeat the FBC once resolved after 4-6wks.

We will refer to haematology urgently if: 

·      The Lymphocytosis is >20x109/L

·      There are other cytopenias

·      There is Lymphadenopathy

·      There is Splenomegaly or if

·      There are B symptoms, that is:

o  Unexplained fever >38

o  Drenching night sweats

o  Weight loss  

Otherwise, if the lymphocyte count is >5, we will repeat the blood in 4 to 6 weeks and investigate the cause by doing:

·      A repeat FBC

·      A Blood film

·      Inflammatory markers such as ESR and CRP

·      Glandular fever screen or other virology serology where indicated due to the clinical presentation and we will also request

·      Immunophenotyping screen 

And after this, we will refer to haematology routinely if the lymphocytosis persists and remains unexplained. 

The next section is lymphopenia, when the lymphocyte count is low, that is below 1 x 109/L.

Possible causes of lymphopenia are:

·      Elderly patients

·      Excess alcohol

·      Malnutrition

·      Medication, for example steroids and chemotherapy

·      Infection including legionella, HIV and hepatitis B and C and post viral lymphopenia is common

·      Malignancy for example, lymphoma, bone marrow infiltration, and myeloma and we should consider a myeloma screen if there are suggestive symptoms.

·      Renal or hepatic impairment

·      Autoimmune conditions like RA and SLE

·      Sarcoidosis

·      Anorexia Nervosa and

·      Primary immune deficiency 

We will refer to haematology urgently if the lymphocyte count is <1 and there are any red flags. Red Flag signs in lymphopenia are: 

·      Recurrent infections or

·      B symptoms, that is :

o  Unexplained fever >38

o  Drenching night sweats

o  Weight loss 

If there are no red flags, we will do a new blood test in 6 weeks and look for causes. So, we will do: 

·      A repeat FBC

·      A blood film

·      Renal and liver function tests

·      Inflammatory markers such as ESR and CRP

·      Autoimmune profile

·      Viral serology as appropriate depending on the clinical presentation and a

·      Myeloma screen if symptoms justify it 

If the cause is found, we will refer to the appropriate specialist department. However, if it persists and remains unexplained, we will refer routinely to haematology. 

There may be times when, if the lymphocyte count is >0.5x109/L and the patient is >70 years of age and otherwise well, we could consider just monitoring the FBC, but this will depend on our clinical judgement.

The next section refers to eosinophilia, when the eosinophil count is high. There may be local variations in the threshold but, in general, eosinophilia is defined as an eosinophil count over 0.5 x 109/L.

Examples of possible causes of eosinophilia are: 

·      Asthma

·      Skin disease like eczema, atopic dermatitis, urticaria, and psoriasis

·      Infections: especially those due to parasites (like hookworm, schistosomiasis and giardiasis), fungal infections as well as TB and malaria.

·      Drugs such as penicillin, allopurinol, amitriptyline, and carbamazepine but in fact any drug is a possible cause

·      Connective tissue disease like rheumatoid arthritis, and polyarteritis nodosa,

·      Solid malignancies, for example breast, renal, stomach and lung cancer

·      Myeloproliferative disorders like leukaemia and lymphoma

·      Respiratory diseases such as bronchiectasis, and cystic fibrosis

·      Endocrine conditions like Addison’s and

·      Post-splenectomy 

If the eosinophil count is >2.5, we will look for signs of organ damage and consider urgent admission if there are red Flags like: 

·      Severe symptoms secondary to organ involvement like:

o  difficulty breathing

o  chest pain

o  abdominal pain, or

o  neurological symptoms or

·      other Complications such as tissue damage, venous thromboembolism, or end-organ damage like AKI or heart failure. 

Criteria for urgent referral to haematology are:  

·      Leucoerythroblastic film or an

·      Absolute Eosinophil Count > 5 x109/L,  

If the eosinophil count is >0.5 and the patient is well, we will check the travel and drug history and check for any evidence of atopy. We will then repeat the blood test within 1 to 2 weeks and look for possible causes.

 Initial investigations will include: 

·      A repeat FBC

·      Blood film

·      Inflammatory markers like ESR and CRP

·      Immunoglobulin E

·      Autoimmune profile

·      Renal and liver function tests

·      Bone profile

·      LDH

·      Vitamin B12 and folate

·      Chest X-ray (e.g. if TB or pulmonary sarcoidosis are suspected)

·      Stool culture for ova, cysts and parasites

·      Serological antibodies for threadworm or other nematode infection and

·      Serological antibodies for Schistosomiasis depending on the travel history and after discussion with microbiology 

If the cause is found, we will treat it accordingly. However, we will refer to haematology routinely if the eosinophilia remains unexplained and 

·      It is more than 1.5 for 3 months or longer or

·      if it is rising without an obvious cause. 

The final section refers to monocytosis when the monocyte count is raised, that is over 0.8 x 109/L. 

Possible causes of monocytosis include: 

·      CMML or Chronic Myelomonocytic Leukemia

·      Myelodysplasia

·      Hodgkins’s lymphoma and

·      Infections such as:

o  Malaria

o  Tuberculosis

o  Brucellosis

o  Infective endocarditis and

o  Rickettsial infections 

Criteria for urgent haematology referral would be: 

·      Evidence of CMML features on blood film

·      A persistently raised monocyte count >1.5 (which is typical of CMML)

·      Associated cytopenias, particularly if involving multiple blood cell lineages or of there is any

·      Clinical Suspicion of Hematologic Malignancy 

If the monocyte count is >0.8 and the patient is well, we will check the travel history and check for any evidence of malignancy. We will then repeat the blood test and look for possible causes.  

Initial investigations could include: 

·      A repeat FBC

·      A blood film

·      Inflammatory markers like ESR and CRP

·      Any investigation as appropriate based on clinical suspicion, for example:

o  A chest X-ray to screen for Tb

o  Malaria parasites, and

o  Serological tests for infectious diseases such as Brucella, Epstein-Barr virus, and cytomegalovirus 

If the monocytosis remains unexplained and over 0.8 we will refer to haematology. 

Well, this is the end of the clinical scenarios. I have created a quick reference guide based on the guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners which you are welcome to have a look at. Where there was a discrepancy between their guidance, I have generally opted for the most conservative approach, for example, if one neutropenia guideline recommends referral if the neutrophil count is <1 and another when it is <1.5, my summary will show <1.5. If you are in any doubt, please consult the original guidance or seek local specialist guidance. I have included links to sources consulted in the document itself, which you will be able to download in the episode description. 

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

Thank you for listening and goodbye.

The video version of this podcast can be found here: https://youtu.be/0r2kJQNzHME?si=hwG9mG3jNVaXRQEq

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

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

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

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

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

The Full NICE News bulletin for January 2024 can be found here:

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

The links to the update guidance covered can be found here:

Suspected sepsis: recognition, diagnosis and early management:

·      https://www.nice.org.uk/guidance/ng51

National early warning score information:

·      National Early Warning Score (NEWS) 2 | RCP London website:

§ https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2

·      eLearning:

§ https://newslms.ocbmedia.com/login

·      The NEWS2 observation chart, score card and clinical responses can be downloaded from the main NEWS2 page at 

§ https://news.ocbmedia.com/resources

·       

COVID-19 rapid guideline: managing the long-term effects of COVID-19:

·      https://www.nice.org.uk/guidance/ng188

COVID-19 rapid guideline: managing COVID-19:

·      https://www.nice.org.uk/guidance/ng191

Skin cancer:

·      https://www.nice.org.uk/guidance/qs130

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

Transcript

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

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

And to be honest, there have not been any major changes, only minor tweaks in the guidelines on sepsis and COVID19.

Today’s episode is not very long so let’s jump into it.

The first clinical area is sepsis. We can’t really look at the whole sepsis guideline here so let’s just look at the update, which points out four aspects:

·      First, that temperature may not rise in cases of spinal cord injury. We know that some groups of people with sepsis may not develop a raised temperature. These include:

o  people who are older or very frail

o  young infants or children

o  people having cancer treatment

o  people severely ill with sepsis and after this update

o  people with a spinal cord injury

·      Second, we should suspect neutropenic sepsis also in immunosuppression which is not related to cancer.

o  That is, we should now suspect neutropenic sepsis and send them to hospital if they become unwell and:

§ Are having or have had systemic anticancer treatment within 30 days or

§ Are receiving or have received immunosuppressants for reasons unrelated to cancer, obviously using our clinical judgement

·      Third, we should give early antibiotics when the person is at high risk from sepsis.

o  This means that if the transfer time to the emergency department is likely to be more than 1 hour, we should give antibiotics if high risk criteria are present. And,

o  If meningococcal disease is specifically suspected, we will give appropriate doses of parenteral benzyl penicillin in the community.

·      And finally, we should use a national early warning score for sepsis. And this is the most interesting part of the update, so let’s have a look at it in a little more detail.

NICE says that the national early warning score should be done in ambulances and secondary care but it is not expected in primary care.

So, let’s have a look at what NICE says that we have to do in Primary Care.

Firstly, we should always ask ourselves 'could this be sepsis?' if there are infection symptoms, taking into account that these symptoms may be non-specific, like feeling very unwell. 

As part of the initial assessment in Primary Care, we will carry out a thorough examination, examining the skin for a mottled appearance, cyanosis and rashes and checking the temperature, heart rate, respiratory rate, oxygen saturation and level of consciousness for everyone. For those aged 12 and over, we will also check the blood pressure, and for the under 12s we will check the capillary refill and, if it is abnormal, we will check the BP if we have the equipment, including a correctly-sized blood pressure cuff. We will also enquire about urine output in the previous 18 hours. 

If we are worried about sepsis, we should send the patient to hospital. Like stated earlier, if, in addition, there are high risk features, we should also consider early antibiotics if there is going to be more than one hour’s delay.

So, what are these high-risk features? Well, for those aged 12 and over they are as follows:

·      New altered mental state

·      Respiratory rate: 25 breaths per minute or more

·      New need for 40% oxygen or more to maintain saturation more than 92% (or more than 88% in known COPD), being aware that pulse oximeters can underestimate or overestimate oxygen levels, and that overestimation has been reported in people with dark skin.

·      Systolic BP < 90 mmHg or more than 40mmHg below their normal

·      Heart rate: more than 130 beats per minute

·      Not passed urine in previous 18 hours.

·      Mottled or ashen appearance of skin

·      Cyanosis and a

·      Non-blanching petechial or purpuric rash- when we will consider meningococcal disease.

Now, let’s go back to the national early warning score or NEWS2 that we were talking about earlier.

The National Early Warning Score or NEWS 2 tool was designed by the Royal College of Physicians to be used in adults in addition to clinical judgement to assess a person's risk of deterioration. It is not advised in children or pregnant women or in cases of spinal cord injury.

The NEWS2 tool scores the same things that we already measure in Primary care, that is, temperature, heart rate, respiratory rate, oxygen saturation, blood pressure and level of consciousness. A score is given to each value where the high-risk criteria that we have just mentioned, score 3 points and other abnormal but less severe criteria only 2 points. I will not go through the score chart today but, if you want to look at it in more detail, I have put relevant links in the episode description.

 And when interpreting the risk from sepsis using the NEWS2 score we will recognise that:

·      a score of 7 or more suggests high risk from sepsis and we should arrange immediate admission.

·      a score of 5 or 6 suggests a moderate risk from sepsis and we should arrange an urgent hospital assessment

·      a single parameter scoring 3 points, is a red flag and we should discuss it with the hospital medical team.

·      a score of 1 to 4 suggests a low risk from sepsis but we should still use our clinical judgement

A score of 0 should not be interpreted as indicating that there is no risk from sepsis and the patient will still need to be monitored.

In summary, while a formal NEWS2 assessment is not mandatory in Primary Care, in practice, by measuring all relevant parameters and recognising high-risk values, we are effectively applying the NEWS2 system. That is why it is a good idea for us to have a good understanding of it.

Let’s now move to the second clinical area, which refers to the COVID-19 rapid guideline, both in managing COVID-19 itself and also managing the long-term effects of COVID.

The update is presentational only and the recommendations are largely unchanged. But since we are here, I will give you a very brief summary.

In respect of the acute COVID-19 guideline, I will keep it extremely brief. We will assess the severity of COVID checking what we have just discussed in the sepsis guideline, that is temperature, heart rate, respiratory rate, oxygen saturation, blood pressure and level of consciousness and we will consider using the NEWS2 tool here too, sending the patient to hospital when necessary.

In terms of managing cough in the community, we will encourage people to avoid lying on their backs, because this makes coughing less effective. And to manage fever, we will advise paracetamol or ibuprofen explaining that there is insufficient evidence to link non-steroidal anti-inflammatory drugs and worsening COVID-19.

Now let’s address the long-term effects of COVID.

And let’s remember that:

·      Acute COVID19 refers to the first 4 weeks.

·      Ongoing symptomatic COVID19 to between 4 and 12 weeks

·      And post-COVID-19 syndrome to more than 12 weeks

·      The term 'long COVID' is commonly used and it includes both ongoing symptomatic COVID‑19 and post‑COVID‑19 syndrome, that is, anything that is longer than 4 weeks

Examples of the most commonly reported symptoms in long COVID are:

·      Respiratory symptoms like Breathlessness and a Cough

·      Cardiovascular symptoms like Chest tightness, chest pain or Palpitations

·      General symptoms like Fatigue, Fever and Pain

·      Neurological symptoms like 'brain fog', loss of concentration or memory issues, Headache, and Dizziness

·      Gastrointestinal symptoms like Abdominal pain, Nausea and vomiting and Diarrhoea

·      ENT symptoms like Tinnitus, Sore throat, Loss of taste and/or smell and Nasal congestion

·      Dermatological symptoms like Skin rashes and Hair loss

·      Mental health symptoms like depression, anxiety and PTSD Symptoms and

·      In addition, absence or reduced performance in education, work or training.

In terms of investigations, we will offer tests and investigations tailored to the symptoms. If clinically indicated, we will offer blood tests, which may include a full blood count, kidney, liver and thyroid function tests, HbA1c, CRP, ferritin, and BNP. 

For people with postural symptoms, for example, palpitations or dizziness on standing, we will check lying and standing blood pressure and heart rate and we will offer a chest X-ray for continuing respiratory symptoms. 

After ruling out severe complications and alternative diagnoses, we will refer to a long COVID clinic.

Their management includes a personalised rehabilitation plan with fatigue management being a key component of this. Breathlessness, fatigue and 'brain fog' are among the most commonly reported long‑term symptoms, so support for these symptoms is also essential.

We will explain that it is not known if over-the-counter vitamins and supplements are helpful, harmful or have no effect in long COVID situations.

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

Thank you for listening and goodbye.

The video version of this episode can be found here:

·      https://youtu.be/2gDK6E85diU

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In the first part of this episode, I go through the NICE guideline [NG28] on Type 2 diabetes in adults, always focusing on what is relevant in Primary Care only. In the second part I go through a thorough review of the guideline with a series of multiple-choice questions. Each question is paired with quotation, aiming to clarify key concepts and enhance understanding. This informative segment is created to support continuous learning 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.  

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 can be found here:

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

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

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

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to do an up to date revision of the NICE guideline on type 2 diabetes. This episode is longer because it has two parts. In the first part, which lasts or about 20 minutes, I go through the NICE guideline itself, always focusing on what is relevant in Primary Care only. In the second part, I will present you with a series of multiple-choice questions so that you can test yourself. After each question, you are given the right answer, which is paired with a guiding quotation. This pairing is designed to clarify key concepts and enhance your continuous learning and retention.

I have created time stamps throughout the video so that you can skip to the section that you wish whenever you want.

Right, let’s jump into it.

Firstly, I will just state that this episode does not cover the management of pregnant women with type 2 diabetes. 

We will offer structured education to patients at the time of diagnosis, with annual reinforcement and, if possible, this should be in the form of group education programmes.

The dietary advice should be the same healthy eating advice as the general population, which includes:

·      high-fibre, low-glycaemic-index sources of carbohydrates

·      low-fat foods and

·      oily fish

And we will discourage foods marketed specifically for people with diabetes. 

If the person is overweight, we should aim for an initial body weight loss target of 5% to 10%, remembering that even a small amount of weight loss may still be beneficial. 

The guideline on type 2 diabetes makes reference to the bariatric surgery guideline which says that we should refer people with type 2 diabetes for consideration of bariatric surgery if they have a BMI of 35 or more. If they have Asian or African-Caribbean family background, we will do so if the BMI is 32.5 or more.

The recommendations on hypertension are broadly the same as for other people so we will simply follow the NICE guideline on hypertension because, when a different approach is needed for people with type 2 diabetes, this is specified in the hypertension guideline.

Additionally, we will not offer antiplatelet therapy (aspirin or clopidogrel) without cardiovascular disease. 

In respect of blood glucose management, broadly speaking we will measure HbA1c:

·      every 3 to 6 months until HbA1c is stable or

·      every 6 months once both HbA1c and therapy are stable. 

If HbA1c is not valid because of disturbed erythrocyte turnover or abnormal haemoglobin type, we will use:

·      plasma glucose levels

·      fructosamine or

·      in cases of abnormal haemoglobins, we will use total glycated haemoglobin

In terms of HbA1c targets, if the diabetes is managed either by diet, or a single drug not associated with hypoglycaemia, we will aim for an HbA1c of 48 mmol/mol or 6.5%. If it’s treated with a drug associated with hypoglycaemia, we will aim for an HbA1c level of 53 mmol/mol or 7.0%. 

If HbA1c on a single drug rises to 58 mmol/mol or 7.5% or higher, we will intensify drug treatment. aiming for an HbA1c of 53 mmol/mol or 7.0%. 

However, we will consider relaxing the HbA1c target, particularly for older or frailer people if:

·      they are unlikely to achieve benefits, for example, because of a reduced life expectancy or if

·      intensive treatment would not be appropriate, for example because of comorbidities or risks of hypoglycaemia. 

If the HbA1c drops below the target, we should consider other possibilities, for example deteriorating renal function or sudden weight loss. 

When considering self-monitoring of blood glucose, we will take into account the DVLA recommendations. But otherwise, we will not routinely offer self-monitoring of capillary blood glucose levels unless:

·      the person is on insulin or oral medication that may increase their risk of hypoglycaemia or

·      there is evidence of hypoglycaemia or

·      they are pregnant or planning to become pregnant

We will consider short-term self-monitoring of blood glucose:

·      when starting oral or intravenous corticosteroids 

·      to confirm suspected hypoglycaemia or

·      if concerned during acute intercurrent illness to help manage their treatment as necessary. 

What about the new technology of continuous glucose monitoring?

Well, we should offer intermittently scanned continuous glucose monitoring (isCGM), commonly referred to as 'flash' if they are on multiple insulin injections and:

·      they have recurrent or severe hypoglycaemia or impaired hypoglycaemia awareness or

·      they are unable to self-test or

·      they have to self-test at least 8 times a day.

We can consider real-time continuous glucose monitoring as an alternative to isCGM if it is available for the same or lower cost.

However, we should advise patients using CGM that they will still need to take capillary blood glucose measurements (although they can do this less often). This is because:

·      they need it to check the accuracy of their CGM device and also because

·      they need it as a back-up

Now let’s have a look at the drug treatment.

In terms of rescue therapy at any stage of treatment, if someone is symptomatically hyperglycaemic, we should consider insulin or a sulfonylurea, and review the treatment when blood glucose control has been achieved. 

Then, as first line drug treatment we will offer standard-release metformin. We will gradually increase the dose over several weeks to minimise the risk of gastrointestinal side effects and, if they appear, we will consider a trial of modified‑release metformin. 

After metformin, we should assess the cardiovascular risk to determine whether they have chronic heart failure or established atherosclerotic cardiovascular disease or are at high risk of it. And then, if they have chronic heart failure or established cardiovascular disease, or are at high risk of it, we will go for an SGLT2 inhibitor. 

When starting dual therapy with metformin and an SGLT2 inhibitor, we will start them sequentially, commencing with metformin and adding the SGLT2 inhibitor as soon as we confirm that metformin is well tolerated.

Now, if metformin is contraindicated or not tolerated, we will do the same. That is, we will assess the cardiovascular risk to determine whether they have chronic heart failure or established atherosclerotic cardiovascular disease or are at high risk of it. And then, if the patient is in any of these categories, we will also go for an SGLT2 inhibitor as monotherapy.

However, if they don’t have chronic heart failure or established atherosclerotic cardiovascular disease, and they are not at high risk of it, we have a lot of flexibility because we can consider:

·      a DPP‑4 inhibitor or

·      pioglitazone or

·      a sulfonylurea or, also,

·      an SGLT2 inhibitor. 

SGLT2 inhibitors have been associated to an increased risk of diabetic ketoacidosis and therefore, before starting them, we need to check whether the person may be at increased risk of DKA, for example if:

·      they have had a previous episode of DKA

·      they are unwell with intercurrent illness or

·      they are following a very low carbohydrate or ketogenic diet

If the patient is following a very low carbohydrate or ketogenic diet, they may need to delay the SGLT2 inhibitor until they have changed their diet, and, once they are on an SGLT2 inhibitor, we will advise them against following this type of diet in the future. 

If a patient’s first line treatment does not include an SGLT2 inhibitor because they do not have chronic heart failure or established atherosclerotic cardiovascular disease, and they are not at high risk of it, but later they fall into one of these categories, we will start an SGLT2 inhibitor either by adding it to their current treatment or by replacing an existing drug with the SGLT2 inhibitor depending on our clinical judgement.

Now, in general, if we need to intensify the drug treatment because monotherapy with metformin is not enough, we also have a lot of flexibility and we will consider adding:

·      a DPP‑4 inhibitor or

·      pioglitazone or

·      a sulfonylurea or

·      an SGLT2 inhibitor. 

Then, if we need to intensify the drug treatment again because dual therapy with metformin and another oral drug is not enough, we will either:

·      start triple therapy by adding a further oral agent, that is, a DPP‑4 inhibitor, pioglitazone, a sulfonylurea or an SGLT2 inhibitor or

·      consider starting insulin

However, if metformin is contraindicated or not tolerated and dual therapy with 2 oral drugs is not enough, we should go straight for insulin. That is, NICE only recommends triple oral therapy if one or the drugs is metformin.

Now, so far, we have not mentioned GLP-1 receptor agonists at all. When does NICE recommend them? Well, if triple therapy with metformin and 2 other oral drugs is not enough, we can consider triple therapy by switching one oral drug for a GLP‑1 receptor agonist if:

·      The BMI is 35 or higher and there are problems associated with obesity, although for people from Black, Asian and other minority ethnic groups we will reduce the BMI to 32.5  or

·      The BMI lower than 35 and:

o  insulin would have occupational implications or

o  weight loss would benefit other comorbidities. 

We will only continue the GLP‑1 receptor agonist if there has been a beneficial metabolic response, which is a reduction of at least 11 mmol/mol or 1.0% in HbA1c and a weight loss of at least 3% of the initial body weight in 6 months. 

NICE also says that a GLP‑1 receptor agonist and insulin should only be combined with specialist advice and ongoing support. 

Now, let’s have a look at the drug management specifically for people with both type 2 diabetes and CKD.

And the guideline on type 2 diabetes says that people with both type 2 diabetes and CKD should have standard CKD treatment with an ACEI or ARB, titrated to the highest licensed dose that the person can tolerate if the ACR is 3 or more.

And once they are on a fully titrated dose of the ACEI or ARB, we will add an SGLT2 inhibitor if:

·      ACR is over 3 (and particularly if it is over 30) and

·      they meet the eGFR thresholds to prescribe the SGLT2 inhibitor.

However, this area is a little confusing because this is the advice on the NICE guideline on type 2 diabetes NG28. However, more recently published NICE guidance in the form of technology appraisals, NICE says that Dapagliflozin is recommended as an add-on to ACEIs or ARBs, if their eGFR is between 25 and 75 and they have type 2 diabetes, without mentioning any ACR thresholds.

And a similar approach appears in the technology appraisal on empagliflozin which says that empagliflozin is recommended as an add-on to ACEIs or ARBs if the patient has type 2 diabetes and their eGFR is between 20 and 90, again without mentioning any ACR levels.

In summary, the technology appraisals recommend the SGLT2 inhibitors dapagliflozin and empagliflozin for people with type 2 diabetes and CKD if eGFR thresholds are met but without ACR thresholds at all. This is in contradiction to the guideline NG28 on type 2 diabetes where ACR thresholds of 3 and 30 are stipulated. Until the situation has been clarified, my personal view would be to follow the most recent guidance, that is, the technology appraisals on dapagliflozin and empagliflozin and offer these drugs to people with type 2 diabetes and CKD if the eGFR thresholds are met without taking into consideration ACR levels.

Now let’s have a look at what NICE says in respect of insulin therapy.

Firstly, when starting insulin, an insulin-specific structured educational programme should be offered to the patient.

If there are no issues, on starting insulin, we will continue to offer metformin and we will review the continued need for other diabetic agents. 

NICE recommends starting insulin following one of these regimens:

·      NPH insulin injected once or twice daily according to need.

·      NPH and short‑acting insulin, administered either:

o  separately or

o  as a pre-mixed or biphasic human insulin preparation.

·      Insulin detemir or insulin glargine can be used, as an alternative to NPH insulin, if:

o  the person needs help to inject insulin, or

o  there is recurrent hypoglycaemia or

o  the person would otherwise need twice‑daily NPH insulin injections as well as oral medication.

·      Pre-mixed or biphasic preparations including short‑acting insulin analogues, rather than short‑acting human insulin preparations, can be used if:

o  injecting immediately before a meal is preferred or

o  hypoglycaemia is a problem or

o  blood glucose levels rise markedly after meals. 

We will switch to insulin detemir or glargine from NPH insulin if:

·      there is hypoglycaemia on NPH insulin or

·      the HbA1c target is not met or

·      they have issues with the device or

·      they need help to inject insulin. 

We will monitor patients on a basal insulin regime, that is, NPH insulin, insulin detemir or glargine for the need for short‑acting insulin. Equally, we will monitor patients on pre‑mixed or biphasic insulin for the need for a further injection of short‑acting insulin before meals or for a change to a basal-bolus regimen, if control remains inadequate. 

Now let’s have a look at the complications and how we would manage them.

We will advise patients at their annual review that:

·      they are at higher risk of periodontitis and that

·      if they get it, managing it can improve their diabetic control and that

·      they should have regular oral health reviews, as advised by their dental team. 

We will suspect gastroparesis if there is erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses and referring if the diagnosis is in doubt or there are persistent or severe symptoms. 

We need to explain to patients with vomiting caused by gastroparesis that:

·      there is no strong evidence that antiemetic therapy is effective

·      some people have had benefit with domperidone, erythromycin or metoclopramide and that

·      the strongest evidence for effectiveness is for domperidone, but its prescribing is limited by its safety profile, in particular its cardiac risk and potential interactions. 

To treat vomiting caused by gastroparesis:

·      we will consider alternating the use of erythromycin and metoclopramide first line and

·      we will consider domperidone only in exceptional circumstances and in accordance with MHRA advice.

For guidance on managing painful diabetic peripheral neuropathy, we are advised to consult the specific guideline on neuropathic pain.

My summary of this guideline is this:

If the neuropathic pain is localised and they wish to avoid oral treatments, we will consider topical treatment in the form of capsaicin cream. 

Otherwise, if oral therapy is preferred, we will offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as the initial treatment. Gabapentin and pregabalin are controlled drugs so it would make sense to start with either amitriptyline or duloxetine first.

If the initial treatment is not effective or tolerated, we will offer one of the remaining 3 drugs, and consider switching again if the second and third drugs are also not effective or tolerated.

And, as a general rule, when withdrawing or switching treatment, we will taper the dose to minimise any withdrawal symptoms.

So, for me, considering the cost of drugs and controlled drug status, I would consider:

1.   Amitriptyline first

2.   Then duloxetine,

3.   Then gabapentin and

4.   Lastly pregabalin

We will obviously refer if despite treatment the pain is severe, disabling or affecting their sleep or if their underlying condition has deteriorated.

As acute rescue therapy for neuropathic pain, we could consider tramadol, but only for short term use, as this is counterproductive in the long term.

When it comes to autonomic neuropathy, we will suspect it if there is a loss of hypoglycaemia awareness. 

After excluding other diagnoses, we will also consider the possibility of autonomic neuropathy affecting the gut or the bladder if there is unexplained diarrhoea or unexplained bladder‑emptying problems respectively. 

In addition, we will bear in mind that patients with autonomic neuropathy who are taking tricyclic drugs and antihypertensive drug treatments, have an increased risk of side effects such as orthostatic hypotension.

For men with erectile dysfunction, also after excluding other diagnoses, we will consider a phosphodiesterase‑5 inhibitor taking into account their cardiovascular state and any contraindications and we will refer them to specialist services if this treatment is unsuccessful. 

I will not go into the management of diabetic foot problems because this is covered in a separate guideline, and in terms of eye disease, I will only say that they need to be referred immediately to the local eye screening service as soon as they are diagnosed with type 2 diabetes.

Right, so this is it, this is the summary of the actual guideline. We will now have a look at some MCQs which will hopefully help you to test your knowledge and also assist you in remembering the facts more effectively.

The range of questions varies from fairly easy and straightforward ones to others which are more complex and require more thinking. After each question and their four options, there will be a pause of a few seconds only.

I also want to stress that the MCQs are intended only to revise concepts in the guideline from a general point of view. We know that diabetes management can be very flexible and it is perfectly fine to deviate from the guideline using our clinical judgement.

Finally, I am going to delegate the reading of the questions to an automated voice. I hope that you find it useful.

Right, so good luck with your self-test!

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/W0LL-1BwV3w?si=OT-GNCXaHoA7dcbs

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through a National Patient Safety Alert released on 3.1.2024 by the Department of Health and NHS England on the shortage of GLP1 receptor agonists, touching on sections of the NICE guideline on type 2 diabetes as well as relevant pharmaceutical information, always focusing on what is relevant in Primary Care only. 

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

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 PDF document related to the safety alert on GLP- RA shortage can be found here:

·      https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAttachment.aspx?Attachment_id=104161

The safety alert on GLP- RA shortage can be found here:

·      https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103245

The Central Alerting System Homepage can be found here:

·      https://www.cas.mhra.gov.uk/Home.aspx

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

Transcript

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

Hello and welcome, I am Fernando, a GP in the UK. In this episode I will go through a National Patient Safety Alert released on 3.1.2023 by the Department of Health and NHS England on the shortage of GLP1 receptor agonists, touching on sections of the NICE guideline on type 2 diabetes as well as relevant pharmaceutical information, always focusing on what is relevant in Primary Care only.

If you want to access the safety alert website or the associated PDF document, the link is in the episode description.

Right, let’s jump into it.

You are probably aware that the supply of GLP-1 receptor agonists continues to be limited, with supplies not expected to return to normal until at least the end of 2024. The supply issues have been caused by an increase in demand for these products for licensed and off-label indications.

The situation at the moment is that exenatide as Byetta® will be discontinued in March 2024. In addition, liraglutide as Victoza® continues to be out of stock and further stock is not expected until end of 2024. The supply of other agents such as injectable semaglutide as Ozempic® and Dulaglutide as Trulicity® may be unreliable and the shortages may cause significant issues.

So, what is the solution?

Well, oral semaglutide has come to the rescue. Semaglutide as Rybelsus® tablets are now available in sufficient quantities to support initiation of GLP-1 RA for type 2 diabetes in line with NICE guidance. 

So let’s remind ourselves of what NICE recommends for type 2 diabetes. 

NICE says that if triple therapy with metformin and 2 other oral drugs is not effective, not tolerated or contraindicated, we can consider triple therapy by switching one drug for a GLP‑1 receptor agonist if:

·      The BMI is 35 or higher and there are psychological or medical problems associated with obesity. We will adjust the BMI to 32.5 for people from Black, Asian and other minority ethnic groups or

·      For lower BMIs if:

o  insulin would have occupational implications or

o  weight loss would benefit other significant comorbidities.  

NICE also says that we should only continue GLP‑1 receptor agonists if there is a reduction in HbA1c of at least 1.0% or 11 mmol/mol and weight loss of at least 3% of the initial body weight in 6 months.  

And NICE also states that starting GLP1 RAs in combination with insulin should only happen following specialist advice and with ongoing support from a consultant-led service.  

So, what do we need to do until supply issues have resolved?

1. First, we must only prescribe GLP-1 RAs for licensed indications.

2. Second, we will prescribe Rybelsus® tablets for new initiations

3. Third, we should identify patients prescribed Byetta® and Victoza® and switch to Rybelsus® tablets, counselling patients accordingly and referring to structured education and weight management programmes where available

4. Fourth, we will discuss stopping GLP1-RA if patients have not achieved a beneficial metabolic response as per the NICE guideline, that is, again, a reduction in HbA1c of at least 1% or 11 mmol/mol and weight loss of at least 3% of initial body weight in 6 months. 

5. And finally, we should not double up a lower dose preparation or switch between strengths solely based on availability. 

So, if oral semaglutide is going to be prescribed a lot more, let’s familiarise ourselves with it and let’s have a look at the summary of product characteristics.

How do we initiate oral semaglutide or Rybelsus tablets?

The starting dose of oral semaglutide is 3 mg once daily for one month. After one month, the dose should be increased to a maintenance dose of 7 mg once daily. After at least one month on 7 mg, if necessary, the dose can be increased to a maintenance dose of 14 mg once daily to further improve glycaemic control.

The maximum recommended dose of oral semaglutide is 14 mg once daily but this should be achieved by prescribing one 14mg tablet, not two 7mg tablets.

What about if the patient is already on subcutaneous semaglutide? Well, switching between oral and subcutaneous semaglutide cannot be easily predicted because of the high pharmacokinetic variability of oral semaglutide. However, we can say that oral semaglutide 14 mg once daily is comparable to s.c. semaglutide 0.5 mg once weekly. An oral dose equivalent to 1.0 mg of s.c. semaglutide has not been established.

How should it be taken? It should be taken on an empty stomach, swallowed whole with a sip of water (up to a maximum of half a glass of water equivalent to 120 ml). Splitting, crushing or chewing the tablets may decrease the absorption.

Patients should wait at least 30 minutes before eating, drinking or taking other drugs. Waiting less than 30 minutes also decreases the absorption.

When oral semaglutide is used in combination with metformin, an SGLT2i or pioglitazone, the current dose of those drugs can be continued.

However, when used in combination with a sulfonylurea or with insulin, a reduction in the dose of sulfonylurea or insulin may be considered to reduce the risk of hypoglycaemia. Blood glucose self-monitoring is necessary for this reduction but otherwise, self-monitoring of blood glucose is not needed to adjust the dose of semaglutide.

No dose adjustment is required for patients with hepatic or renal impairment but semaglutide is not recommended in patients with end-stage renal disease.

When should we use it with caution?

Semaglutide should not be used in patients with bariatric surgery, severe congestive heart failure, type 1 diabetes mellitus or for the treatment of DKA. Diabetic ketoacidosis has been reported in insulin-dependent patients who had a rapid dose reduction of insulin following the start of oral semaglutide.

The use of GLP-1 receptor agonists may be associated with gastrointestinal adverse reactions that can cause dehydration, which in rare cases can lead to a deterioration of renal function. Nausea, diarrhoea, and vomiting tend to be mild to moderate in severity and of short duration normally during the first months on treatment.

Patients should be informed of the risk of acute pancreatitis and if it is suspected, semaglutide should be discontinued and, if confirmed, it should not be restarted. Caution should be exercised in patients with a history of pancreatitis.

In patients with diabetic retinopathy treated with insulin and s.c. semaglutide, an increased risk of developing diabetic retinopathy complications has been observed, and this risk cannot be excluded for oral semaglutide.

Because of a drug interaction, patient on levothyroxine should have their thyroid function tests monitored closely.

So, we have an oral medication that is simple to take and has few interactions. Why has it not been more widely recommended instead of the seemingly more problematic injections?

And the answer is because of its pharmacokinetic properties.

Oral semaglutide has a variable absorption and a low bioavailability, approximately 1% following oral administration. As we have mentioned, the absorption of semaglutide is decreased if taken with food or large volumes of water and a longer post-dose fasting period results in higher absorption.

The variability in absorption between patients is also high and if the treatment response is lower than expected, we need to be aware that it may be due to a low absorption and that 2-4% of patients will not have any exposure to it after oral administration.

On the other hand, with an elimination half-life of approximately 1 week, semaglutide will be present in the circulation for about 5 weeks after the last dose. The primary excretion routes are via the urine and faeces. 

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

Thank you for listening and goodbye.

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through new and updated guidelines published in December 2023 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. 

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

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 2023 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2023-12-01&to=2023-12-30&ndt=Guidance&ndt=Quality+standard 

The links to the update guidance covered can be found here:

Bipolar disorder: assessment and management:

·      https://www.nice.org.uk/guidance/cg185

Empagliflozin for treating chronic kidney disease:

·      https://www.nice.org.uk/guidance/ta942

Cardiovascular disease: risk assessment and reduction, including lipid modification:

·      https://www.nice.org.uk/guidance/ng238

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in December 2023, focusing on what is relevant in Primary Care only. We will be covering: valproate toxicity, empagliflozin for CKD, and cardiovascular risk reduction.  

The episode is fairly short so let’s jump into it.

The first clinical area refers to the use of valproate in the bipolar disorder guideline, in line with new MHRA guidance published in November 2023.

And perhaps we should remember that the previous MHRA advice stated that valproate must not be used in women and girls of childbearing potential unless other options are unsuitable and a pregnancy prevention programme is in place.

But the new safety advice is much stricter and states that valproate must not be started in people (either male or female) younger than 55 years, unless 2 specialists independently consider that there is no other treatment, or that the reproductive risks do not apply.

So, let’s have a look at this in a bit more detail.

We know that valproate must not be used in pregnancy as well as in any female of child bearing age unless there is a Pregnancy Prevention Programme in place, which involves an annual review and the requirement for highly effective methods of contraception (such as a hormonal intrauterine device). This is because of the risks of malformations and developmental problems.

Valproate is a known teratogenic drug, resulting in both physical birth defects and neurodevelopmental harm including lower intellectual abilities, poor language skills and memory problems.

Although the risk of structural malformations is greatest in the first trimester, the risk of neurodevelopmental harm is thought to be present throughout, and therefore valproate is never safe in pregnancy.

But the new guidance also includes males. Why is this?

Well, although less information is available regarding reproductive risk in male patients; these risks remain an area of concern. The risks of impaired fertility or male infertility with valproate have been known for some years. Additionally, there is suspected testicular toxicity in younger males and further studies are being carried out in this respect.

Furthermore, it is thought that there is an unknown risk to the foetus from paternal exposure to valproate in respect of both congenital abnormalities and neurodevelopmental disorders, including autism spectrum disorders, and further studies are underway to evaluate this.

Finally, there is also a concern about possible transgenerational risk. Whilst we know about harm in the first-generation offspring, animal studies have shown that some behavioural changes are transmitted by both males and females in the second and third generations. The underlying mechanisms of these findings are unknown, although we know that valproate can induce DNA changes which could lead to this transmission.

At present, we still await more studies focusing on transgenerational risk as well as possible epigenetic effects of valproate.

The next area refers to empagliflozin for treating chronic kidney disease.

And we know that the management of CKD aims to slow its progression. Standard care is lifestyle changes, and usually ACE inhibitors or ARBs. In addition, dapagliflozin is also recommended as an add-on to optimised standard care if eGFR is between 25 and 75 and the patient has type 2 diabetes or an ACR of 22.6 or more.

Clinical trial evidence suggests that empagliflozin plus standard care is also beneficial. There are no clinical trials directly comparing empagliflozin with dapagliflozin in CKD but an indirect comparison suggests that empagliflozin has a similar effectiveness and safety to dapagliflozin. The main empagliflozin clinical trial did not include anyone with eGFR levels less than 20 and patients with eGFR between 45 and 90 were only included if they also had an ACR of 22.6 or more. Therefore, empagliflozin can also be recommended, but only:

·      as an add-on to optimised standard care with an ACEi or ARB, unless contraindicated, and

·      if eGFR is:

o  more than 20 and but less than 45 or

o  between 45 and 90 and either the patient has:

§ an ACR of > 22.6

§ or type 2 diabetes

And the third and final area refers to the risk reduction of cardiovascular disease. The main update affects the lipid targets in the secondary prevention of CVD. But there are also some other changes in the recommendations for primary prevention.

So, let’s look at the statin recommendations for primary prevention first:

People with and without type 2 diabetes should have atorvastatin 20 mg daily if they have a 10‑year QRISK3 score of 10% or more. But, and this is slightly different now, we should not exclude patients just because the 10‑year QRISK3 score is less than 10% if either the patient would like to take a statin or if we feel that the risk may be underestimated. 

The lipid target for primary prevention is a greater than 40% reduction in non-HDL cholesterol. 

For people with type 1 diabetes, the recommendations are slightly different. We will offer atorvastatin 20 mg if they:

·      are over 40 or

·      have had diabetes for > 10 years or

·      have nephropathy or other CVD risk factors. 

But equally, we should now consider statin treatment for those aged 18 to 40 with type 1 diabetes, including those who have had diabetes for 10 years or less. 

NICE has changed the recommendations because evidence shows that statins are cost effective for people with 10‑year CVD risk scores of less than 10% because of the greater reduction in CV events. However, the recommendation to consider atorvastatin 20 mg for people with QRISK3 scores less than 10% is a change in practice and will have practical consequences in Primary Care in terms of both cost and workload.

Let’s now have a look at the recommendations for statin therapy for secondary prevention, which apply to people both with and without type 1 and 2 diabetes.

And the main change relates to a change in the lipid target. So, now, for secondary prevention, we need to aim for LDL cholesterol levels of 2.0 or less, or non-HDL cholesterol levels of 2.6 or less.

The initial treatment for secondary prevention is with atorvastatin 80 mg, whatever their cholesterol level, although we can consider a lower dose if:

·      there are drug interactions

·      there is a high risk of side effects or

·      the person would prefer a lower dose. 

In terms of escalating treatment for people on statins, there are also new recommendations.

First, if the person is on the maximum dose of a statin but the lipid target for secondary prevention is not met, we should consider additional lipid-lowering treatments with ezetimibe or the injectables alirocumab, evolocumab and inclisiran

This is because studies have shown that the combination of a statin and one of those other 4 lipid-lowering drugs produces reductions in both cholesterol and major CV events. The use of these drugs is also cost effective in people with an LDL of 2 or more or a non HDL cholesterol of 2.6 or more.

Second, we can also consider ezetimibe in addition to statins, even if the lipid target is met. This is because studies have shown that the combination is effective in reducing CV events and ezetimibe is cost effective regardless of cholesterol levels.

It is expected that the new recommendations will lead to an increased use of lipid-lowering treatments. This will result in higher costs to the NHS and also an increased workload in primary care. However, the extra cost of lipid-lowering treatment would be partly offset by savings due to a reduction in CVD events

There are also some new minor changes as to when to repeat blood tests. The guidance says that we should measure liver transaminase and full a lipid profile at 2 to 3 months after starting or changing the lipid-lowering treatment. A timeframe of 2 to 3 months offers more flexibility and is reflective of actual clinical practice, rather than at 3 months of treatment as recommended in the 2014 guideline. The requirement to check a full lipid profile instead of a random cholesterol level, will result in higher monitoring costs too.

After that, we will measure liver transaminase at 12 months, but not again unless clinically indicated. However, an annual medication review offering an annual full lipid profile is recommended for both primary and secondary prevention.

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

Thank you for listening and goodbye.

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the NICE guidance on the management of lower urinary tract symptoms in men.

I will summarise the guidance from a Primary Care perspective only.

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

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

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

The full clinical guideline CG97 on lower urinary tract symptoms in men: management can be found here:

·      https://www.nice.org.uk/guidance/cg97

The International Prostatism Symptom Score calculator can be found here:

·       https://www.uptodate.com/contents/calculator-international-prostatism-symptom-score-ipss

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

• Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE guidance on the management of lower urinary tract symptoms in men, which I have summarised from a Primary Care perspective.

So, let’s jump into it.

And to appreciate fully the importance of this subject, let’s have a look at this anonymous poem:

“As man draws near the common goal

Can anything be sadder

Than he who, master of his soul

Is servant to his bladder‟

And, of course, we know that the prevalence and severity of male lower urinary tract symptoms, also known as LUTS, increase with age and although transurethral resection of the prostate is often effective, about a quarter of men have poor post-surgical outcomes and some failures can be attributed to an incorrect initial diagnosis.

So, let’s start by talking about the conditions that can cause LUTS in men.

And in order to get the correct diagnosis, we should remember the ancient Chinese proverb that says that the “bladder is the mirror of the soul‟ and therefore LUTS can result from not only bladder dysfunction or prostatic pathology but also from a number of other causes, e.g., metabolic, hormonal, cardiac, respiratory, etc. And therefore, effective therapy depends on the accurate diagnosis of the underlying problem.

Although, the most common cause is benign prostate enlargement (BPE), which obstructs the bladder outlet, the term LUTS is an umbrella term introduced to dispel the perception that male urinary symptoms are simply caused by prostate problems.

Because other conditions, for example, detrusor muscle problems, prostatitis, UTIs, prostate cancer and neurological disease, can also cause LUTS.

We also need to be aware of the 3 stages of the bladder cycle, which are:

·      Storage - during which filling of the bladder occurs

·      Voiding - during which the bladder actively expels its contents and

·      Post micturition - immediately after voiding when the bladder returns to storage function.

And as a result, LUTS comprise three different types of symptoms:

·      First, storage symptoms normally causing daytime urinary frequency, nocturia, urgency and urinary incontinence

·      voiding symptoms, causing slow stream, spraying, intermittency, hesitancy, straining, and terminal dribbling and

·      post micturition symptoms, for example, sensation of incomplete emptying, and post micturition dribbling

In the management of male LUTS we need to understand that we are dealing with a complex functional unit comprising the bladder, bladder neck/prostate and urethra. LUTS may result from a combination of factors and, to avoid confusion, we should use the correct clinical terms. So let’s have a look at them:

·      “Benign prostatic hyperplasia” or BPH should be reserved for histopathological prostate hyperplastic changes (i.e. abnormality at the cell level). The prevalence of BPH increases with age and whilst it is often associated with LUTS, only 25% to 50% of men with BPH have symptoms.

·      “Benign prostatic enlargement” or BPE refers to an increase in size of prostate gland due to BPH. But only about half of men with hyperplasia will develop clinical enalrgement.

·      “Bladder outlet obstruction” (BOO) is an urodynamically diagnosed condition characterised by increased detrusor pressure and reduced urine flow rate.

·      “Overactive bladder” presents with urinary urgency, with or without incontinence, usually with frequency and nocturia. OAB does not include stress incontinence due to a weak sphincter or overflow incontinence due to chronic retention.

·      And finally, Detrusor overactivity (DO) is urodynamically characterised by involuntary detrusor contractions during the bladder filling phase and occurs in about two thirds of OAB cases and 50% of those with BOO.

There is also a clear association between LUTS and sexual dysfunction, including erectile dysfunction, ejaculatory dysfunction, decreased sexual activity and decreased sexual desire. However, we will not cover this area in today’s episode.

At initial assessment in General Practice, we will review their current medication and take a history and examination including an examination of the abdomen, genitalia, a digital rectal examination as well as a urine dipstick. 

We will check creatinine and eGFR if concerned about renal impairment and we will give information about PSA testing if:

·      their LUTS are suggestive of bladder outlet obstruction secondary to benign prostate enlargement (BPE) or

·      their prostate feels abnormal on digital rectal examination or

·      they are concerned about prostate cancer

If there are bothersome LUTS we could ask the patient to complete a urinary frequency volume chart and we will refer if the patient has not responded to the initial management or have complications such as UTIs, retention, renal impairment or suspected urological cancer. 

For uncomplicated LUTS, we will not routinely offer:

·      Cystoscopy

·      Imaging of the upper urinary tract

·      Flow-rate measurement

·      a post-void residual volume measurement

Although these investigations as well as other ones may be carried out following specialist referral.

To assess response to treatment, we should use a validated symptom score (for example, the International Prostatism Symptom Score or IPSS) before and after the intervention. There are online calculators that can facilitate this and I have included a link in the episode description.

As conservative management, we should offer advice on fluid intake and lifestyle measures, for example:

• cut down on fizzy drinks, and/or drinks that contain alcohol or caffeine

• avoid excessive drinking, aiming for between 1.5 and 2 litres of fluid a day and

• avoid constipation

If there is post-micturition dribble, we will advise how to perform urethral milking. 

If LUTS are suggestive of overactive bladder, we should refer to local community continence services for supervised bladder training

We should refer to urology if there is stress urinary incontinence but

If stress urinary incontinence is caused by prostatectomy, we should offer supervised pelvic floor muscle training for at least 3 months, again via local community continence services.

For urinary incontinence:

·      We will give temporary products, for example, pads or collecting devices, while waiting for a definitive management.

·      External collecting devices, for example, sheath appliances, pubic pressure urinals should be used before indwelling catheterisation

·      Intermittent bladder catheterisation should be considered before indwelling catheterisation.

·      Long-term indwelling urethral catheterisation maybe suitable when:

• medical management has failed and surgery is not appropriate and
• the patient is unable to manage intermittent self-catheterisation or
• there are skin problems aggravated by contact with urine or
• the patient is distressed by bed and clothing changes and

We will refer patients with symptoms of urinary retention and ensure that:

·      Men with acute retention are catheterised urgently and that

·      An alpha blocker should be given before removal of the catheter

·      Checking creatinine and imaging of the upper urinary tract is recommended for chronic urinary retention and

·      Surgery or permanent catheterisation will be guided by urology services

Drug treatment will be offered only when conservative management has been unsuccessful, after taking into account comorbidities and current medication.

Drug treatment may be guided by Urology but, in summary, we should be aware of the following:

·      An alpha blocker (like alfuzosin, doxazosin, tamsulosin or terazosin) can be offered to men with moderate to severe LUTS

·      An anticholinergic can be given if there are symptoms of an overactive bladder

·      A 5‑alpha reductase inhibitor such as finasteride can be given if LUTS are present with a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml

·      A combination of an alpha blocker and a 5‑alpha reductase inhibitor can be given if they have both moderate to severe LUTS and a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml.

·      An anticholinergic as well as an alpha blocker can be given if there are storage symptoms such as daytime urinary frequency, nocturia, urgency and urinary incontinence after treatment with an alpha blocker alone. 

·      A late afternoon loop diuretic may be offered if there is nocturnal polyuria although this is an unlicensed indication

·      Oral desmopressin may be offered to men with nocturnal polyuria if other medical causes have been excluded and they have not benefited from other treatments. This is an unlicensed indication and sodium should be measured 3 days after the first dose and desmopressin should be stopped if sodium is below the normal range.

We need to be aware that medical conditions that can cause nocturnal polyuria symptoms include diabetes mellitus, diabetes insipidus, adrenal insufficiency, hypercalcaemia, liver failure, polyuric renal failure, chronic heart failure, obstructive apnoea, dependent oedema, pyelonephritis, chronic venous stasis, and sickle cell anaemia.

Equally, medications that can cause nocturnal polyuria symptoms include calcium channel blockers, diuretics, and SSRIs.

We will review patients regularly to monitor symptoms and medication:

·      We will review men taking alpha blockers at 4 to 6 weeks and then every 6 to 12 months. 

·      We will review men taking 5‑alpha reductase inhibitors at 3 to 6 months and then every 6 to 12 months. 

·      We will review men taking anticholinergics every 4 to 6 weeks until symptoms are stable, and then every 6 to 12 months. 

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

Thank you for listening and goodbye.

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through a number of NICE products on insomnia, including guidance on the medical technology sleepio, and the prescribing of z-drugs, daridodexant and melatonin.

I will summarise the guidance from a Primary Care perspective only.

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

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:  

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here:  

The Practical GP YouTube Channel: 

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

The Medical technologies guidance [MTG70] on “Sleepio to treat insomnia and insomnia symptoms” can be found here:

·      https://www.nice.org.uk/guidance/mtg70

The Technology appraisal guidance [TA77] “Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia” can be found here:

·      https://www.nice.org.uk/guidance/ta77

The Technology appraisal guidance [TA922] “Daridorexant for treating long-term insomnia” can be found here:

·      https://www.nice.org.uk/guidance/ta922

The Evidence summary [ES38] “Melatonin for treating sleep disorders in adults who are blind” can be found here:

·      https://www.nice.org.uk/advice/es38/chapter/Product-overview

Thumbnail photo: from Freepik: https://www.freepik.com/

·      Image by Freepik

·      Image by a href="https://www.freepik.com/free-photo/flat-lay-woman-laying-bed_28694061.htm#query=insomnia&position=21&from_view=search&track=sph&uuid=65539da6-4c29-453b-9d22-c39df5176601"Freepik/a

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

Music provided by Audio Library Plus   

Watch: https://youtu.be/aBGk6aJM3IU  

Free Download / Stream: https://alplus.io/halfway-through  

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through a number of NICE publications on insomnia, including guidance on digital cognitive behavioural therapy for insomnia (CBT-I), and the prescribing of hypnotics, daridodexant and melatonin, all of them from a Primary Care perspective.

By the way, make sure that you stay for the entire episode because, at the end, I will go through some audit ideas backed by NICE which you could use as a Quality Improvement Project in your practice.

So, let’s jump into it.

Let’s talk a little about the condition first.

Insomnia is a disturbance of sleep characterised by difficulty in initiating and/or maintaining sleep. However, insomnia is highly subjective and although most healthy adults typically sleep between 7 and 9 hours per night, patterns vary between people, and in any given person there are also variations from night to night.

Estimates of the prevalence of insomnia vary and while up to 48% of people have reported sleeping issues, only 6% met the criteria for a diagnosis of insomnia. So, in general practice, differentiating between simple sleeping problems and significant insomnia is important before considering treatment.

The prevalence of insomnia is higher in women and increases with age and, although the majority do not seek medical advice, the treatment depends on the duration and nature of the symptoms. Appropriate management of co-morbidities may help and sleep hygiene advice is fundamental, for example, avoiding stimulants and maintaining regular sleeping hours with a suitable environment for sleep. Other non-pharmacological interventions, for example, cognitive behavioural therapies, are also effective.

Insomnia can have a number of different causes: primary insomnia can be differentiated from insomnia associated with factors such as personal circumstances, physical or psychiatric co-morbidities, concomitant drug treatments or substance abuse. Epidemiology surveys have shown that over half of people with sleep problems have either a mental or a physical health disorder.

And in this video, we will not be talking about specific issues caused by physical conditions such as sleep apnoea or narcolepsy or sleep disturbances associated to severe mental illness.

For the management, it is crucial to differentiate between short-term insomnia and long-term insomnia.

For short-term insomnia, sleep hygiene advice is offered. After this, medicines such as zopiclone, zolpidem and melatonin can be used for a short time, that is, less than 4 weeks or less than 13 weeks for melatonin. In addition, up to 40% of people with insomnia self-medicate with over-the-counter drugs, for example, sedative antihistamines.

However, long-term insomnia, also known as chronic insomnia, is different and it’s defined as dissatisfaction with quantity or quality of sleep for 3 nights or more per week for at least 3 months with an effect on daytime functioning. Therefore, long-term insomnia has both night-time and daytime symptoms. Furthermore, once insomnia has lasted for more than 6 months, it may last for years and be difficult to resolve.

For long term insomnia, sleep hygiene advice is given first and then, CBT-I is the recommended first-line treatment. But there are access difficulties to CBT-I across the country and in many areas access is poor. And this is a real pity because CBT-I has a 70% to 80% response rate and roughly 50% experience long-term remission.

NICE has published 17 products on insomnia but the majority are for sleep apnoea and narcolepsy. Only 4 would be relevant for this video and these are:

·      The Medical Technology Sleepio

·      Advice on hypnotics like benzodiazepines and Z-drugs such as zolpidem and zopiclone

·      Recommendations on Daridorexant

·      And finally, we will also briefly touch on melatonin

Sleepio is a digital self-help programme that includes CBT‑I and that reduces symptoms compared with sleep hygiene and sleeping tablets. The gold standard treatment for insomnia is face-to-face CBT-I, but its availability is very limited and therefore Sleepio is recommended as an alternative to sleeping tablets. Unfortunately, Sleepio is not available on the NHS in all regions of the UK either.

Let’s have a look at the recommendations on hypnotics like benzodiazepines and Z-drugs such as zolpidem and zopiclone. They can be considered after sleep hygiene but for a short time only and bearing in mind that they do not treat any underlying cause.

A number of hypnotic agents are licensed for the treatment of insomnia, including benzodiazepines and Z-drugs.

Benzodiazepines enhance the effects of GABA, which is the major inhibitory neurotransmitter in the central nervous system. Examples licensed for insomnia are, amongst others, nitrazepam, temazepam and lorazepam.

The effects of benzodiazepines are dependent upon the dose administered and the pharmacokinetic profile. The BNF refers to temazepam and lorazepam, as having a shorter duration of action. Benzodiazepines with a longer half-life like diazepam and nitrazepam tend to have prolonged effects the next day.

The main concern with benzodiazepines is that many people develop tolerance to their effects, gain little benefit from chronic use, become both physically and psychologically dependent on them, and suffer withdrawal symptoms when stopping them. 'Rebound insomnia' also occurs and is characterised by worsening insomnia symptoms.

The use of benzodiazepines for the treatment of insomnia should be restricted to severe insomnia and treatment should not be continued beyond 4 weeks.

Zolpidem and zopiclone (the Z-drugs) are non-benzodiazepine hypnotics. Although the Z-drugs differ structurally from the benzodiazepines, they are also agonists of the GABA receptor complex and therefore enhance GABA-mediated neuronal inhibition.

Zolpidem has a half-life of 2.5 hours and Zopiclone of between 3.5 and 6.5 hours. They are licensed for "the short-term treatment of insomnia in situations where the insomnia is debilitating or is causing severe distress for the patient". The duration of treatment is a maximum of 4 weeks, including tapering off where appropriate.

Although the Z-drugs were developed to overcome the disadvantages of benzodiazepines, the sedative effects of the Z-drugs may also persist into the next day and they can cause tolerance, dependence and withdrawal symptoms.

It may be worth mentioning that, a review of the trial evidence comparing the Z-drugs with benzodiazepines licensed for insomnia showed, in summary, that there were no clinically useful differences between the drugs.

Because of the lack of evidence to distinguish between zolpidem and zopiclone, the drug with the lowest purchase cost should be prescribed and switching from one to another should only occur if a patient experiences adverse effects considered to be directly related to a specific agent.

Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others.

So, we have now seen that short term insomnia can be treated with sleep hygiene and short-term use of hypnotics and long-term insomnia with sleep hygiene and either face to face CBT-I or digital CBT-I like Sleepio.

But what does NICE recommend for long term insomnia if CBT-I or Sleepio have not worked or are not available?

And here is where we find the latest NICE guidance on this issue, published in October 2023. It refers to a new type of drug, Daridorexant.

And NICE says that Daridorexant is both clinically and cost effective and it is recommended for insomnia lasting for 3 nights or more per week for at least 3 months, with affected daytime functioning but only if:

·      cognitive behavioural therapy for insomnia (CBT-I) is ineffective or

·      it is not available or is unsuitable.

What is daridorexant? Well, Daridorexant is now available on the BNF and unlike benzodiazepines and Z-drugs, which work by increasing sedation, daridorexant is a new type of drug, an orexin antagonist, which works in a different way. It inhibits arousal mechanisms. To understand this, we need to know that orexins are neuropeptides produced by the hypothalamus which promote a state of wakefulness. Therefore, daridorexant, by blocking the orexin receptors, reduces wakefulness and helps sleep.

Because of the different mechanism of action, if necessary, daridorexant could be used at the same time as other medicines or non-medicine treatments available for insomnia.

And the good news is that, in clinical studies, there has been no evidence of abuse or withdrawal symptoms indicative of physical dependence.

NICE recommends that the length of treatment should be as short as possible and the treatment should be reviewed within 3 months of starting and at regular intervals thereafter. But it can be used as maintenance treatment for managing longer-term symptoms if necessary.

Now let’s touch on the prescribing of Melatonin for insomnia.

Melatonin is a hormone that occurs naturally in the body. It is involved in regulating sleep and circadian rhythms and it can be given as an oral medication to treat sleeping problems.

There is little NICE guidance on the use of melatonin. There is only an evidence summary on the use of melatonin for treating sleep disorders in adults who are blind, and, because of insufficient evidence, NICE was unable to determine its clinical effectiveness and safety.

The BNF states that melatonin is indicated as:

·      Short-term treatment for Insomnia in adults over 55 for up to 13 weeks

·      Short-term treatment for Jet lag in adults for up to 5 days, and

·      Treatment for Insomnia in patients with learning disabilities and challenging behaviour, although this use is unlicensed and it needs to be initiated under specialist supervision

Cautions for melatonin include autoimmune disease, as exacerbations have been reported occasionally, and susceptibility to seizures, as there is a risk of increased seizure frequency

Reported side effects are, amongst others, arthralgia, increased risk of infection, drowsiness, headaches, and pain

Now, as promised let’s have a look at audit ideas on the use of hypnotics (including Z-drugs) suggested by NICE and that you could use for a Quality Improvement Project in your Practice.

The objectives for the audit would be to assess the appropriateness of use of zolpidem and zopiclone.

The patients to be included in the audit could be, for example, all those for whom zolpidem and zopiclone are prescribed for a suitable period of time, for example, 3–6 months.

Possible audit criteria could be the following four:

Criterion 1- Non-pharmacological measures are considered before prescribing:

·      The standard would be 100% of all patients without exception

Criterion 2- When prescribed, hypnotic drug therapy is prescribed for a short period of time only, in strict accordance with the licensed indications:

·      The standard would also be 100% of all patients without exception

Criterion 3- When prescribed, the hypnotic drug with the lowest cost is chosen:

·      The standard would be 100% of all patients with the exception of those who have developed side effects with a cheaper first line agent

Criterion 4- A patient is switched from one hypnotic drug to another:

·     As switching is not recommended, the standard would be 0% of all patients with the exception of those who have developed adverse effects considered to be directly related to a specific agent

Once compliance has been calculated, the Practice can identify whether clinical management can be improved, agree on a plan and repeat the measurement after a period of time to close the audit cycle and to confirm that the desired improvement has been achieved.

And there you have it, a simple project to fulfil your QIP requirements for appraisal.

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

Thank you for listening and goodbye.

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through new and updated guidelines published in November 2023 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

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

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

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

The Clinic BP targets flowchart can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFp2iUfq8rimJSmo?e=BnJaCD

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

The Full NICE News bulletin for November 2023 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2023-11-01&to=2023-11-30&ndt=Guidance&ndt=Quality+standard

The links to the update guidance covered can be found here:

Hypertension in adults: diagnosis and management:

·      https://www.nice.org.uk/guidance/ng136

Transient loss of consciousness ('blackouts') in over 16s:

·      https://www.nice.org.uk/guidance/cg109

Suspected acute respiratory infection in over 16s: assessment at first presentation and initial management:

·      https://www.nice.org.uk/guidance/ng237

Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction:

·      https://www.nice.org.uk/guidance/ta929

Thumbnails photos: From Freepik: Download Free Videos, Vectors, Photos, and PSD - https://www.freepik.com/

o  Image by Freepik: Image by a href="https://www.freepik.com/free-photo/doctor-checking-blood-pressure-male-patient_14001674.htm#query=blood%20pressure%20lying%20down&position=38&from_view=search&track=ais&uuid=cdea12ca-0d0a-43b4-a4a1-2b7142ffb839"Freepik/a

o  Image by master1305 on Freepik:

o  a href="https://www.freepik.com/free-photo/visiting-nurse-health-visitor-taking-care-senior-man_11163175.htm#query=low%20blood%20pressure&position=40&from_view=keyword&track=ais&uuid=e445d882-3755-471d-a9f6-61aaa7f1bbd9">Image by master1305/a on Freepik

o  Image by kjpargeter on Freepik:

o  a href="https://www.freepik.com/free-photo/3d-render-medical-background-with-male-figure-lungs-covid-19-virus-cells_22404919.htm#page=2&query=chest%20infection&position=24&from_view=search&track=ais&uuid=9048f228-9941-4745-8afd-4d60e59daa45">Image by kjpargeter/a on Freepik

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

Music provided by Audio Library Plus  

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in November 2023, focusing on what is relevant in Primary Care only. We will be covering: postural hypotension, empagliflozin for HFpEF, and acute respiratory infections.

Make sure to stay for the entire episode because, at the end, I will go through the new tables published by NICE summarising blood pressure targets in the hypertension guideline as well as in the guidelines on type 1 diabetes and CKD. If you wish to download a version of this table, I will put a link in the episode description

The episode is fairly short so let’s jump into it.

The first clinical area is an update on the guidance on measuring and managing postural hypotension.

This update is the result of an issue raised with NICE. The previous outdated guideline recommended that for people with symptoms of postural hypotension such as falls or postural dizziness, we should take the initial measurement of blood pressure either in the seated or supine position, and then have the BP measured again with the person standing for at least 1 minute. This is to establish if there is a significant BP drop when the person is standing.

However, it was queried that measuring blood pressure in the sitting (rather than the supine position) followed by the standing position may miss a significant proportion of postural hypotension cases, particularly in older and frail people.

So, following the review, it was decided that, based on international consensus, supine to standing blood pressure measurement is the best practice and it is preferable to the sitting to standing measurements.

Therefore, the guideline was updated along these lines. However, the guidance still says that if it is inconvenient to take the blood pressure measurement in the supine position, a seated position may be considered.

This change affects not only the guideline on hypertension but also the guideline on transient loss of consciousness.

So, in summary the new recommendations state that when checking for postural hypotension, the lying down or supine position is preferred to a seated position, then we will recheck the standing BP after at least 1 minute of the patient standing and if the systolic blood pressure falls by 20 mmHg or more, or diastolic blood pressure falls by 10 mmHg or more when standing, then we will diagnose postural hypotension. In that case:

·      We will consider the likely causes including a medication review

·      We will manage the risk of falls appropriately

·      And we will consider referral to specialist care if symptoms persist

However, if the BP drop is less than these thresholds despite a suggestive history:

·      We will repeat the measurements with the person lying down if the first measurement was taken while seated and

·      We will refer the person for specialist cardiovascular assessment if the symptoms persist and remain unexplained.

As a reminder, we should check for postural hypotension in people:

·      With symptoms such as falls or postural dizziness as well as people

·      With type 2 diabetes and those

·      Aged 80 or over

And we must also remember that if there is a significant postural drop or three are symptoms of postural hypotension, we will treat to a blood pressure target based on standing blood pressure.

Finally, on a separate issue, NICE will no longer use in their guidelines the term “orthostatic hypotension” and they will only use the term “postural hypotension” instead.

The second clinical area refers to the use of empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction

You may be aware that empagliflozin is already recommended for chronic heart failure with reduced ejection fraction in adults and that dapagliflozin is recommended for both HFrEF and HFpEF.

And following this update, empagliflozin is now recommended as an option for chronic heart failure with preserved or mildly reduced ejection fraction in adults, although it should only be started on the advice of a heart failure specialist.

And let’s remind ourselves that chronic heart failure with preserved or mildly reduced ejection fraction is usually treated with standard care using loop diuretics, and treatment for other comorbidities that the patient may have and, following a recent NICE updates, patients may also have dapagliflozin.

Empagliflozin works in a similar way to dapagliflozin and evidence shows that empagliflozin also reduces cardiovascular mortality and hospitalisations for heart failure. There is no clinical trial evidence directly comparing empagliflozin with dapagliflozin but when adjustments for clinical trial differences are made, the comparison suggests that both drugs have similar clinical effect on quality of life.

Also, because empagliflozin has similar costs to dapagliflozin, empagliflozin can therefore be recommended too.

The third and final clinical area is on the initial management of suspected acute respiratory infection. And, to be honest, this update is hardly worth mentioning because it only spells out what we have always been doing, that is, that the threshold for treatment or referral may be lower for people who are more likely to have a poor outcome, for example, people with comorbidities or multimorbidity and people who are frail. So, we may be justified prescribing antibiotics early, or admitting those patients who we are most worried about because of their age, frailty or medical conditions.

And now, as promised, let’s have a look at the two tables that NICE has produced to clarify the blood pressure targets. But we must first remember that there are separate guidelines for hypertension in pregnancy.

And there are 2 tables, one for the under 80s and one for those aged 80 and over. And these tables cover people with hypertension with or without type 2 diabetes as well as people with CKD or type 1 diabetes.

So, in the under 80s we have two targets:

·      Below 140/90 for those with:

o  Hypertension, with or without type 2 diabetes

o  Type 1 diabetes and ACR less than 70 or

o  CKD and ACR less than 70

·      Below 130/80 for those with

o  Type 1 diabetes and ACR of 70 or more or

o  CKD and ACR of 70 or more

And, in those aged 80 and over, we have three targets:

·      Below 150/90 for those with:

o  Hypertension, with or without type 2 diabetes or, and this may come as a surprise,

o  Type 1 diabetes regardless of ACR levels. Then it is

·      Below 140/90 for those with:

o  CKD and ACR less than 70 and finally it is

·      Below 130/80 for those with

o  CKD and ACR of 70 or more

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

Thank you for listening and goodbye.

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom.

In this episode I will go through the NICE guideline on “Menopause: diagnosis and management” or NICE guideline NG23.

I will summarise the guidance from a Primary Care perspective only.

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

There is a YouTube version of this and other videos that you

can access here: 

• The Practical GP YouTube Channel: 

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

The NICE guideline NG23 “Menopause: diagnosis and

management” can be found here: 

https://www.nice.org.uk/guidance/NG23

The guidance

from the Faculty of Sexual & Reproductive Healthcare on contraception for

women aged over 40 years can be found here:

http://www.fsrh.org/pdfs/ContraceptionOver40July10.pdf

The MHRA summary of HRT risks and benefits during current use and

current use plus post-treatment from age of menopause up to age 69 years, per

1000 women with 5 years or 10 years use of HRT can be found here:

https://assets.publishing.service.gov.uk/media/5d680409e5274a1711fbe65a/Table1.pdf

The summary flowchart with examples of preparations can be found here:     

https://1drv.ms/b/s!AiVFJ_Uoigq0mFjbJIiJs842urJB?e=FcfiJl

Thumbnail photo: from Freepik: https://www.freepik.com/    

Image by LipikStockMedia on

Freepik: ahref="https://www.freepik.com/free-photo/beautiful-woman-50-years-old-enjoys-yoga-she-is-meditating-by-cupping-her-palms-front-her-with-her-eyes-closed-she-dreams-personal-one-close-up-shot_23935463.htm#page=2&query=menopause&position=9&from_view=search&track=sph&uuid=9a84a386-a034-42ca-ac20-add7c2fb2d27"Image

by LipikStockMedia/a on Freepik

Intro / outro music: Track:

Halfway Through — Broke In Summer [Audio Library Release]  

Music

provided by Audio Library Plus  

Watch: https://youtu.be/aBGk6aJM3IU 

Free

Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome, I am Fernando, a GP in the UK. Mrs Brown sees you

because wants to discuss HRT in detail, including the pros and cons of the

various preparations available. Do you say?: “of course, ask me anything you

want” or do you go? …..

If you are in the second group then you know exactly how I feel. So, today,

we will go through the NICE guideline on the diagnosis and management of the

menopause from a Primary Care perspective.

Make sure to stay for the entire episode because, at the end, I will

also go through a one-page summary flowchart giving cost effective examples of

various preparations available which you will also be able to download

So, let’s jump into it.

And let’s start by saying that possible symptoms of

the menopause include:

·       a change in their menstrual

cycle

·       vasomotor symptoms (e.g., hot

flushes and sweats)

·       musculoskeletal symptoms (e.g.,

joint and muscle pain)

·       effects on mood (e.g., low mood)

·       urogenital symptoms (e.g.,

vaginal dryness) and

·       sexual difficulties (e.g., low

sexual desire).

When these symptoms are present, most women will

ask for a blood test to check if they are menopausal. Is this really necessary?

Well, most of the time, it isn’t. Because NICE says that we can make the

following diagnoses without checking FSH:

perimenopause in women over 45 with vasomotor

symptoms and irregular periods and

menopause in women over 45:

·       If they are not using

contraception and have had no periods for at least 12 months or

·       based on symptoms alone if the

woman does not have a uterus

Of course, diagnosis can be more difficult if they are on hormonal

treatments but still, we should not check FSH if the woman is on combined

hormonal contraception or high-dose progestogen.

However, we will consider checking FSH levels to diagnose menopause:

·       in women aged 40 to 45 with

menopausal symptoms, including a change in their menstrual cycle and

·       in women under 40 in whom the menopause

is suspected.

Once we have made the diagnosis, we will give information about lifestyle

changes, and benefits and risks of treatments, giving information about:

·       hormonal treatment, e.g. HRT

·       non-hormonal treatment, e.g.

clonidine

·      

non-pharmaceutical treatment,

e.g. CBT

We will also give information about contraception in the perimenopausal

and postmenopausal phase. I have put a link to the guidance in the episode

description but a very simplified summary is that:

·       CHC should be stopped at 50 and

switch to a safer method

·       Contraception can be stopped at

55 as the risk of pregnancy is extremely low by then

If the menopause is a result of medical or surgical treatment, we will:

·       Give information about fertility

before that treatment and

·       We will refer to a menopause

specialist

In terms of managing menopausal symptoms, this

summary is not intended for women with premature ovarian insufficiency, that is, women aged under 40

For vasomotor symptoms we will offer HRT after discussing benefits and

risks. We will offer a choice of:

·       oestrogen and progestogen to

women with a uterus or

·       oestrogen alone to women without

a uterus.

We will not routinely offer SSRIs, SNRIs or clonidine as first-line

treatment for vasomotor symptoms alone.

We will explain that there is some evidence that isoflavones or black

cohosh may relieve vasomotor symptoms but that:

·       preparations may vary

·       their safety is uncertain and

·       Drug interactions have been

reported

In terms of psychological symptoms, we will consider HRT to treat menopause

related low mood

And also consider CBT to treat menopause related low mood or anxiety

Remember that there is no clear evidence for SSRIs or SNRIs for low mood

in menopausal women without a diagnosis of depression.

We will consider testosterone supplementation for menopausal women with

low sexual desire if HRT alone is not effective. The BNF says that it is not licensed for this indication so seeking specialist

advice before initiation may be advisable

For urogenital atrophy we will offer vaginal oestrogen (including for

those on systemic HRT) and we will continue treatment for as long as needed to

relieve symptoms.

We will also consider vaginal oestrogen for urogenital atrophy in those

for whom systemic HRT is contraindicated, after seeking specialist advice.

If vaginal oestrogen does not relieve symptoms we will also seek

specialist advice before increasing the dose

However we will also explain that:

·       symptoms often come back when

treatment is stopped

·       that adverse effects from

vaginal oestrogen are very rare and

·       that they should report

unscheduled vaginal bleeding

Moisturisers and lubricants for vaginal dryness can be used alone or in

addition to vaginal oestrogen.

And finally we will not offer routine monitoring of endometrial

thickness during treatment with vaginal oestrogen.

In terms of complementary therapies we will explain that the efficacy,

safety, quality and purity of unregulated compounded bioidentical hormones may

be unknown and we will also advise that there is also uncertainty about the

appropriate use of St John's wort

Once treatment has been started, we will review patients:

·       at 3 months to assess the efficacy

and tolerability and

·       annually thereafter unless more

often is clinically indicated

We will refer women for specialist advice if:

·       treatments are ineffective or

cause side effects

·       there are contraindications to

HRT or

·       there is uncertainty about the

most suitable treatment option

In terms of starting and stopping HRT, we will explain that unscheduled vaginal

bleeding is a common side effect of HRT within the first 3 months of treatment

but it should be reported at the 3-month review, or promptly if it occurs after

the first 3 months

When stopping HRT we will consider the choice of gradually reducing or

immediately stopping treatment explaining that:

·       gradually reducing HRT may limit

recurrence of symptoms in the short term but that

·       either approach makes no

difference to their symptoms in the longer term

There are separate guidelines on the treatment of

menopausal symptoms for women with, or at high risk of, breast cancer, but

in general:

·       we will refer to a menopause

specialist

·       and ensure that paroxetine and

fluoxetine are not given if the patient is on tamoxifen

In terms of long-term benefits and risks of HRT, there

is an MHRA summary of HRT risks and benefits that we can refer to explain the

absolute rates per 1000 women with 5 years or 10 years use of HRT. It is a

useful one-page resource and I have included a link to this table in the

episode description.

But in summary, let’s go through the different possible risks.

In terms of venous thromboembolism we will explain that:

·       the risk of VTE is increased by

oral HRT

·       that the risk is greater for

oral than transdermal preparations and

·       that the risk of transdermal HRT

is no greater than baseline

Therefore we will consider transdermal rather than oral HRT if the woman

is at increased risk of VTE, including those with a BMI over 30

But we will consider haematology referral if the patient is at high

risk, e.g.:

·       if there is a strong family

history of VTE or thrombophilia

For cardiovascular disease we will explain that HRT:

·       does not increase CVD risk if

aged under 60 and

·       that it does not affect the

cardiovascular mortality

And we must remember that cardiovascular risk factors are not a

contraindication to HRT as long as they are optimally managed.

So we will explain that:

·       the baseline CVD risk varies

depending on risk factors

·       that HRT with oestrogen alone is

associated with no, or reduced, risk of coronary heart disease

·       and that HRT with oestrogen and

progestogen is associated with little or no increase in the risk of coronary

heart disease

But we will also explain that oral oestrogen is associated with a small

increase in the risk of stroke but that the baseline risk under 60 is very low

We will indicate that HRT does not increase the risk of developing type

2 diabetes and does not have an adverse effect on glucose control but we will consider

comorbidities and specialist advice before giving HRT in type 2 diabetes

In terms or breast cancer risk, we will make it

clear that:

·       the baseline risk varies

according to risk factors

·       that HRT with oestrogen alone is

associated with little or no change in the risk

·       that HRT with oestrogen and

progestogen can be associated with an increase in the risk of breast cancer but

·       that any increase in the risk is

related to treatment duration and it goes down after stopping HRT

When discussing osteoporosis, we will give women advice on bone health

and inform them that the risk of fragility fracture around menopausal age is

low and varies from one woman to another.

We will say that their risk of fragility fracture is reduced while

taking HRT and that this benefit:

·       remains during treatment but

decreases once HRT stops and

·       that it may continue for longer

for those who take HRT for longer

We will tell patients that the effect of HRT on the

risk of dementia is unknown

And that:

·       HRT may improve muscle mass and

strength

·       And that Being active helps

maintain muscle mass and strength

We will now touch on the diagnosis and management

of premature ovarian insufficiency

And we will diagnose premature ovarian insufficiency under 40 years of

age based on:

·       menopausal symptoms (including

no or infrequent periods) and

·       elevated FSH levels on 2 samples

taken 4–6 weeks apart

We will not diagnose premature ovarian insufficiency on a single blood

test and we will not routinely check anti-Müllerian hormone to diagnose it

If there is doubt about the diagnosis, we will seek specialist advice

For their management we will consider referral but

we may also offer a choice of HRT or a combined hormonal contraceptive unless

contraindicated

We will explain:

·       the importance of hormonal

treatment either with HRT or a combined hormonal contraceptive until at least

the age of natural menopause

·       that the baseline population

risk of diseases such as breast cancer and cardiovascular disease increases

with age and is very low in women aged under 40

·       that HRT may have a beneficial

effect on blood pressure when compared with a combined oral contraceptive

·       that both HRT and combined oral

contraceptives offer bone protection and

·       that HRT is not a contraceptive 

If hormonal treatment is contraindicated we will give advice on bone and

cardiovascular health.

Now, as promised, let’s have a look at our one-page summary flowchart,

giving you some cost-effective examples of preparations that we can use.

Obviously, these will change from time to time so keep an eye on your local

formulary too. You can download this flowchart by clicking on the link in the

episode description.

And we will start with the transdermal options remembering that they

should be the first-choice route particularly for women with high risk factors,

including a BMI over 30, as they are unlikely to increase the risk of VTE or

stroke, unlike the oral preparations.

Examples of oestrogen only preparations for women with no uterus, we

have twice weekly patches like evorel and estradot with their different

strengths as well as gels and sprays like oestrogel, sandrena and lenzetto. We

may also use these preparations for women with a uterus if we avoid endometrial

hyperplasia and the increased risk of endometrial cancer by giving

progestogenic opposition with a levonorgestrel IUS or Mirena Coil or micronized

progesterone like utrogestan capsules.

As an example of sequential combined HRT causing a monthly bleed for

women with a uterus, we have twice weekly Evorel sequi patches

Continuous period free combined HRT, is not suitable in the

perimenopause or within 12 months of the last menstrual period and an example

would be twice weekly evorel contipatches

We will now look at the oral options.

And an example of an oestrogen only oral preparation is Elleste Solo

with two different strengths

Examples or oral sequential combined HRT offering a monthly bleed are

femoston and elleste duet also with their two different strengths

 And examples of period free oral

continuous combined HRT preparations, again not suitable in the perimenopause

or within 12 months of the last menstrual period we have femoston conti and its

low dose version, indivina, kliofem and elleste duet conti. Second line

preparations would be bijuve and tibolone but researching the pros and cons of

these last two may be advisable

We also have a few boxes about low oestrogen options, for example for

women 60 or over like evorel 25 patch and oestrogel as unopposed oestrogens or,

as continuous combined preparations, femoston conti with 0.5mg of oestradiol or

kliovance.

We also have a reminder about addressing lifestyle factors and optimally

managing conditions like hypertension and diabetes.

And also, that herbal medicines are not available on prescription and

they are largely unregulated products lacking consistency.

And for urogenital atrophy we can use ovestin cream, vagirux vaginal

tablets, imvaggis pessaries, estring vaginal rings and blissel gel

And finally, of course, we have over the counter vaginal moisturisers

such as replens MD and Yes VM

We have come to the end of this episode. Remember that this is not

medical advice and it is only my summary and my interpretation of the

guideline. You must always use your clinical judgement.

Thank you for listening and goodbye.

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the NICE guideline on “Headaches in over 12s: diagnosis and management”, or NICE guideline CG150.

I will summarise the guidance from a Primary Care perspective only.

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

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

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

The NICE guideline CG150 “Headaches in over 12s: diagnosis and management” can be found here:

·      https://www.nice.org.uk/guidance/cg150/chapter/Recommendations

Thumbnail photo: from Freepik: https://www.freepik.com/

·      Image by Drazen Zigic on Freepik

·      a href="https://www.freepik.com/free-photo/low-angle-view-distraught-man-holding-his-head-pain-while-sitting-living-room_26343742.htm#query=headache&position=2&from_view=search&track=sph"Image by Drazen Zigic/a on Freepik

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

• Music provided by Audio Library Plus  
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 



Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE guideline on headaches and I will summarise the guidance from a Primary Care perspective only.

So, let’s jump into it.

We will start by looking at the diagnostic clinical features that could help differentiate between tension‑type headache, migraine and cluster headache.

·      First, we have the Pain location which:

o  In Tension headache:  is usually Bilateral

o  In Migraine: can be Unilateral or bilateral

o  And in Cluster headache: is Unilateral (usually around the eye, above the eye and along the side of the head/face)

·      Then we look at the Pain quality which:

o  In Tension headache: is usually Pressing or tightening and non‑pulsating

o  In Migraine: is generally Pulsating (although it can be described as throbbing or banging in those aged 12 to 17 years)

o  And in Cluster headache: it is Variable (sharp, boring, burning, throbbing or tightening)

·      The Pain intensity is:

o  Mild or moderate in Tension headache:

o  Moderate or severe in Migraine:

o  And Severe or very severe in Cluster headache:

·      In terms of the Effect on activities we find that:

o  Tension headache: Is Not aggravated by routine activities

o  Migraine: is Aggravated by, or causes avoidance of, routine activities

o  And Cluster headache: causes Restlessness or agitation

·      Looking at Other possible symptoms we find that:

o  Tension headache: doesn’t usually have any

o  Migraine: usually produces Sensitivity to light and/or sound or nausea and/or vomiting. There can also be aura symptoms, which we will cover in more detail later.

o  and Cluster headache: will normally present On the same side as the headache:

• red and/or watery eye
• nasal congestion and/or runny nose
• swollen eyelid
• forehead and facial sweating
• constricted pupil and/or drooping eyelid

·      and finally, in terms of Duration of the headache:

o  Tension headaches can be from 30 minutes to continuous:

o  Migraine: can be 4 to 72 hours in adults but 1 to 72 h in those aged 12 to 17 

o  And Cluster headache:  usually lasts 15 to 180 minutes

Episodic tension-type headaches or episodic migraines occur on fewer than 15 days per month. Chronic tension-type headaches or chronic migraines occur on 15 or more days per month for more than 3 months. Chronic migraine and chronic tension‑type headache commonly overlap so, if there are features of migraine, we will diagnose chronic migraine.

On the other hand, Episodic cluster headaches occur from once every other day to 8 times a day with a pain-free period of more than 1 month. Chronic cluster headaches have the same frequency, that is from once every other day to 8 times a day but with a pain-free period of less than 1 month in a 12-month period.

And now let’s look at Migraine with aura in more detail.

And we will Suspect aura with or without headache if the symptoms:

·      are fully reversible and

·      develop gradually over at least 5 minutes and

·      last for 5 to 60 minutes. 

And typical aura symptoms include:

·      visual symptoms that may be positive (for example, flickering lights, spots or lines) and/or negative (for example, partial loss of vision)

·      sensory symptoms that may be positive (for example, pins and needles) and/or negative (for example, numbness)

·      and speech disturbance. 

We can diagnose migraine with aura if typical aura symptoms are present, but we will Consider further investigations and referral if the symptoms are atypical such as:

·      motor weakness 

·      double vision 

·      visual symptoms affecting only one eye 

·      poor balance or

·      decreased level of consciousness. 

We will Suspect Menstrual‑related migraine if it’s predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles. 

And now we will touch on Medication overuse headache, which we will Consider if taking the following drugs for 3 months or more:

·      triptans, opioids, ergots or combination analgesics on 10 days/month or more or

·      paracetamol, aspirin or an NSAID on 15 days per month or more. 

In terms of Management of all headache disorders we will consider further investigations and referral if there worrying symptoms or signs such as:

·      worsening headache with fever

·      thunderclap headache or a sudden‑onset headache with maximum intensity within 5 minutes

·      new‑onset neurological deficit

·      new‑onset cognitive dysfunction

·      change in personality

·      impaired level of consciousness

·      recent head trauma (within the past 3 months)

·      headache triggered by cough, Valsalva, sneeze or exercise

·      orthostatic headache (headache that changes with posture)

·      symptoms suggestive of giant cell arteritis- Branches of the carotid artery and the ophthalmic artery are usually involved, giving rise to symptoms of headache, visual disturbances and jaw claudication.

·      symptoms and signs of acute narrow angle glaucoma, which may include headache with a painful red eye and misty vision or haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster headache by the presence of a semi‑dilated pupil compared with the presence of a constricted pupil in cluster headache.

·      And a substantial change in the headache. 

We will also consider further investigations and/or referral if there is new‑onset headache with:

·      compromised immunity, for example, by HIV or immunosuppressive drugs

·      age under 20 years and a history of malignancy

·      a history of malignancy known to metastasise to the brain

·      and vomiting without other obvious cause. 

If we want to consider a headache diary, it should be followed for a minimum of 8 weeks.

Now let’s have a look at the acute and prophylactic treatments of the various types of headaches. 

For the Acute treatment of Tension‑type headache we will Consider aspirin, paracetamol or an NSAID but we will not offer opioids and because of Reye's syndrome, aspirin should not be offered to under 16s

For the Prophylactic treatment of tension-type headache we will Consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks

For the Acute treatment of Migraine with or without aura, we will Offer combination of an oral triptan and an NSAID, or an oral triptan and paracetamol. If aged 12 to 17 years consider a nasal triptan in preference, for example nasal sumatriptan. And For people who prefer to take only one drug, we will consider monotherapy with an oral triptan, NSAID, aspirin (900 mg) or paracetamol.

We will not offer ergots or opioids for the acute treatment of migraine but we will Consider additional anti‑emetic even in the absence of nausea and vomiting. 

If oral preparations (or nasal preparations if aged 12 to 17 years) are ineffective or not tolerated:

·      we will consider a non‑oral preparation of metoclopramide or prochlorperazine (for example buccal prochlorperazine) and

·      we will consider adding a non‑oral NSAID or triptan if they have not been tried.

And following a recent update, NICE says that the drug Rimegepant can be used, only if:

·      at least 2 triptans have been tried before but were ineffective or

·      if triptans cannot be used, and Paracetamol and NSAIDs are not effective.

For migraine prophylaxis, we will advise that riboflavin (400 mg once a day) may be effective for some people and that this is available as a food supplement. We will also offer topiramate or propranolol and we will consider amitriptyline but we will not offer gabapentin. We will then Review the need for continuing migraine prophylaxis after 6 months.

When prescribing migraine prophylaxis, we will consider:

·      consider the risk of foetal malformations with topiramate

·      discuss the risk of reduced effectiveness of hormonal contraceptives with topiramate

·      explain the importance of effective contraception with topiramate, for example, by using medroxyprogesterone acetate depot injection, an intrauterine method or combined hormonal contraception with a barrier method, bearing in mind that we will not routinely offer combined hormonal contraceptives if there is migraine with aura. 

·      And we will Use caution when prescribing propranolol if there is a history of depression as they could be at an increased risk of using propranolol for self-harm.

If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks

For Menstrual-related migraine we will Consider frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) on the days migraine is expected. 

And for Treatment of migraine during pregnancy, we will Offer paracetamol but we may Consider triptan or an NSAID after discussing the risks during pregnancy and we will Seek specialist advice for migraine prophylaxis during pregnancy. 

For the Acute treatment of Cluster headache we will Discuss with a specialist the need for neuroimaging for people with a first bout of cluster headache and we will then Offer oxygen and/or a subcutaneous or nasal triptan. 

When using oxygen for the acute treatment of cluster headache:

·      We will use 100% oxygen at a flow rate of at least 12 litres per minute with a non‑rebreathing mask and a reservoir bag and

·      We will arrange provision of home and ambulatory oxygen. 

When using a subcutaneous or nasal triptan, we will prescribe an adequate supply calculated according to their history and on the manufacturer's maximum daily dose. 

And we will not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for cluster headache. 

As Prophylactic treatment of cluster headache, we will Consider verapamil and, The BNF says that it should be initiated under specialist supervision, including advice on ECG monitoring and we will seek specialist advice if it does not respond or during pregnancy. 

For Medication overuse headache we will Explain that it is treated by withdrawing the overused medication and we will Advise to stop overused medications for at least 1 month and to stop abruptly rather than gradually. 

We will also explain that headache is likely to get worse before they get better and we will provide them with close follow‑up and support, considering prophylactic treatment for the underlying primary headache disorder.

We will Consider specialist referral and inpatient management for people who are using strong opioids, or have relevant comorbidities, or if previous attempts have been unsuccessful. 

We will then Review the diagnosis and management 4 to 8 weeks after stopping overused medication. 

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

Thank you for listening and goodbye.