Primary Care Guidelines

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 “Heavy menstrual bleeding: assessment and management”, or NICE guideline [NG88.

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 NG88 “Heavy menstrual bleeding: assessment and management” can be found here:

·      https://www.nice.org.uk/guidance/ng88/chapter/Recommendations

The Menorrhagia mind map or flow chart can be downloaded here:

·      https://1drv.ms/i/s!AiVFJ_Uoigq0mFegr4-vdKdhitAI?e=BJRIDK

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

·      Image by benzoix on Freepik

·      a href="https://www.freepik.com/free-photo/young-woman-with-pain-stomach-holding-hands-belly-feeling-terrible-ache-menstrual-cramps-stand_34232826.htm#query=heavy%20periods&position=17&from_view=search&track=ais"Image by benzoix/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 
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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE guideline on menorrhagia or, to be precise, “Heavy menstrual bleeding: assessment and management” and I will summarise the guidance from a Primary Care perspective only.

So, let’s jump into it.

We will obviously start with the history including the nature and impact of the bleeding and we will particularly pay attention to what NICE refers to as “related symptoms”. These are symptoms such as:

·      Persistent intermenstrual bleeding

·      Pelvic pain and/or

·      Pressure symptoms, because

they might suggest a uterine abnormality.

What may come as a surprise is that NICE says that if none of these symptoms are present, that is, no IMB, no pain and no pressure symptoms, we will consider pharmacological treatment without necessarily carrying out a physical examination.

But the converse is true, a physical examination is recommended if such symptoms exist or if we are considering a levonorgestrel-releasing intrauterine system [LNG IUS], that is, a Mirena coil or similar. 

In terms of blood tests:

·      we will perform a FBC for all patients and

·      we will consider testing for coagulation disorders if they have had heavy periods since they started and there is a personal or family history suggestive of it

·      However, NICE says that there is no need for routine ferritin, hormone or thyroid testing

We will then consider investigations for the cause of the HMB but

We will also consider starting pharmacological treatment without investigating the cause if we feel that there is a low risk of uterine abnormality.

If we do investigate further, we will consider the need for:

·      Hysteroscopy

·      A pelvic USS or

·      A transvaginal USS

And we will choose each investigation depending on whether we suspect:

·      submucosal fibroids, polyps or endometrial pathology (in which case a hysteroscopy would be needed)

·      larger fibroids (in which case a pelvic USS would be needed) or

·      adenomyosis (when a transvaginal USS would be recommended)

And we will use our clinical judgement to decide which one of those we should consider as most likely. For example:

·      We will suspect submucosal fibroids, polyps or endometrial pathology (and therefore the need to refer for possible hysteroscopy plus / minus biopsy) if, for example:

o  They are taking tamoxifen

o  They have persistent intermenstrual or irregular bleeding,

o  They have infrequent heavy bleeding and are obese or have PCOS or if

o  They have not responded to treatment. 

·      We will think about larger fibroids (and therefore the need to request a pelvic USS) if:

o  there is a palpable uterus on abdominal examination,

o  a Pelvic mass is suspected and

o  we will also consider a pelvic USS if the examination is inconclusive or difficult, because, for example, obesity

·      And we will think about adenomyosis (and therefore the need for a transvaginal USS) if:

• There is a bulky, tender uterus on examination or
• There is significant dysmenorrhoea or period pain but we also need to be aware that pain may be caused by endometriosis rather than adenomyosis

If hysteroscopy is declined, we will consider a pelvic ultrasound, explaining its limitations

If a transvaginal ultrasound is declined or unsuitable, we will consider a transabdominal ultrasound or MRI, also explaining their limitations.

Let’s now look at the management of menorrhagia. As we have previously said, we will refer for hysteroscopy those patients in whom we suspect an endometrial pathology, so we will leave their management in the hands of secondary care. 

So, from a Primary Care perspective, and for the purpose of their management we need to group the remaining patients into two types:

·      Patients with no identified pathology, with fibroids less than 3 cm in diameter, or with adenomyosis and

·      Patients with fibroids of 3 cm or more in diameter

For the first group, that is, patients with no identified pathology, with small fibroids, or adenomyosis, we will consider an LNG-IUS first line, as long as, if there are small fibroids, they do not cause distortion of the uterine cavity 

On offering this treatment, we will explain to them:

·      about the anticipated changes in bleeding pattern, particularly in the first few cycles and maybe lasting longer than 6 months and

·      that it is advisable to wait for at least 6 cycles to see the benefits of the treatment. 

If LNG-IUS is declined or unsuitable, we will consider pharmacological treatments, either:

·      non-hormonal like:

o  tranexamic acid and

o  NSAIDs or

·      Hormonal like:

o  combined hormonal contraception and

o  cyclical oral progestogens, also bearing in mind that

o  Progestogen-only contraception may suppress menstruation, which could be beneficial for some patients too

If the symptoms are severe or do not respond to pharmacological treatment, or the patient declines pharmacological treatment, we will refer.

For the second group, that is, patients with fibroids of 3 cm or more in diameter

We will consider referral and, if pharmacological treatment is needed while waiting investigations, we will consider tranexamic acid and/or NSAIDs, but we need to be aware that the effectiveness of pharmacological treatments may be limited if fibroids are substantially greater than 3 cm in diameter. 

Depending on the size, location and number of fibroids, and the severity of the symptoms a number or other treatments may be considered by secondary care, including further pharmacological or surgical treatments.

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 October 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 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 bulleting for October 2023 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2023-10-01&to=2023-10-31&ndt=Guidance&ndt=Quality+standard

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

Rimegepant for treating migraine:

·      https://www.nice.org.uk/guidance/ta919

Thyroid disease: assessment and management

·      https://www.nice.org.uk/guidance/ng145

Tirzepatide for treating type 2 diabetes

·      https://www.nice.org.uk/guidance/ta924

Suspected cancer: recognition and referral

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

Suspected neurological conditions: recognition and referral

·      https://www.nice.org.uk/guidance/ng127

Hearing loss in adults: assessment and management

·      https://www.nice.org.uk/guidance/ng98

Daridorexant for treating long-term insomnia

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

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 October 2023, focusing on what is relevant in Primary Care only. We will be covering: migraines, thyroid function tests, diabetes, suspected cancer and insomnia.

So let’s jump into it.

The first clinical area is an update on a new migraine medication, rimegepant.

And NICE says that Rimegepant is recommended, 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.

What is Rimegepant?

Well, gepants are a new class of drugs that have been developed specifically for the treatment of migraines. Rimegepant is a calcitonin gene-related peptide receptor antagonist so it works by blocking this CGRP receptor. And although the mechanism of action is not fully understood, we know that this receptor is involved in the development of migraines. Gepants can be used as an acute treatment and, although rimegepant has a licence for migraine prophylaxis, NICE does not recommend it for this indication.

Unlike triptans, gepants do not cause vasoconstriction so they do not have the same cardiovascular contraindications and cautions as triptans. Rimegepant is an oral lyophilisate that should be placed on the tongue or under the tongue and it will disintegrate in the mouth and can therefore be taken without liquid.

The next update refers to thyroid disease and it says that when ordering thyroid function tests, patients should be routinely asked about biotin use. This is because the MHRA has reported that biotin may cause thyroid test results to be falsely increased or decreased, leading to inappropriate management. Biotin is increasingly found in dietary supplements which are typically taken for hair, skin and nail health so we should always check whether patients are taking such supplements over the counter.

The third area refers to a new diabetic agent, tirzepatide, and, like GLP1 receptor agonists, it is recommended if type 2 diabetes is not controlled:

·      on triple therapy with metformin and 2 other drugs, and

·      they have a BMI of 35 or more, with obesity related health problems, or

·      they have a BMI of less than 35, and:

o  insulin therapy would have significant occupational implications, or

o  weight loss would benefit other significant complications.

But we will use lower BMI thresholds (usually reduced by 2.5) for people from non-white family backgrounds.

We all know the supply issues that we have had with various GLP1 receptor agonists, so is tirzepatide a new GLP1 drug coming to the rescue? Well, not really. Because Tirzepatide is both a GIP and a GLP-1 receptor agonist, so it is a dual agent. It is a weekly injectable and clinical trials suggest that tirzepatide reduces HbA1c and BMI more than semaglutide. Weight reduction with tirzepatide is more pronounced with higher doses, whereas reductions in HbA1c seem less dose-dependent. 

No dose adjustment is required for patients with hepatic and renal impairment including end stage renal disease (ESRD) but experience with these patients is limited so we should exercise caution.

The Mechanism of action of tirzepatide is by increasing Insulin secretion and sensitivity, reducing Glucagon and delaying Gastric emptying

The next clinical area refers to suspected cancer: recognition and referral, and the guidance has been updated to reflect the new NHS standard on faster cancer diagnosis.

So, what this means is that, rather than focusing on these patients being seen within 2 weeks, the aim now is for them to have a diagnosis or have cancer ruled out within 28 days from referral.

This change applies when:

·      the referring GP suspects cancer

·      there are breast symptoms even where cancer is not initially suspected or when

·      there is an abnormal National Cancer Screening result.

So, this update will also appear in a number of other guidelines including, for example:

-         Neurological conditions

-         Ovarian cancer and

-         Urinary incontinence

Next there is also an update saying that we should use a suspected cancer pathway for adults of Chinese or south-east Asian family origin who develop hearing loss and a middle ear effusion not associated with an upper respiratory tract infection.

This is because of the higher incidence of nasopharyngeal carcinoma (NPC) in these populations. Nasopharyngeal carcinoma is rare in most parts of the world, but it’s much more common in East and Southeast Asia, which suggests that genetic and/or environmental factors can contribute substantially to its development.  

The final guidance is on Daridorexant for treating long-term insomnia. And NICE says that Daridorexant 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 (CBTi) is ineffective or

·      it is not available or is unsuitable.

What is daridorexant? Well, 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

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.

However, it is worth mentioning that, in October 2023, Daridorexant was still not available on the BNF.

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 Clinical 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 GP in the United Kingdom. In today’s episode I look at a fictitious clinical case of a patient created by Chat GPT to see how the NICE guidelines could apply to it. 

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: 

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 patient was created using the following Chat GPT prompt:

A)   Provide a fictitious patient. Details that you should include are:

1)   patient's medical information including:

·      name

·      age

·      sex

·      ethnicity

·      BMI

·      blood pressure

2)   medical history- you must include:

·      either one or two of the following poorly controlled conditions:

·      type 2 diabetes

·      hypertension

·      dyslipidaemia,

·      Asthma or COPD

·      Any number of other medical conditions of your choice, along with whether they are well controlled or not – the medication for these conditions should appear in the next section “medications”

1. Medications given:

·      indicate whether the patient is currently taking medication for each medical condition or not.

·      If medication is prescribed for a condition, indicate the specific drug(s) and their dosages. You may choose to prescribe one, two, or three drugs for each condition as appropriate.

3)   State whether the patient tolerates the medication well or not, and if not, describe the side effect(s) and their severity.

4)   blood test results (give a bulleted list but do not number them):

·      HbA1c expressed in % and mmol/mol

·      renal function tests to include creatinine (expressed first in µmol/L and then in mg/dL), eGFR, urea, sodium, and potassium (expressed in UK units first and then USA units)

·      lipid profile expressed both in mmol/L first and then in mg/dL.

·      If the patient has asthma, give the peak flow reading expressed as a percentage of their best or expected reading.

·      If the patient has COPD, give the FEV1 reading expressed as a percentage of the predicted reading

·      include any other relevant test results for the patient, expressing them in both UK and USA units. If the patient has hypothyroidism or takes levothyroxine medication, provide the results of their thyroid function tests, including both T4 and TSH levels, in both UK and USA units. Also, include the normal range for these investigations.

B)  Provide the patient's cardiovascular risk using the QRISK2 tool, calculated as a percentage of the likelihood of experiencing a cardiovascular event over the next 10 years.

C)   At the end of the patient information, ask: 'What treatment recommendations would you make?' – do not make recommendations yourself

D)  Do not include a disclaimer that the patient is fictitious.

The NICE hypertension flowcharts can be found here: 

• Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517 
• Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn 

The full NICE Guideline on hypertension (NG136) can be found here: 

• Website: https://www.nice.org.uk/guidance/NG136 
• Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus 

The full NICE Guideline on Type 2 diabetes (NG28) can be found here: 

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

The full NICE guidance on cardiovascular disease risk reduction (CG181) can be found here: 

·      https://www.nice.org.uk/guidance/cg181

The full NICE guidance on asthma (NG80) can be found here: 

·      https://www.nice.org.uk/guidance/ng80 

The full NICE guidance on depression in adults (NG222) can be found here:

·      https://www.nice.org.uk/guidance/ng222 

The full guidance on obesity (CG189) can be found here:

·      https://www.nice.org.uk/guidance/cg189

Thumbnail photos-

From: www.freepik.com

·      Image by Freepik: Image by a href="https://www.freepik.com/free-photo/excited-young-friends-running-beach_9057871.htm#page=2&query=45%20year%20old%20obese%20woman&position=10&from_view=search&track=ais"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 everyone. My name is Fernando and I am a GP in the United Kingdom. Today we are looking at a fictitious patient generated by Chat GPT with a view to looking at the NICE guidelines from a practical perspective.  

Right, so let’s jump into it.

Patient Information:

·      Name: Sarah Davis

·      Age: 45

·      Sex: Female

·      Ethnicity: Caucasian

Examination:

·      BMI: 32 (Obese)

·      Blood Pressure: 153/91 mm Hg

Medical History:

·      Type 2 Diabetes

·      Hypertension

·      Dyslipidemia

·      Asthma

·      Obesity

·      Depression

Medications:

·      Metformin 1000 mg twice daily

·      Gliclazide 80 mg once daily

·      Amlodipine 10 mg once daily

·      Indapamide MR 1.5 mg once daily

·      Atorvastatin 20 mg once daily

·      Salbutamol inhaler as needed

·      Sertraline 50 mg once daily

Medication Tolerance:

·      Sarah tolerates her medications well. She has not reported any significant side effects.

Blood Test Results:

·      HbA1c: 8.5% (69 mmol/mol)

·      Renal Function:

o  Creatinine: 90 µmol/L (1.02 mg/dL)

o  eGFR: 91 mL/min/1.73m²

·      Lipid Profile:

o  Total Cholesterol: 5.2 mmol/L (200 mg/dL)

o  LDL Cholesterol: 3.0 mmol/L (116 mg/dL)

o  HDL Cholesterol: 1.2 mmol/L (46 mg/dL)

o  Triglycerides: 2.5 mmol/L (220 mg/dL)

Cardiovascular Risk (QRISK3):

·      Sarah's 10-year cardiovascular risk is estimated at 18%.

So, what treatment recommendations would we make?

Although there is a lot that we can do from a lifestyle perspective, we will focus on the drug treatment only.

Right, let’s start with her diabetes, which is poorly controlled with an hba1c of 8.9% or 74 mmol/mol. Sarah is on metformin 1gr BD and gliclazide 80 mg OD and we know she is at high risk of cardiovascular disease with a QRISK3 of 18%.

NICE says that for step 2 treatment after metformin, if a patient is at high risk of CVD, we should choose an SGLT2 inhibitor. But this patient has been given gliclazide instead. We would like to see if there is a reason for this and whether an SGLT2 inhibitor was tried before but not tolerated.

So, assuming that there have been no issues, I would recommend starting an SGLT2 inhibitor.

SGLT2 inhibitors are also associated with a degree of weight loss, and given that Sarah is obese, this will be good for her.

Gliclazide on the other hand is associated with weight gain, which is the last thing that Sarah needs. The question now is whether we should stop gliclazide and, if so, when.

In my opinion, gliclazide should be definitely stopped and substituted by another diabetic agent which is weight neutral, for example, a DPP4 inhibitor.

A more difficult question would be when to make this switch. Doing it straightaway has got the disadvantage that, if a side effect develops, we may not know which drug is the culprit. Also, we do not know how much the HbA1c will drop with the SGLT2 inhibitor so there could be a risk of overtreatment.

Right, a balanced decision that you can make depending on your clinical judgement.

I think that I would start the SGLT2 inhibitor first, so, I would start her on something like dapagliflozin 5 mg OD initially and, if tolerated, I may increase it to 10 mg daily fairly quickly, possibly within 3 or 4 weeks to get the maximum effect as soon as possible.

Research studies have shown that the introduction of an SGLT2 inhibitor can lead to a drop in Hba1c of around 1%. Although this could vary depending on the individual patient, Sarah’s HbA1c is poor at 8.9% so even after the SGLT2 inhibitor, she is likely to require a third diabetic agent.

NICE says that if dual therapy with metformin and another oral drug is not enough, we should consider either triple therapy by adding a DPP‑4 inhibitor, pioglitazone or a sulfonylurea or starting insulin. Because of the risk of weight gain, I would try to avoid gliclazide and insulin.

Given that she is on gliclazide 80 mg daily, that is, a quarter of the maximum daily dose of gliclazide, I would probably switch Sarah to a DPP4 inhibitor as soon as she is tolerating the full dose of dapagliflozin. So, we could stop gliclazide and start her on, for example, sitagliptin 25mg daily, which is also a quarter of the maximum daily dose of 100mg.

But I do not think that there is a right or wrong approach in terms of the gliclazide switch. The decision about the timing is very dependent on the individual patient and your clinical judgement. Switching early has some more uncertainty about treatment response whereas switching later may mean that the patient remains on a potentially unsuitable drug for longer.

We have to make sure that we inform the patient that SGLT2 inhibitors have been associated with an increased risk of DKA, toe and lower limb amputations and Fournier’s gangrene.

So, on starting the SGLT2 inhibitor:

1.   We will educate her about DKA symptoms and when to seek advice.

2.   We will also advise against ketogenic diets to lose weight while on an SGLT2 inhibitor, as this also increases the risk of DKA.

3.   We will improve foot care and

4.   We will advise patients to seek urgent medical advice if they experience pain, erythema or swelling in the genital or perineal area, as this may precede Fournier’s gangrene or necrotising fasciitis. 

If we were managing her diabetes according to the European or American guidelines, we would be talking a lot more about GLP 1 receptor agonists, given that they are also recommended for patients with high CVD risk and they are much better in terms of weight loss. We are following the NICE guidelines, which are more restrictive with GLP1 receptor agonists, but we can always use our clinical judgement to deviate from the guideline if we think that it is appropriate for a particular patient. 

Now that we have dealt with her diabetes, let’s look at her hypertension. 

Unless we have specific concerns, we do not need to arrange an ABPM or HBPM because NICE says that we can use clinic blood pressure measurements to monitor drug treatment for people already diagnosed with hypertension. However, NICE also say that in diabetes, we should check both the sitting and standing BP because of their higher risk of postural hypotension, especially if there is autonomic neuropathy. 

Sarah’s BP is 153/91 and NICE says that the target BP for people under the age of 80 is below 140/90. So, her BP is high.

She is on amlodipine and indapamide, which is not in keeping with NICE guidance. NICE says that, for people with diabetes of any age and any ethnicity background, an ACEI or ARB should be used as first line treatment.

So, I would have a look to see if an ACE inhibitor or ARB has been tried before and then stopped because of side effects like a cough or angioedema. Both of these side effects can happen with ACEIs and they are normally managed by switching to an ARB. But, although much rarer, these symptoms can also be a side effect of ARBs 

Assuming that there is no previous problem, I would start her on an ACE inhibitor, for example lisinopril 2.5 mg daily monitoring her renal function and titrating up according to response. 

If the target BP is achieved at a lower dose than the maximal dose of the ACE inhibitor, then I would recommend stopping indapamide and continue titrating up the ACE inhibitor dose to compensate. Thiazide like diuretics can worsen diabetes so stopping indapamide and replacing it with a higher dose of lisinopril would be the right thing to do.   

Once indapamide has been stopped, if the target BP is achieved before the ACE inhibitor is at the maximal dose, we could consider reducing the dose of amlodipine while we increase the ACE inhibitor further, because of the benefits that ACE inhibitors have particularly in diabetes. 

Now, let’s look at her hyperlipidaemia. Sarah has no history of cardiovascular disease so she is on atorvastatin 20 mg daily for primary prevention.

NICE says that we should offer atorvastatin 20 mg for the primary prevention of CVD if they have a QRISK score of 10% or more.

After atorvastatin 20mg has been started, and unlike secondary prevention, there are no specific lipid targets in primary prevention but, if we judge the person to be at higher cardiovascular risk, we will consider increasing the dose of atorvastatin in order to achieve a greater than 40% reduction in non‑HDL cholesterol.

In Sarah’s case, both her cholesterol and QRISK3 score are still high on atorvastatin 20 mg, so we could consider her to be at higher risk and, if the 40% drop in non HDL cholesterol has not happened, we could increase atorvastatin to 40 mg and monitor her blood tests.

Let’s now move on to her asthma. Sarah is on step 1 treatment, that is, on-demand Salbutamol inhaler as needed. If Sarah has infrequent symptoms, this is fine, but we should check that she has no symptoms that could indicate the need for maintenance therapy, for example, asthma-related symptoms 3 times a week or more, or symptoms causing waking at night. In that case, we should offer a low dose of an ICS, for example standard beclomethasone 100mcg, one or two inhalations twice daily. 

The next issue is Sarah’s depression, for which she takes sertraline 50 mg daily. We don’t know how long she has been taking them for but NICE recommends that SSRIs are taken for at least 6 months (and for some time after symptoms remit). So we should assess how long she has been on it and if she wishes to continue treatment or whether the time has come to consider stopping after a gradual reduction of the dose. 

It is worthwhile mentioning that the BNF says that SSRIs should be prescribed with caution in diabetes because SSRIs can affect diabetic control. We are advised to monitor blood glucose when starting or stopping an SSRIs. 

Finally, let’s have a look at her obesity. Her BMI is 32. Apart from the obvious dietary and lifestyle changes, NICE recommends a number of pharmacological treatments for obesity such as orlistat, liraglutide and semaglutide. They all have different BMI thresholds and I would advise you to look at the different criteria before prescribing. 

Except orlistat, liraglutide and semaglutide can only be given for obesity by a secondary care service. However, as discussed earlier and based on our clinical judgement, we could deviate from the NICE guideline and give a GLP1 receptor agonist for her diabetes instead of an SGLT2 inhibitor. 

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" as well as other institutions such as the British Association of the Urological Surgeons, as well as the American and European Urology Associations. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through clinical guidance and advice on erectile dysfunction provided by the following institutions:

·      BAUS- British Association of Urological Surgeons

·      AUA- American Urology Association

·      EAU- European Association of Urology

·      NICE- National Institute for Health and Care Excellence

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

I am not giving medical advice; this podcast 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 guidelines can be found here: 

·      BAUS: https://www.baus.org.uk/patients/conditions/3/erectile_dysfunction_impotence

·      NICE : https://cks.nice.org.uk/topics/erectile-dysfunction/

·      EAU: https://www.europeanurology.com/article/S0302-2838(21)01813-3/fulltext

·      AUA : https://www.bing.com/ck/a?!&&p=c5356f703dad5a45JmltdHM9MTY5Njg5NjAwMCZpZ3VpZD0xM2M1MGRhYS1mMDZkLTZlM2EtMWIzYi0wMTRhZjQ2ZDZkYjcmaW5zaWQ9NTI1OQ&ptn=3&hsh=3&fclid=13c50daa-f06d-6e3a-1b3b-014af46d6db7&psq=erectile+dysfunction+american+guideline&u=a1aHR0cHM6Ly93d3cuYXVhbmV0Lm9yZy9kb2N1bWVudHMvR3VpZGVsaW5lcy9QREYvRUQtSlUucGRm&ntb=1 

The shortened Sexual Health Inventory for Men (SHIM/IIEF-5) can be found here:

·      https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/SHIM.pdf

Thumbnail photo:

·      Image by Drazen Zigic on Freepik

·      a href="https://www.freepik.com/free-photo/young-man-having-headache-holding-his-head-pain-home_26343730.htm#query=upset%20men&position=1&from_view=search&track=ais"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 clinical guidance and advice on erectile dysfunction. For this I have looked at guidance by the:

·      BAUS- British Association of Urological Surgeons

·      AUA- American Urology Association

·      EAU- European Association of Urology

·      NICE- National Institute for Health and Care Excellence

·      As well as other local NHS Hospital Trusts protocols available in the London area.

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

So let’s jump into it.

Erectile dysfunction is seen in 50 - 55% of men between 40 and 70 years old. It is often associated with obesity, high blood pressure, high cholesterol and diabetes and most treatable causes can be identified by a clinical history, physical examination and routine blood tests.

And we will start by taking a detailed sexual history. It is advisable to use validated patient questionnaires, such as the shortened Sexual Health Inventory for Men (SHIM/IIEF-5), to assess the presence, severity, and impact of erectile dysfunction. A link to this questionnaire can be found in the episode description. Otherwise, we will ask about:

·      onset, duration, and quality of erections;

·      whether night-time or early-morning erections are still present

·      whether there are problems with their sex drive or libido, arousal, and orgasm;

·      whether there are symptoms of premature ejaculation or symptoms of prostatic obstruction because they are often associated with erectile dysfunction and

·      whether the relationship with their partner is affected.

We will then ask about lifestyle factors such as their:

·      Job and work pressures

·      Ability to exercise

·      Smoking and alcohol and

·      Drug consumption

And we will then look at their past medical history for other medical conditions which may be contributing to it. We must remember that ED can be a marker for cardiovascular disease.

Then we will perform a general physical examination checking their:

·      BP, heart rate,

·      Height, weight and waist circumference,

·      peripheral pulses and the nerve reflexes in their legs.

·      We will also look for any abnormality of the penis or testicles and

·      We will check for gynecomastia or possible signs of hypogonadism.

·      Rectal examination may be performed to assess the anal tone and to examine the prostate.

After this we should do a few routine tests that will normally include:

·      HbA1c, lipid profile, and fasting morning testosterone level (that is, before 11AM) in all men.

·      Other blood tests such as a FBC, renal, liver and thyroid function tests, and PSA can be done depending on our clinical judgement.

·      We should also consider urinalysis to test for glycosuria and haematuria

If the free testosterone level is low or borderline, we will repeat it together with FSH, LH, sex hormone binding globulin, and prolactin levels. If on repeat testing, testosterone is still low and LH is high, then we are talking about primary hypogonadism, whereas if testosterone is low and LH is also low, then it would be secondary hypogonadism.

When considering the possible cause, we should bear in mind that a physical cause normally has a gradual onset of symptoms, lack of tumescence, and low-to-normal libido, whereas a psychogenic cause normally has a sudden onset, low libido, and good quality spontaneous or self-stimulated erections.

A psychological component, often called "performance anxiety", is common in men with ED, as well as relationship issues; stress; anxiety; and depression. However, a purely psychological problem is seen in only 10%.

Of the 90% of men who have an underlying physical cause, the main abnormalities found are:

·      Up to 40% of men may have cardiovascular disease, for example, heart disease, hypertension and peripheral artery disease

·      Up to 33% of men may have diabetes 

·      Up to 11% of men may have hormonal or drug problems. Examples of

o  Hormonal problems are hyperprolactinaemia and hypogonadism and

o  Drugs commonly associated with ED are:

§ Antihypertensives and diuretics,

§ Antipsychotics and antidepressants,

§ Antihistamines,

§ methadone and

§ recreational drugs such as heroin and cocaine.

§ If a drug cause is suspected, we will consider stopping or switching the medication, depending on our clinical judgement.

·      Around 10% of men may have neurological disorders, for example, MS, Parkinson's disease, stroke, or other diseases of the spinal cord or central nervous system

·      Up to 3-5% of men may have a history of pelvic surgery or trauma and

·      Between 1 to 3% of men will have anatomical abnormalities like phimosis, short penile frenulum, Peyronie’s disease, inflammation, penile curvature and prostate cancer

When it comes to treatment in Primary care, we should advise on sources of information and support as well as encouraging lifestyle improvements. In fact, losing weight and increasing exercise can dramatically improve erectile dysfunction. by up to 70%.

We should obviously optimise the management of any underlying conditions and, if clinically appropriate, we should consider drug treatment with a phosphodiesterase-5 (PDE-5) inhibitor.

However, before offering PDE-5 inhibitors we will need to do a cardiac risk stratification which will assess men into low-, intermediate-, or high-risk cardiovascular categories, depending on their risk factors and co-morbidities. Men at low risk would be asymptomatic doing moderate exercise, and may have controlled hypertension, mild stable angina, mild valvular heart disease and mild heart failure or may have had an uncomplicated MI or a successful revascularisation procedure

Men with a more significant cardiac history will be at intermediate or high risk and we would normally arrange a referral to a cardiologist for advice and recommend stopping all sexual activity until the specialist assessment.

The European Association of Urology estimates that sexual activity is equivalent to walking 1 mile on the flat in 20 min or briskly climbing two flights of stairs in 10 seconds. Men who can complete this level of exercise without symptoms are deemed to be low risk and those who would struggle would be referred to cardiology for further assessment, including an exercise ECG. Sexual activity is generally considered to be equivalent to 4 min of the Bruce treadmill protocol.

We should refer to secondary care:

·      As an emergency if there is priapism (that is, painful prolonged erection for more than 4 hours following ED treatment).

·      To Urology if there is anatomical abnormality; young age or not responding to maximum tolerated dose of at least two PDE-5 inhibitors.

·      To Endocrinology if we suspect testosterone deficiency or hypogonadism.

·      To Cardiology if at high or intermediate cardiac risk of sexual activity and

·      To Psychosexual and relationship counselling, or mental health services if there is a psychogenic cause or severe mental health condition.

Alternatively, if we decide to prescribe a PDE-5 inhibitor in Primary Care, we will:

·      Explain that these drugs will have no effect on their sex drive and that they require sexual stimulation to be effective

·      And that sildenafil 50 mg tablets (Viagra Connect®) can be purchased over-the-counter without a prescription.

·      We will warn, however, that ED medications are amongst the most commonly counterfeited medicines in Europe and that buying online should only be through legitimate sources like registered pharmacies 

·      and we will advise about the importance of dose timing.

o  Sildenafil should be taken about one hour before planned sexual intercourse and the effect can last about 4-5 hours. We also need to explain that food intake can reduce the absorption of sildenafil by an average of one hour.

o  On the other hand, tadalafil for example needs to be taken only 30 minutes before sexual intercourse, has a duration of up to 36 hours and food ingestion has not effect on it.

·      We will also explain that PDE-5 inhibitors, except generic sildenafil, are not automatically prescribable on the NHS. Therefore, before prescribing it, we need assess whether the man qualifies for an NHS prescription and, if not, we will offer a private prescription. NHS prescriptions should be endorsed SLS if the man qualifies for NHS treatment because of:

o  diabetes,

o  Neurological conditions such as multiple sclerosis, Parkinson's disease, spina bifida etc,

o  prostate cancer,

o  pelvic trauma like in pelvic injuries, radical pelvic surgery or prostatectomy,

o  renal failure treated with dialysis or by transplant or

o  Is experiencing 'severe distress' as assessed by a specialist

o  However, as already mentioned, generic sildenafil does not need to be endorsed with 'SLS' for NHS prescribing.

·      Phosphodiesterase-5 (PDE-5) inhibitors are usually taken intermittently as needed, normally as one treatment dose per week on the NHS. However, if clinically appropriate, NICE says that a higher frequency may also be prescribed on the NHS.

After the initial prescription:

·      we will follow-up the patient after 6–8 weeks, and, if there is a poor response,

·      we will consider increasing to the maximum dose, trying each PDE-5 inhibitor 4–8 times at the maximum tolerated dose before switching to an alternative.

·      We will suggest a trial of at least two different PDE-5 inhibitors taken sequentially before considering the patient as a 'non-responder'.

·      If taking tadalafil, we can consider increasing the dose frequency, such as switching to once daily (rather than 'on-demand') dosing depending on our clinical judgement.

o  The BNF states that tadalafil may be prescribed daily as a dose of 5 mg once daily, for patients who anticipate sexual activity at least twice a week, although the dose can be reduced to 2.5 mg once daily, depending on the response,

·      We also need to be aware that hypogonadism and a low testosterone level may result in a reduced response or non-response to phosphodiesterase-5 (PDE-5) inhibitors.

I will now give just an overview of some prescribing information and, in terms of contraindications, we will not prescribe a phosphodiesterase-5 (PDE-5) inhibitor if there is:

·      Unstable angina or angina occurring during sexual intercourse.

·      Regular or intermittent use of nitrates in any form

·      Hypotension (that it, a systolic blood pressure below 90 mmHg).

·      A Recent MI or stroke or

·      A history of non-arteritic anterior ischaemic optic neuropathy (NAION).

There are a number of other contraindications for specific PDE-5 inhibitors in renal or hepatic impairment and other cardiovascular conditions, so I would recommend looking at the specific recommendations for whichever drug you intend to prescribe. Equally, there is also a long list of cautions which we would need to check for each individual patient.

In terms of drug interactions, there is a severe interaction with nitrates and concurrent use of PDE-5 inhibitors and nitrates, including nicorandil, or amyl nitrate (also known as 'poppers') are absolutely contraindicated due to the risk of hypotension.

There is also an increased risk of hypotension with alpha-blockers and sacubitril/valsartan so caution is advised. 

Finally, just to mention that other treatments available for Erectile Dysfunction are:

·      Penile injections

·      Medicated urethral system for erection (MUSE)

·      Vacuum erection assistance devices (VEDs)

·      Vascular surgery/angioplasty and

·      Penile prostheses

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 a real-life case of a young woman with hypertension. It will focus on the NICE guidance on Hypertension in pregnancy: diagnosis and management addressing issues 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 YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

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

The link to the PDF version of this episode can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEqfJs8aMAUqULYy?e=wDydMJ

The visual summary- pre-pregnancy advice can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEsJdGIU4F7fR9MF?e=7nTS0f

The Full NICE guideline Hypertension in pregnancy: diagnosis and management [NG133] can be found at:

·      https://www.nice.org.uk/guidance/ng133/chapter/Recommendations 

Thumbnail photo:

·      Image by rawpixel.com on Freepik

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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 real-life case of a young woman with hypertension. We will focus on the NICE guidance addressing issues relevant to Primary Care only. 

So let’s jump into it.

Maria is a 31-year-old woman of mixed Afro-Caribbean family origin. She has hypertension and, because of her young age, she has been fully investigated for secondary causes and her diagnosis is essential hypertension.

Her medication is amlodipine 10 mg daily and she is otherwise fit and healthy.

Her blood pressure is 155/92 mmHg.

What should we do?

She is on step 1 treatment with 1 drug, in this case the maximum dose of amlodipine, a calcium channel blocker, which is the preferred choice for people who do not have diabetes and who are of Afro-Caribbean background.

NICE says that if the BP is not controlled with a CCB alone, we have to start step 2 treatment with two drugs adding either:

·      an ACE inhibitor or an ARB, and if the person is of Afro-Caribbean background an ARB should be used in preference to an ACE inhibitor

·      or alternatively we can prescribe a thiazide-like diuretic

So, our instinct will probably tell us to start an ARB, something like, for example, losartan 25 mg daily and titrate it up according to response. This seems to be fairly straightforward so far.

But then she tells you: doctor, I am actively trying to get pregnant. Is that going to be OK?

And obviously, it will not be OK. In fact, we should have thought about it even before she mentioned it because, being a woman of childbearing age, it is a possibility that we must always bear in mind.

And this is where we need to look at the NICE guideline: Hypertension in pregnancy: diagnosis and management which was last updated in April 2023 and which not only covers hypertension during pregnancy, but also includes advice for women with hypertension who wish to conceive.

We know that ACE inhibitors and ARBs have an increased risk of congenital abnormalities if taken during pregnancy and NICE recommends an alternative if the woman is planning to get pregnant.

There is also an MHRA drug safety advice, which states that the use of ACEIs or ARBs in women who are planning pregnancy should be avoided unless absolutely necessary, in which case the potential risks and benefits should be discussed.

So, if a woman taking an ACEI or ARB becomes pregnant, it should be stopped preferably within 2 working days and we should offer an alternative.

Equally, we should advise women taking thiazide or thiazide-like diuretics that there may be an increased risk of congenital abnormalities and we should also offer an alternative.

We should explain to the patient that antihypertensive treatments other than ACE inhibitors, ARBs, thiazide or thiazide-like diuretics have not shown an increased risk of congenital malformation, although the evidence is limited.

So how should we treat her?

NICE recommends offering referral to a specialist in hypertensive disorders of pregnancy to discuss the risks and benefits of treatment. And perhaps we should do just that.

Should we be doing something else in the meantime?

Well, we could if we are worried. But this is where, apart from the usual lifestyle advice, NICE does not give specific drug advice for this group of patients.

It does say, though, that for women who are pregnant  and who have chronic hypertension we should consider:

·      Labetalol first

·      Then we will consider nifedipine if labetalol is not suitable, but we will bear in mind that some brands of nifedipine were specifically contraindicated in pregnancy by the manufacturer, so we will check the specific product characteristics for each preparation of nifedipine

·      And lastly, methyldopa if both labetalol and nifedipine are not suitable.

This patient is already taking amlodipine as a calcium channel blocker, so we would not be considering nifedipine. If I wanted to add a second agent, I would recommend starting labetalol, for example 100mg BD while waiting to see the specialist.

In summary, we will:

·      Refer her to secondary care for expert advice

·      And we may consider adding labetalol in the meantime if we are worried.

Please note that this is the advice for chronic hypertension in pregnancy, that is, women with hypertension who become pregnant. It is different from gestational hypertension, that is, hypertension that develops during pregnancy, which has different recommendations. Gestational hypertension, including pre-eclampsia, should be assessed, and managed in secondary care.

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 new and updated guidelines published in September 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 YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel:  

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

The link to the PDF version of this video can be downloaded here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEl3L2KH_8bOGFrM?e=NqGNSZ 

The Full NICE News bulleting for September 2023 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2023-09-01&to=2023-09-30&ndt=Guidance&ndt=Quality+standard

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

Chronic obstructive pulmonary disease in adults: quality standard

·      https://www.nice.org.uk/guidance/qs10

Semaglutide for managing overweight and obesity: Technology appraisal

·      https://www.nice.org.uk/guidance/ta875

 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 September 2023, focusing on what is relevant in Primary Care only. 

So, let’s jump into it.

The first clinical area is an update on COPD because some of the quality standards have changed.

And the first one says that we have to refer patients with COPD to a pulmonary rehabilitation programme if they have a score of 3 or above on the Medical Research Council (MRC) dyspnoea scale. And this is because pulmonary rehabilitation improves exercise capacity, quality of life, and levels of anxiety and depression.

And let’s remember what a score of 3 or above means on the MRC dyspnoea scale:

Grade 3 is defined as 'walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace'.

Grade 4 is defined as 'stops for breath after walking about 100 metres or after a few minutes on level ground' and

Grade 5 is defined as 'too breathless to leave the house, or breathless when dressing or undressing'.

NICE also specifies that pulmonary rehabilitation will be at least 6 weeks in duration and include a minimum of twice‑weekly supervised sessions of structured training.

The second Quality standard change refers to patients being discharged from hospital after an acute COPD exacerbation. We will be able to expect these patients to receive a care bundle before discharge which means that before they leave hospital they will have:

·      a good understanding of their medication and inhaler use,

·      a self-management plan,

·      a smoking cessation intervention,

·      a referral to pulmonary rehabilitation if appropriate, and

·      a follow-up within 72 hours from discharge

The second clinical area refers to the use of Semaglutide for managing overweight and obesity. The update in September 2023, is not a clinical one and it refers to the company’s commercial arrangement that makes semaglutide available to the NHS with a discount.

But let’s quickly review the recommendations for semaglutide for managing overweight and obesity.

Semaglutide is recommended with a low-calorie diet in adults, only if:

·      it is used for a maximum of 2 years, with specialist input, and

·      they have at least 1 weight-related comorbidity and:

o  a BMI of 35.0 or more, or

o  a BMI between 30.0 and 35 and meets other referral criteria (for example failure of conventional treatment or when we are considering surgery).

·      We will use lower BMI thresholds (usually reduced by 2.5) for people from non-White family backgrounds. This is because they have an equivalent risk from obesity at a lower BMI than people from a White ethnic family background

And we will consider stopping semaglutide if less than 5% of the initial weight has been lost after 6 months of treatment.

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 video I will go summarise the pharmacological management of neuropathic pain reviewing the guidelines on Neuropathic Pain and, because of the overlap in the clinical areas, also the guideline on Low Back Pain and Sciatica, both by the National Institute for Health and Care Excellence (NICE).

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 link to the PDF summary can be downloaded here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEiBizIQiitY4as7?e=HS9lhY 

The Full NICE guidance can be found at:  

·      Neuropathic pain : https://www.nice.org.uk/guidance/cg173

·      Low back pain and sciatica: https://www.nice.org.uk/guidance/ng59

Pictures:

·      Image by kjpargeter on Freepik: a href="https://www.freepik.com/free-photo/3d-female-with-pain-head_1270692.htm#query=neuropathic%20pain&position=0&from_view=search&track=ais"Image by kjpargeter/a on Freepik

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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 guideline on neuropathic pain and, because of a slight clinical overlap, I will also touch on the management of sciatica. Please note that I will only be focusing on the pharmacological treatment from a primary care perspective.

So let’s jump into it.

And we will start with a very straightforward condition: trigeminal neuralgia.

And for this, we will offer carbamazepine initially 100mg once or twice a day, increasing gradually according to response. The usual dose is 200mg 3-4 times a day but it can be increased to a maximum of 1.6 gr daily in divided doses. Of course, we will bear in mind that there is a risk of major congenital malformations in pregnancy and advise contraception accordingly.

And we have nothing else to offer in primary care so, if carbamazepine is not effective, or suitable, we will need to refer.

For all other neuropathic pain

We will discuss with the patient whether to give oral or topical treatment.

And if the neuropathic pain is localised and they wish to avoid or cannot tolerate oral treatments, we will consider capsaicin cream. 

Otherwise, 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 to minimise the risk of dependency.

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 not 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 risk of dependency, I would consider:

1.   Amitriptyline first

2.   Then duloxetine,

3.   Then gabapentin and

4.   Lastly pregabalin

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

As acute rescue therapy, we could consider tramadol, but only for short term use.

The rest of the guidelines is going to sound like this:

No, no, no, no, no

Because it is going to tell us what treatments should not be used. And we should not start:

·      cannabis extract

·      capsaicin patch

·      opiates like morphine and tramadol (this is referring to long-term use; because careful short-term use of tramadol is allowed)

·      venlafaxine

·      antiepileptics such as lacosamide, lamotrigine, levetiracetam, oxcarbazepine, topiramate or sodium valproate

For sciatica, there is a separate guideline.

And from a Pharmacological perspective, we are very limited because nothing really seems to work very well in sciatica.

We can give NSAIDs but we need to be aware of their risks and limited evidence that they are of much benefit.

If prescribing NSAIDs for sciatica:

·      We will take into account gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age

·      think about risk factors, and the use of gastroprotective treatment

·      use the lowest effective dose for the shortest possible time. 

Can we use anything else if NSAIDs do not work?

For acute low back pain, we can consider weak opioids (with or without paracetamol) but only when managing acute low back pain and only if an NSAID hasn’t worked or can’t be used. We should not offer paracetamol alone for low back pain. 

But we should not be giving opioids for on-going, non-acute sciatica

For chronic sciatica, if NSAIDs are not effective, we are going to encounter the same as before.

So, we should not offer:

·      Gabapentinoids

·      other antiepileptics

·      oral corticosteroids

·      benzodiazepines

·      opioids 

If a person is already taking any of these drugs, we will consider a safe and gradual withdrawal regime

Although we are focusing on the pharmacological treatment, I would like to say that we should also discuss non-pharmacological treatments, for example, physical and psychological therapies and surgery.

We will advise self-management and appropriate exercise, including return to work programmes if possible.

Psychological therapy or manual therapies like spinal manipulation or massage should be offered only as part of a treatment package including exercise and

Combined physical and psychological programmes should be offered for people with persistent and significant symptoms that have not responded to treatment.

We should not offer:

·      Orthotics such as belts, corsets or foot orthotics

·      Traction

·      Acupuncture

·      Ultrasound

·      Electrical nerve simulation, either percutaneous or transcutaneous (PENS or TENS)

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 video I will go through the new diagnostic guidance on Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care, which was published in August 2023 by the National Institute for Health and Care Excellence (NICE).

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 link to the PDF summary can be downloaded here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEQYDkYwIy2vUALl?e=RcrJuC 

The Full NICE guidance can be found at:

·      https://www.nice.org.uk/guidance/dg56

Joint guidelines from ACPGBI and BSG can be found at: 

·      https://www.acpgbi.org.uk/resources/1075/fit_in_patients_with_signs_or_symptoms_of_suspected_crc_a_joint_guideline_from_acpgbi_and_bs 

Other references:

·      https://gpnotebook.com/en-gb/simplepage.cfm?ID=x20230616201913313209&linkID=82871 

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

• Music provided by Audio Library Plus  
• Watch: https://youtu.be/aBGk6aJM3IU 
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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the new NICE guidance on faecal immunochemical tests, commonly known as FIT tests, to guide colorectal cancer referrals and which represents a change in the criteria for cancer referrals

So let’s jump into it.

John Smith is 77 and has recurrent rectal bleeding. He has no other symptoms and his abdominal and rectal examination is normal. What should we do next?

·      Should we refer?

·      Or should we do a FIT test?

And NICE now says that we need to do a FIT test.

And you may ask yourself, why? If the test is positive, it is not going to tell us anything that we did not already know and, if it is negative, are we not going to refer him for further investigations? So, what’s the point?

Well, let’s have a look at the new guidance and try to understand it. But first let’s remind ourselves that FIT tests detect blood in stools using antibodies specific to human haemoglobin. Human haemoglobin, degrades as it travels through the gastrointestinal tract, so FIT tests are less accurate in upper gastrointestinal bleeding. They were developed as an alternative to the old technique of faecal occult blood tests, which could react with chemicals in food and medicines resulting in false positive results.

Before considering the rationale of the NICE recommendations, let’s look at them first. And it is probably easier if we start by looking at when we will NOT need to request a FIT test, which is when there is:

·      a rectal or anal mass, or an unexplained anal ulceration. They are what NICE refers to as “red flags” or “bypass symptoms”, meaning that they will trigger an automatic urgent cancer referral

And what about an abdominal mass? Is that a bypass symptom? Well, yes and no, depending on how you look at it. It is not a bypass symptom given that you should still request a FIT test because, if it is positive, it will point towards a colorectal cause and will help us refer the patient to the appropriate service. But, and this is a big BUT, we are going to refer the patient regardless of the result. So, if the result is positive, we will refer to a colorectal service, and if it is negative, provided that we have a clinical suspicion of cancer, we will refer them urgently to another secondary care service. Which one will depend on our clinical judgement. However, if we have concerns that the patient may delay or not engage with the FIT test because of any reason, we should consider making the urgent cancer referral without the FIT test.

And now let’s look at when we will organise the FIT test. And please note that some of these clinical situations would have triggered an urgent cancer referral according to the old guidelines. Also, we need to remember that a FIT test should still be offered even if the patient has had a negative result through the screening programme because the thresholds are different.

So, a FIT test should be requested for:

1.   Adults of any age:

·      with an abdominal mass,

·      with a change in bowel habit,

·      with iron-deficiency anaemia,

2.   If they are 40 or over with:

·      unexplained weight loss AND abdominal pain

3.   If they are under 50 with rectal bleeding AND either:

·      abdominal pain or

·      weight loss,

4.   If they are 50 or over with either:

·      rectal bleeding

·      abdominal pain or

·      weight loss,

5.   And lastly, if they are 60 or over with anaemia even in the absence of iron deficiency.

And we will organise an urgent cancer referral if the FIT test result is 10 or more.

And now let’s try to understand why NICE has made these recommendations.

And it is basically because FIT tests are an excellent way of assessing a patient’s risk of having colorectal cancer. A patient with a FIT test <10 has a less than 1% of risk of having colorectal cancer and we should consider alternative diagnoses and investigatory. This means that colonoscopy resources can be prioritised for people who most need them.

In the old cancer referral guidelines, patients with 'high risk' symptoms were referred urgently without a FIT test.

However, many of these referred patients did not have cancer following colonoscopy, even in situations such as iron deficiency anaemia and rectal bleeding. So, NICE concluded that using FIT tests could reduce the number or the urgency of patients referred for colonoscopy and therefore also reduce the waiting times.

It is all good so far but, are there any drawbacks?

Well, there are concerns about patients that may not return the FIT test, which may be related to sociodemographic factors or disability and this group of patients may need more support.

There is also the concern of those patients with symptoms and a FIT test <10.

We said earlier that a patient with a FIT test <10 has a less than 1% risk of having colorectal cancer. However, this low risk partly reflects the rarity of colorectal cancer in the general population and we need to be aware that between 10 and15% of patients with colorectal cancer may have a FIT test result which is <10. Therefore, if we have any concerns or any reasons for suspecting cancer, it is reasonable to refer the patient to rule it out. 

The joint guideline from the Association of Coloproctology of Great Britain & Ireland and the British Society of Gastroenterology also recommend referral of patients with persistent or recurrent anorectal bleeding for flexible sigmoidoscopy even if the FIT test result is <10.

So, the summary is that for patients who have not returned a faecal sample or who have a FIT test result < 10 we should either:

·      Refer them if we are concerned because of cancer or unexplained symptoms or

·      Provide safety netting. Now, what safety netting actually means is going to vary according to our clinical judgement and it may include things like:

o  management in Primary Care following a “watch and wait” approach or

o  offering further tests, including another FIT test or tests for other possible conditions.  

So, let’s quickly go back to John, our 77-year-old patient with rectal bleeding. We are going to do a FIT test and if it is 10 or more, we will organise an urgent colorectal cancer referral. And if it is <10 we will refer him for further investigations, possibly a flexible sigmoidoscopy. The urgency of this referral will depend on our clinical judgement and on how concerned we may be.

The take home message is that FIT testing is, despite imperfections, the best method that we have to assess the urgency of a referral to exclude colorectal cancer, but we can still refer if we think it is needed.

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 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 August 2023 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. 

By way of disclaimer, 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 link to the PDF version of this video can be downloaded here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEMuxr60pkhK-T5g?e=n81cOC 

The Full NICE News bulleting for August 2023 can be found at:

·      https://www.nice.org.uk/guidance/published?from=2023-08-01&to=2023-08-31

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

Otitis media with effusion in under 12s

·      https://www.nice.org.uk/guidance/ng233

Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care

·      https://www.nice.org.uk/guidance/dg56

Venous thromboembolic diseases: diagnosis, management and thrombophilia testing

·      https://www.nice.org.uk/guidance/ng158

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 guidance and advice published in August 2023, focusing on what is relevant in Primary Care only. 

It’s a fairly short and straightforward episode today so let’s jump into it.

The first clinical area is an update on the management of otitis media with effusion, also known as 'glue ear', in under 12s. Please don’t confuse the term otitis media with effusion with acute or chronic otitis media, which we are not covering today. 

The updated paragraphs of the guideline refer to giving information about the fluctuating nature of the condition and its impact on hearing, language development, behaviour, and emotional wellbeing. We should also explain that exposure to smoking increases the risk of developing glue ear in children.

OME often present with one or more of the following: hearing difficulties, delayed speech and language development, ear discomfort and tinnitus. Also, behavioural problems, poor educational progress, and balance difficulties (for example, clumsiness).

NICE now also says that we should consider snoring as a reason to suspect glue ear.

If OME is clinically suspected based on the history and examination, we will make a referral for a formal assessment which will include a hearing test.

I will not cover all the various recommendations following referral as this is outside the scope of primary care. But it is worthwhile mentioning that we should not offer any of the following for OME or its related hearing loss: antibiotics, oral or nasal steroids, antihistamines, leukotriene receptor antagonists, mucolytics, anti-reflux medications, PPIs or decongestants 

Equally, we will advise against homeopathy, cranial osteopathy, acupuncture, massage, and dietary modification, including probiotics

And finally, we will treat children with otorrhoea after grommet insertion with non-ototoxic topical antibiotic ear drops (such as ciprofloxacin) for 5 to 7 days.  

The next clinical area refers to Venous thromboembolic diseases. There is not much to say as it does not really affect primary care too much, other than making you aware that there are updated recommendations for PEs and DVTs for people with COVID-19 and we are advised not to stop short-term interim anticoagulation for these patients following negative tests and to follow the COVID-19 rapid guideline instead. 

The last clinical area refers to the recognition and referral of suspected colorectal cancer, in particular the use of quantitative faecal immunochemical testing, commonly referred to as a FIT test.

I found this extremely interesting and I will dedicate a separate video to the subject. For now, I will just say that the updated guidance recommends FIT tests in some clinical situations where before a two-week rule cancer referral pathway would have been recommended. FIT tests are now recommended in adults:

·      with an abdominal mass,

·      with a change in bowel habit,

·      with iron-deficiency anaemia,

·      aged 40 and over with unexplained weight loss and abdominal pain,

·      aged under 50 with rectal bleeding and either:

o  abdominal pain or

o  weight loss,

·      aged 50 and over with either:

o  rectal bleeding

o  abdominal pain or

o  weight loss,

·      and lastly, those aged 60 and over with anaemia even in the absence of iron deficiency

But I think that this issue deserves more reflection so watch out for my next episode, which will look into it in more detail, including the rationale for changing and other considerations.

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 video makes reference to guidelines produced by the "National Institute for Health and Clinical 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 GP in the United Kingdom. In today’s episode I go through the Guideline in Dementia by the National Institute for health and Clinical Excellence guideline, guideline [NG97], Published: 20 June 2018:

Dementia: assessment, management and support for people living with dementia and their carers 

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 NICE GP YouTube Channel: https://youtube.com/@practicalgp?si=a99JH9FBPB3BVtFd 

The full guideline can be downloaded here: 

·      https://www.nice.org.uk/guidance/ng97 

You can download a summary of my summary / interpretation of the guidance here:  

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mDynkIBny7vD2G-O?e=f0XrDp 

Thumbnail photos- Image by rawpixel.com on Freepik:

Image by rawpixel.com 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 everyone and welcome, I am Fernando, a GP in the UK. In this episode, we look at the NICE guidelines on dementia and we start by emphasising the importance of involving patients in the decision-making process regarding their care. As we know, Dementia has symptoms, that include memory loss, challenges in reasoning and communication, and personality changes. As a result, often, people with dementia are inadvertently excluded from these crucial decisions, and information may not be well communicated. Additionally, many patients may not readily share their thoughts on their care. Considering this, we should actively encourage and enable them to express their views and opinions, using structured tools to enhance communication.

We also need to give clear information about their specific dementia subtype. We should also discuss advance care planning to ensure a proactive approach in addressing evolving care needs. Moreover, at each care review, we must provide patients with the opportunity to revisit and modify any advance statements and decisions they have previously made."

One of the most important parts of the initial assessment and diagnosis in Primary Care is obtaining a thorough history. Ideally, this should not only come from the patient but also from someone that knows the patient well.

In cases where dementia is suspected following the initial assessment, our next step involves a full physical examination and relevant blood and urine tests to rule out any reversible causes for cognitive decline. Additionally, we should incorporate cognitive testing into the evaluation process. When using cognitive tests in primary care, we should opt for brief, validated tools like the 10-point cognitive screener (10-CS), mini COG, or the 6-item cognitive impairment test (6CIT), as opposed to longer assessments such as the MMSE. But we need to be aware that a normal score alone does not rule out dementia.

After investigating reversible causes of cognitive decline, if we still suspect dementia, we must refer the patient to a specialist dementia service.

We must remember that ordering of imaging in primary care is not recommended and this should be done by specialist services.

Furthermore, case finding for suspected dementia should only be done as part of a clinical trial. 

In terms of Interventions to promote cognition, we can offer group cognitive stimulation therapy, group reminiscence therapy and cognitive rehabilitation in mild to moderate dementia. But we will not provide acupuncture or cognitive training as part of the intervention plan.

Starting pharmacological treatment for Alzheimer's disease should be done exclusively under the guidance of a specialist. However, once the decision to commence treatment with a cholinesterase inhibitor or memantine has been made, the initial prescription may be issued in primary care.

Cholinesterase inhibitors such as donepezil, galantamine, or rivastigmine can be given in Alzheimer’s as monotherapy.

Memantine may be considered for those with moderate Alzheimer's disease, but only as monotherapy when the patient cannot tolerate a cholinesterase inhibitor.

In cases of moderate and severe Alzheimer's disease, a combination of a cholinesterase inhibitor and memantine can be used.

Cholinesterase inhibitors should not be discontinued in patients with Alzheimer's disease only because of disease severity.

For people already diagnosed with Alzheimer's disease and currently taking a cholinesterase inhibitor, we have the option to initiate memantine in Primary Care without requiring specialist advice.

In cases of dementia with Lewy bodies, we can use donepezil, rivastigmine, galantamine, and memantine.

We will consider the use of cholinesterase inhibitors or memantine in vascular dementia only when we suspect comorbid Alzheimer's, Parkinson's, or dementia with Lewy bodies.

Cholinesterase inhibitors or memantine should not be offered to patients with frontotemporal dementia. 

Many commonly prescribed medications are linked to increased anticholinergic burden, which can lead to cognitive impairment. These drugs have the potential to exacerbate cognitive symptoms in dementia or even lead to inaccurate diagnoses. There are validated tools, such as the Anticholinergic Cognitive Burden Scale and we should consider reducing these medications whenever possible, and look for alternatives."

In terms of managing Non-Cognitive Symptoms such as agitation, distress, depression, anxiety, and sleep problems we will say that before initiating any treatment, we need to investigate potential causes for their distress and provide psychosocial and environmental interventions to alleviate it.

Antipsychotic medications should only be used when they are at risk of harming themselves or others, or when they are suffering from severe distress due to agitation, hallucinations, or delusions.

We must remember that patients with Parkinson's or dementia with Lewy bodies, antipsychotics can exacerbate the motor symptoms of their condition.

When employing antipsychotics:

We will use the lowest effective dose and for the shortest duration possible.

We will review the treatment at least every six weeks and we will stop it if there is not a clear and ongoing benefit from it.

Furthermore, valproate should not be offered as a means to manage agitation or aggression in dementia, unless indicated for another medical condition.

For mild to moderate depression or anxiety, we will consider psychological treatments and antidepressants should not be the primary approach, unless there is a pre-existing severe mental health condition. 

We should not give melatonin for insomnia in Alzheimer's disease.

We will use a structured observational pain assessment tool for those who seem to be in pain or show signs of behavioural changes that may be caused by pain and we will use a stepwise treatment protocol that balances pain management and potential adverse events.

We must remember that multifactorial falls interventions may not be suitable for patient with severe dementia and

We will consider relaxing HbA1c targets for people with severe dementia who have type 2 diabetes.

We will consider referring adults with cognitive impairment to an audiology service for a hearing assessment, as hearing loss may be a comorbid condition.

For adults with diagnosed dementia or mild cognitive impairment without hearing loss, we should refer them for a hearing assessment every two years. We will also encourage them to have an eye test every two years. 

We must be aware of the increased risk of delirium following hospital admission, and we should consider the importance of maintaining a familiar environment for these patients.

As part of palliative care, the routine use of enteral feeding should not be used in cases of severe dementia, unless there is a specific indication related to a potentially reversible comorbidity.

Finally, we should ensure that carers are informed of their entitlement to undergo a formal needs assessment, including for respite, psychoeducation, and skills training.  

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.