Primary Care Guidelines

THIS GUIDELINE IS NOW OBSOLETE. PLEASE CHECK THE UPDATED 2024 ASTHMA GUIDELINE AVAILABLE ON THIS CHANNEL. YOU CAN FIND IT IN THE VIDEO DESCRIPTION, BY CLICKING THE LINK IN THE TOP-RIGHT CORNER OF THIS VIDEO, OR ON THE END SCREEN.

The asthma playlist including the 2024 asthma guideline can be found here:

https://youtube.com/playlist?list=PLkDRVxR2chuhrU7IiPYiFYj7Wu_h3PURb&si=DmdpArNj9anQa5qx

My name is Fernando Florido and I am a GP in the United Kingdom. With today’s episode we continue on the series on asthma, focusing on the NICE guidelines on the diagnosis and management asthma. I am going to go through the diagnosis flow charts and I am going to do them over 3 different episodes. In today's episode, the second one, I go through the objective tests for children and young people. In the first one I go through the initial clinical assessment for all patients, and in the third one I will consider the diagnostic tests for adults. There will be other videos on the pharmacological treatment of asthma so make sure you subscribe and stay tuned.

There is YouTube version of the podcast and other guidance that you can access here: 

·      https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw

The full NICE guideline on asthma can be found here: 

·      Website:

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

·      Or download here:

https://1drv.ms/b/s!AiVFJ_Uoigq0lgCTpT8m-jvCCavu?e=z1Vs5z

The diagnostic flow chart “initial assessment” (Episode 1) can be

·      Viewed on website: https://www.nice.org.uk/guidance/ng80/resources/algorithm-a-initial-clinical-assessment-for-adults-young-people-and-children-with-suspected-asthma-pdf-4656176749

·      Or, if outside the UK, downloaded here:

o  Image: https://1drv.ms/u/s!AiVFJ_Uoigq0lXZgO7_Zad1zMIfX?e=cmzv91

o  PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0lXWWt7TqIN0Cye1M?e=kL0i0p

The diagnostic flow chart “children and young people” (Episode 2) can be

·      Viewed on website: https://www.nice.org.uk/guidance/ng80/resources/algorithm-b-objective-tests-for-asthma-in-children-and-young-people-aged-5-to-16-pdf-4656176750

·      Or, if outside the UK, downloaded here:

o  Image: https://1drv.ms/u/s!AiVFJ_Uoigq0lXTL5o5XU2aOfChx?e=6qJk1M

o  PDF: 

https://1drv.ms/b/s!AiVFJ_Uoigq0lXlBBD1Wq7lak-mg?e=iLpgAX

The diagnostic flow chart “adults” (Episode 3) can be

·      Viewed on website: https://www.nice.org.uk/guidance/ng80/resources/algorithm-c-objective-tests-for-asthma-in-adults-aged-17-and-over-pdf-4656176751

·      Or, if outside the UK, downloaded here:

o  Image: https://1drv.ms/u/s!AiVFJ_Uoigq0lXgUR4QxwwxNNynL?e=OrBRwi

o  PDF: 

https://1drv.ms/b/s!AiVFJ_Uoigq0lXcaf4BUKI2k3TsR?e=tCn86P

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

THIS GUIDELINE IS NOW OBSOLETE. PLEASE CHECK THE UPDATED 2024 ASTHMA GUIDELINE AVAILABLE ON THIS CHANNEL. YOU CAN FIND IT IN THE VIDEO DESCRIPTION, BY CLICKING THE LINK IN THE TOP-RIGHT CORNER OF THIS VIDEO, OR ON THE END SCREEN.

The asthma playlist including the 2024 asthma guideline can be found here:

https://youtube.com/playlist?list=PLkDRVxR2chuhrU7IiPYiFYj7Wu_h3PURb&si=DmdpArNj9anQa5qx

My name is Fernando Florido and I am a GP in the United Kingdom. With today’s episode I am going to start a new series on asthma, focusing on the NICE guidelines on the diagnosis and management asthma. Firstly, I am going to go through the diagnosis flow charts and I am going to do them over 3 different episodes. In the first one I will go through the initial clinical assessment for all patients, in the second, I will go through the objective tests for children and young people and in the third one I will consider the diagnostic tests for adults. There will be other videos on the pharmacological treatment of asthma so make sure you subscribe and stay tuned.

There is YouTube version of the podcast and other guidance that you can access here:

·      https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw 

The full NICE guideline on asthma can be found here: 

·      Website:

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

·      Or download here:

https://1drv.ms/b/s!AiVFJ_Uoigq0lgCTpT8m-jvCCavu?e=z1Vs5z

The diagnostic flow chart “initial assessment” (Episode 1) can be

·      Viewed on website: https://www.nice.org.uk/guidance/ng80/resources/algorithm-a-initial-clinical-assessment-for-adults-young-people-and-children-with-suspected-asthma-pdf-4656176749 

·      Or, if outside the UK, downloaded here:

o  Image: https://1drv.ms/u/s!AiVFJ_Uoigq0lXZgO7_Zad1zMIfX?e=cmzv91 

o  PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0lXWWt7TqIN0Cye1M?e=kL0i0p

The diagnostic flow chart “children and young people” (Episode 2) can be

·      Viewed on website: https://www.nice.org.uk/guidance/ng80/resources/algorithm-b-objective-tests-for-asthma-in-children-and-young-people-aged-5-to-16-pdf-4656176750

·      Or, if outside the UK, downloaded here:

o  Image: https://1drv.ms/u/s!AiVFJ_Uoigq0lXTL5o5XU2aOfChx?e=6qJk1M 

o  PDF: 

https://1drv.ms/b/s!AiVFJ_Uoigq0lXlBBD1Wq7lak-mg?e=iLpgAX

The diagnostic flow chart “adults” (Episode 3) can be

·      Viewed on website: https://www.nice.org.uk/guidance/ng80/resources/algorithm-c-objective-tests-for-asthma-in-adults-aged-17-and-over-pdf-4656176751 

·      Or, if outside the UK, downloaded here:

o  Image: https://1drv.ms/u/s!AiVFJ_Uoigq0lXgUR4QxwwxNNynL?e=OrBRwi 

o  PDF: 

https://1drv.ms/b/s!AiVFJ_Uoigq0lXcaf4BUKI2k3TsR?e=tCn86P

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

Episode: EASD ADA consensus guidelines on the overall approach in glucose lowering medication in type 2 diabetes

This podcast is intended for healthcare professionals. My name is Fernando Florido and I am a GP in the United Kingdom. In this episode I go through the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus guidelines on the overall approach in glucose lowering medication in type 2 diabetes. I will firstly give you a list of the changes to the previous consensus recommendations followed by a description of the consensus recommendations flowchart on the subject. The original article was published on 19 December 2019 with a subsequent correction published on 15 May 2020.

There is a YouTube version of this episode in the NICE GP YouTube Channel that you can access here:

·      https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw

This episode also appears in the

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

Diabetes in Primary Care podcast:

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

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

·      Apple podcasts: https://podcasts.apple.com/us/podcast/diabetes-in-primary-care/id1562910252

The ADA-EASD consensus guidelines can be found here:

·      Website:

o  https://link.springer.com/article/10.1007/s00125-019-05039-w

·      Or download here:

o  https://1drv.ms/b/s!AiVFJ_Uoigq0lW-4rilnP_mruV41?e=FjPLGo

The Summary of the changes to the previous consensus recommendations can be

·      Viewed on website above:

o  https://link.springer.com/article/10.1007/s00125-019-05039-w

·      Or downloaded here:

o  https://1drv.ms/b/s!AiVFJ_Uoigq0lW72FZuzZZiv8bPr?e=7Fib8M

The Visual summary “glucose lowering medication in type 2 diabetes- overall approach” can be found here:

·      Website:

o  Figure 1 | 2019 update to: Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) | SpringerLink

·      Or download here:

o  https://1drv.ms/u/s!AiVFJ_Uoigq0lXCNFscGYei60BiV?e=3n0Ern

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:

This podcast is intended for healthcare professionals. Thank you for listening and welcome to a new episode, bringing you medical information and clinical guidance from a primary care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.

In today’s episode I am going to go through the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus guidelines on the overall approach in glucose lowering medication in type 2 diabetes.

I will firstly give you a list of the changes to the previous recommendations followed by a description of the consensus recommendations flow chart.

If you have been following previous episodes, you may be familiar with the updated NICE guidelines on the management of type 2 diabetes. However, the NICE recommendations, primarily followed in the UK, have some substantial differences when compared to other international recommendations and this is why I have decided to do this episode today. You will notice that the main difference with NICE refers to the use of GLP1 mimetics which NICE considers to be less cost effective. However, from a clinical perspective, there is now ample evidence in their favour, which justifies a wider use as described in the consensus guidelines.

I will put in the description below a link to download the full article as well as the summary of the changes and the flow chart. There is a YouTube version of this episode and other NICE guidance on the NICE GP YouTube Channel and a link to access it can be found in the podcast description. Because of the visual nature of the flow chart, I would highly recommend watching the YouTube video if you can.

Although describing visual aids as audio files can be challenging, I hope that you find the content clear and informative.

Right, let’s go right in. So, we are going to start looking at the European Association for the Study of Diabetes and the American Diabetes Association consensus guidelines on managing hyperglycemia in type 2 diabetes, published in December 2019, corrected in May 2020 and I have put links in to it in the episode description.

Now, before starting the treatment flow chart, we are going to go through the changes to the consensus recommendations and this is just a brief summary of what the changes are.

As a general consideration we will say that, in high-risk patients, the decision to treat with a GLP 1 receptor agonist or an SGLT 2 inhibitor should be considered independently of the HbA1c. This is because these agents have been proven to reduce major adverse cardiovascular events, hospitalisation for heart failure, cardiovascular deaths and CKD progression.

We will say that in patients with established atherosclerotic cardiovascular disease, the level of evidence for cardiovascular benefit is greatest for GLP 1 receptor agonist and this is in terms of reducing major adverse cardiovascular events.

And because of this, to reduce the risk of cardiovascular disease, the GLP 1 receptor agonists can also be considered in patients who have no cardiovascular disease but who are at high risk of cardiovascular disease.

For patients with heart failure, especially if their heart failure has a reduced ejection fraction, that is, an ejection fraction less than 45%, or if they have CKD with an eGFR between 30 and 60 and microalbuminuria, with urine albumin creatinine ratio greater than 30 particularly if it is greater than 300, the level of evidence is greatest for SGLT 2 inhibitors. So, SGLT 2 inhibitors are recommended with patients with heart failure and equally the SGLT 2 inhibitors are recommended for patients we CKD to prevent progression of CKD as well as the cardiovascular outcomes.

Obviously, because there is a link between SGLT 2 inhibitors and an increased risk of amputation, patients with foot ulcers or at high risk of amputation, should only be treated with SGLT 2 inhibitors after careful shared decision making around the risks and benefits and with comprehensive education and foot care and amputation prevention.

Well, that was the summary of the changes. Now we are going to dive in straight into the flow chart, which is titled: “glucose lowering medication in type 2 diabetes: overall approach”. And in the right top corner there is a note that tells us that, to avoid clinical inertia, we need to review the patients regularly, ideally every three or six months.

Now, the first thing that the flow chart tells us is that the first line therapy is always metformin and comprehensive lifestyle including weight management and physical activity. So, metformin first of all, and then, we are going to see if there are indicators of high risk or established atherosclerotic cardiovascular disease, CKD or heart failure. If the patient has any of these, then we will consider independently of the HbA1c the treatment.

This side of the flow chart then divides in two, one if cardiovascular disease predominates or, two, if heart failure or CKD predominate.

So, if atherosclerotic cardiovascular disease predominates, either because there is established cardiovascular disease or there are indicators of high risk for getting cardiovascular disease, then we will preferably give a GLP 1 receptor agonist with proven cardiovascular disease benefit and the chart tells us at the bottom in the notes that proven cardiovascular benefit means that it has a label indication for reducing cardiovascular events.

If you cannot give or do not want to give a GLP 1 receptor agonist then we will give an SGLT 2 inhibitor with proving cardiovascular benefit, as long as the eGFR is adequate. And again, it reminds us at the bottom of the chart that we have to be aware that SGLT 2 inhibitor labelling varies by region and individual agents with regard to the indicated level of eGFR for initiation and continued use.

Right, so we repeat again, independently of the HbA1c and if cardiovascular disease predominates, we will give either GLP 1 receptor agonist or an SGLT 2 inhibitor.

And then, we will look at the HbA1c and if the HbA1c remains above the target then we will consider further intensification of the treatment.

For patients who are on GLP 1 receptor agonists we will give an SGLT 2 inhibitor and, likewise, if they had initiated an SGLT 2 inhibitor then we will give them a GLP 1 receptor agonist. As an alternative, we can give a DPP 4 inhibitor if the patient is not on a GLP 1 receptor agonist, and this is because of their mode of action or we can also give basal insulin, pioglitazone or a sulphonylurea. So, we are just going to mix and match those agents, always preferably starting with GLP 1 receptor agonist, then SGLT 2 inhibitors and then we can give a DPP 4 inhibitor if the patient is not on a GLP 1 receptor agonist, or basal insulin, pioglitazone or a sulphonylurea.

And, also in the notes at the bottom, it tells us that degludec and U 100 glargine have demonstrated cardiovascular disease safety. It also tells us that a low dose of pioglitazone may be better tolerated though less well studied for cardiovascular effects and, in terms of sulphonylureas, it reminds us that we should choose later generations of sulphonylureas to lower the risk of hypoglycaemia and glimepiride has shown similar cardiovascular safety to the DPP 4 inhibitors.

So, that concludes the section where cardiovascular disease predominates. Now if heart failure or CKD predominate, particularly if it is reduced ejection fraction heart failure or if CKD has an eGFR between 30 and 60 and microalbuminuria at least 30mg per gram or more, we will use preferably an SGLT 2 inhibitor with evidence of reducing heart failure and / or CKD progression in cardiovascular outcome trials, as long as the EGFR is adequate.

So, it tells us in the notes at the bottom that both empaglifozin and canaglifozin have shown reduction in heart failure and also reduced CKD progression in cardiovascular outcome trials. Canaglifozin has primary renal outcome data from CREDENCE and dapaglifozin has primary heart failure outcome from the DAPA HF trial. But all these details may be becoming less and less relevant because it is now increasingly thought that the SGLT 2 inhibitors have a class effect.

Now if an SGLT 2 inhibitor is not tolerated or contraindicated or if the eGFR is less than adequate, we will give a GLP 1 receptor agonist with proven cardiovascular benefit.

So, it is more or the other way round from the cardiovascular disease branch. There we gave a GLP 1 receptor agonist first and then an SGLT 2 inhibitor. Here, in heart failure of CKD we are going to give an SGLT 2 inhibitor first and then GLP 1 receptor agonist second.

And, again, we need to remember that if a patient has heart failure or CKD, we will consider this treatment with an SGLT2 inhibitor or a GLP 1 receptor agonist independently of the HbA1c.

And then, we will look at the HbA1c, and if the HbA1c is above the target, we will consider further treatment.

The first thing that we have to consider is that we need to avoid pioglitazone in the setting of heart failure because it tends to worsen it because of fluid retention. We will try to stick to agents with cardiovascular safety. So, for patients on an SGLT 2 inhibitor, we will consider a GLP 1 receptor agonist. Or we can give a DPP 4 inhibitor but not saxagliptin in the setting of heart failure, as long as the patient is not on a GLP 1 receptor agonist. Alternatively, we can give basal insulin or a sulphonylurea.

So, in summary, after an SGLT 2 inhibitor and a GLP 1 receptor agonist, if we need to give anymore drugs, we will avoid pioglitazone and saxagliptin in in the setting of heart failure. We can consider a DPP 4 inhibitor, if not on a GLP 1 receptor agonist, or basal insulin or a sulphonylurea.

Right, this ends the branch of heart failure or CKD patients.  So, we have now covered both if a patient has got atherosclerotic cardiovascular disease, heart failure or CKD. However, if a patient has not got those conditions and they are not at high risk of those conditions, then we will give metformin and then will be guided by the HbA1c in order to decide whether to give more treatment.

And we will divide this treatment in three, depending on whether, one, we want to minimise hypoglycaemia, two, we want to minimise weight gain or promote weight loss and, three, when cost of treatment is a major issue. So again, we divide the treatment on whether we focus on hypoglycaemia, on weight or on cost.

Firstly, we will look at the branch where minimising hypoglycaemia is our priority. And for those patients, we will use any of the agents that are not associated with hypoglycaemia. That is, a DPP 4 inhibitor, a GLP 1 receptor agonist, an SGLT 2 inhibitor or pioglitazone. So, we give dual therapy with metformin and one of those drugs. If the HbA1c remains above target then we will give triple therapy with metformin and any combination of the drugs already mentioned, a DPP 4 inhibitor, a GLP 1 receptor agonist, an SGLT 2 inhibitor or pioglitazone bearing in mind that we must not combine a GLP 1 receptor agonist and a DPP 4 inhibitor. But all other combinations are allowed.

And then, if the HbA1c remains above target on triple therapy, we will continue with additions of other agents so we can go to quadruple therapy.

Finally, if the HbA1c remains above target. Then we will consider the addition of a sulphonylurea or basal insulin. And with sulphonylureas we will choose the later generations with lower risk of hypoglycaemia such as glimepiride or we will consider a basal insulin with lower risk of hypoglycaemia. And there is a small note at the bottom of the chart that tells us that the insulin with lowest risk of hypoglycaemia is degludec and glargine U300, followed by glargine U100 and detemir, followed by finally NPH insulin.

Now, the second branch is when we are going to focus on the weight because we need to minimise weight gain or promote weight loss. In these cases, we will give either at GLP 1 receptor agonist or an SGLT 2 inhibitor because both these agents are associated with weight loss. And a small note at the bottom of the chart tells us the GLP 1 receptor agonists with good efficacy for weight loss. The best one is semaglutide, followed by liraglutide, then dulaglutide, then exenatide and finally lixisenatide. So, if we can, we will give them always either semaglutide or liraglutide.

And then if the HbA1c remains above target then we will give the second of those two agents, so, if the patient is had a GLP 1 receptor agonist, we will give an SGLT 2 inhibitor and if they have had an SGLT 2 inhibitor then we will give in GLP 1 receptor agonist.

And if the HbA1c remains above target, then we will start quadruple therapy because the patient would already be on metformin, a GLP 1 receptor agonist and an SGLT 2 inhibitor. But if this combination is not tolerated or contraindicated, then the lowest risk of weight gain is with a DPP 4 inhibitor and this is because the DPP 4 inhibitors have got weight neutrality, but that can only be given if the patient is not already on a GLP 1 receptor agonist.

If the DPP 4 inhibitor is not tolerated or contraindicated or if the patient is already on a GLP 1 receptor agonist, we should use cautiously a sulphonylurea, pioglitazone or basal insulin, and this is because all these agents are associated with weight gain.

Finally, the last branch of the flowchart is when we are going to focus on the cost, because cost is a major issue. And there is a note at the bottom of the page that is going to tell us when we should consider cost to be a major issue. Therefore, cost should be our focus if there are no specific comorbidities, that is, no established cardiovascular disease, there is a low risk of hypoglycaemia and weight is not a real concern.

Also, there is a warning in terms of cost, saying that we need to consider country and region-specific cost of drugs because, in some countries for example, pioglitazone can be relatively more expensive and a DPP 4 inhibitor relatively cheaper.

So, looking at the flowchart, if cost is a concern, after metformin we will start with either a sulphonylurea or pioglitazone, which are generally the cheapest agents and if the HbA1c is above target, we will go into triple therapy with metformin, a sulphonylurea and pioglitazone. And if the HbA1c remains above target, then we will consider either insulin therapy, giving basal insulin with the lowest acquisition cost or we can consider a DPP 4 inhibitors or an SGLT 2 inhibitors with the lowest acquisition cost. Or, in other words, we go into quadruple therapy according to whatever is the most cost-effective combination.

Right, this is it, we have completed the review of the EASD ADA consensus guidelines flow chart. So, this is the end of this video and the summary of the consensus recommendations. There is also a YouTube version of this episode in the NICE GP YouTube Channel and I will leave a link in the episode description. Thank you for listening and I hope that you will join me in the next one.

My name is Fernando Florido and I am a GP in the United Kingdom. In this video I go through the Visual summary “choosing medicines for first-line and further treatment” corresponding to the 2022 updated NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline), updated on 29th June 2022. The video focuses on the drug treatment recommendations in blood glucose management in adults with Type 2 Diabetes.

This podcast will be saved on a website. 

There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:

https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw

This podcast also appears in the Diabetes in Primary Care podcast which can be found here:

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

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

·      Apple podcasts: https://podcasts.apple.com/us/podcast/diabetes-in-primary-care/id1562910252

NICE Guideline NG28 can be found here:

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

The full NG28 full guideline PDF document can be found here:

·      Website:

https://www.nice.org.uk/guidance/ng28/resources/type-2-diabetes-in-adults-management-pdf-1837338615493

·      If outside the UK, you can download it here: https://1drv.ms/b/s!AiVFJ_Uoigq0lWqK_tYk1rnOolRO

The visual summary “choosing medicines for first-line and further treatment” can be found here:

·      Website:

https://www.nice.org.uk/guidance/ng28/resources/visual-summary-full-version-choosing-medicines-for-firstline-and-further-treatment-pdf-10956472093

·      If outside the UK, you can download it here: https://1drv.ms/b/s!AiVFJ_Uoigq0lWugUmhgaYv1PHyf

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

Thank you for listening and welcome to a new episode of this podcast bringing medical information and NICE guidance from a primary care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.

Now, imagine that we have Mr. Johnson, who is 78 and has type 2 diabetes. His diabetes control is reasonable or metformin, 500mg BD. With an HbA1c of 7.1% or 54 mmol/mol, but he has just developed stable angina. How should his diabetic treatment change? We have covered the 2022 NICE diabetes management update in previous episodes, but perhaps we need a quick reminder?

And this is what we’re going to do today because in this video I am going to go through the flow charts produced by NICE in respect of the blood glucose management in type 2 diabetes. The full guideline has 59 pages in a PDF format and NICE has produced a 5-page summary on the blood glucose management. This video is going to focus on the two flow charts that will advise how to choose first line medicines and how to choose medicines for further treatment.

I will put in the description below a link to download the full NICE guideline as well as the five-page summary. There is a YouTube version of this episode and other NICE guidance on the NICE GP YouTube Channel and a link to access it can be found in the podcast description. Because of the visual nature of the flow chart, I would highly recommend watching the YouTube video if you can.

Although describing visual aids as audio files can be challenging, I hope that you find the content clear and informative.

Now the first flow chart that we are going to look at is the one about how to choose first line medicines. It is only one page and there is a combination of arrows that will guide us through the treatment pathways and a number of boxes with further information and clarification on the treatments described.

Right at the top of the chart, we find a box that tells us about rescue therapy and it reminds us that for patients with symptomatic hyperglycaemia, we will consider insulin or a sulphonylurea and then review the treatment when their blood glucose control has been achieved.

Then the next step is to assess the HbA1c, the cardiovascular risk and kidney function. Obviously, as you know, to calculate the cardio vascular risk with, for example, the QRISK2 tool, we will need to know the patient’s age, sex, smoking status, blood pressure and the total cholesterol/HDL ratio.

Now, having checked the renal function, before starting to follow the pathway, there is a little box on the left telling us that for information on using SGLT 2 inhibitors for people with type 2 diabetes and CKD, there is specific guidance that is not on this flow chart and we will have to refer to CKD section of the diabetic guideline.

So, after we have done our initial assessment with the HbA1c, cardiovascular risk and kidney function, the flow chart divides into three categories. One, it could be that the patient is not at high cardiovascular risk. Two, that the patient has chronic heart failure or established atherosclerotic cardio vascular disease. Or three, that the patient has a high risk of cardiovascular disease, which is defined as a QRISK 2 of 10% or higher over ten years, or an elevated lifetime risk.

Now, the first pathway would be when the patient is not at high risk of cardio vascular disease and for these patients, we will offer metformin, or, if there are gastrointestinal side effects, we will give Metformin slow release. Now if metformin is contraindicated, we will consider one of the other antidiabetic agents, either a DPP-4 inhibitor, pioglitazone or a sulphonylurea, although it does also tell us that SGLT 2 inhibitors can also be given as monotherapy for some patients. Basically, NICE recommends an SGLT 2 inhibitor as monotherapy in people who can’t take metformin and for whom the diabetic control is poor, and only if a DPP-4 inhibitor would otherwise be prescribed and a sulphonylurea or pioglitazone is not appropriate. So, it is fairly restrictive.

We also see a small note saying that using your ertugliflozin to reduce cardiovascular risk when the blood glucose is well controlled was an off-label use.

So, if no cardiovascular risk, we give metformin first and if contraindicated one of the other agents, sulphonylurea, pioglitazone, DPPG4 inhibitors of an SGLT2 inhibitor, although the latter with a few restrictions.

Now the second pathway would be when the patient has got chronic heart failure or established atherosclerotic cardiovascular disease. And the flow chart tells us in a box what they actually mean by established atherosclerotic cardiovascular disease, and this is fairly intuitive. It includes CHD, acute coronary syndrome, previous MI, stable angina, prior coronary or other revascularisation, cerebrovascular disease, which includes both ischemic stroke and TIAs and finally, peripheral arterial disease. So, for those patients, we will do very similar. We will start with metformin or if there are gastrointestinal side effects, we will give Metformin slow release and then, as soon as metformin tolerability is confirmed, we will offer an SGLT 2 inhibitor with proven cardiovascular benefit. And this is because SGLT 2 inhibitors have now been found to reduce cardio vascular events. However, if metformin is contraindicated, then we will give an SGLT 2 inhibitor alone. So, this is fairly straight forward.

Finally, the third option after the initial assessment is that the patient has not got cardiovascular disease but is at high risk of it. In this case, the flow chart is basically fairly similar. We will give metformin or, if there are side effects, metformin slow release and then as soon as metformin tolerability is confirmed we will consider an SGLT 2 inhibitor with proven cardiovascular benefit. And also, if metformin is contraindicated, we will consider an SGLT 2 inhibitor alone.

So, you may ask what is the difference between those two, having cardiovascular disease and being at high risk of CVD? And the difference is basically that, if the patient has got cardiovascular disease or heart failure, we will definitely offer an SGLT 2 inhibitor, whereas if a patient is only at high risk of cardiovascular disease, we will consider it. But in practice you will probably find that pathways are exactly the same, because you’re going to consider it seriously and you're going to give it unless a contraindication or other major consideration.

In the middle of the flow chart there’s a little box that reminds us that we always have to start metformin alone to assess tolerability before adding an SGLT 2 inhibitor. So, metformin is always the start.

So, this is really the flowchart on how to choose first line medicines. After this, if the person’s HbA1c is not controlled below the target or a person develops cardio vascular disease or a high risk of cardiovascular disease, then we will move to the second flow chart, which is the one about treatment options if further interventions are needed.

So, there we go. The second flow chart which is on how to choose medicines for further treatment.

Here, at the beginning, there’s another box telling us again about rescue therapy and using insulin, or a sulphonylurea for symptomatic hyperglycaemia until the levels are controlled.

Now, if further treatment options are needed, it will be because either at any point the HbA1c is not well controlled, or at any point, the cardio vascular risk or cardiovascular status change.

Right, we’re going to start with the cardiovascular risk of cardiovascular status change and we’ve got two options. The first one is that the person has or develops chronic heart failure or established atherosclerotic cardiovascular disease, and the second one is that the person develops a high risk of cardiovascular disease.

If the person has or develops chronic heart failure or established atherosclerotic cardiovascular disease, we will basically switch or add treatments to make sure that we offer an SGLT 2 inhibitor if this is not already prescribed. So, if the person develops the condition, we will either add an SGLT 2 inhibitor if the HbA1c could do with lowering further or, if the HBA 1C, is fairly low and we don’t want to lower it any more then we will switch one of the existing drugs for an SGLT 2 inhibitor.

On the other hand, if the person has or develops a high risk of cardio vascular disease, then we will consider an SGLT 2 inhibitor when switching or adding treatments. So, like before in the previous flow chart, giving an SGLT2 is slightly more imperative when the person has developed cardiovascular disease, whereas, if the person is just at a high risk, we will only consider it. But again, in practice it may not make much difference.

Now, if at any point the HbA1c is not well controlled, there is a box that  tells us that we will switch or add treatments from different drug classes up to triple therapy or dual therapy if metformin is contraindicated. So basically, we will consider any combination to dual or triple therapy of the antidiabetic agents, that is, either a DPP 4 inhibitor, pioglitazone or a sulphonylurea, although it also tells us that SGLT 2 inhibitors may also be an option both in dual therapy or triple therapy.

Now you may ask when should we start insulin? Well at the bottom left corner we find a box that tells us that, when dual therapy is not enough to control the HbA1c, we can consider insulin-based therapy, with or without other drugs and there is additional guidance on how to use insulin with SGLT 2 inhibitors. So basically, if a patient goes up to dual therapy and is not well controlled, you may consider triple therapy if the patient is on metformin or just consider insulin as the next step.

And finally, what is happening to GLP 1 mimetics? Well, this is where NICE has been quite restrictive in their approach because it tells us that if triple therapy with metformin and two other oral drugs is not enough, we will consider triple therapy by switching one drug for a GLP 1 mimetic, but only for people:

·      who have a BMI of 35 or higher and specific psychological or other medical problems associated with obesity, although it does say that you can adjust the BMI to lower for people from Black, Asian and other minority ethnic groups, because these groups are at higher risk of cardiovascular disease and GLP mimetics have also been shown to reduce cardiovascular events, or

·      we can give it to patients who have a BMI lower than 35 and for whom:

o   insulin therapy would have a significant occupational implication or

o  weight loss would benefit other significant obesity related comorbidities.

Right, so this is it, we have finished our second flow chart and therefore we have come to the end of this episode, I hope that you have found it useful. There is also a YouTube version in the NICE GP YouTube Channel and I will leave a link in the podcast description. Thank you for listening and I hope that you will join me in the next one. Goodbye.

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Hypertension in adults: diagnosis and management (NG136 guideline), updated on 18th March 2022.

This podcast will be saved on a website. 

There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:

https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw

NICE Guideline NG136 can be found here:

https://www.nice.org.uk/guidance/NG136 

Other links referred to in this episode:

·     guideline on hypertension in pregnancy

·     NICE's guideline on cardiovascular disease

·     patient decision aid on treatment options for hypertension

·     NICE's guideline on multimorbidity

·     NICE guidelines on chronic kidney disease

·     type 1 diabetes 

·     MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, recommendations on how to use for breastfeeding and the related clarification on breastfeeding

·      drug therapy for secondary prevention in the NICE guideline on acute coronary syndromes

·      treatment after stabilisation in the NICE guideline on acute heart failure

·      treating heart failure with reduced ejection fraction in the NICE guideline on chronic heart failure

·      drugs for secondary prevention of cardiovascular disease in the NICE guideline on stable angina

·      blood pressure management in the NICE guideline on type 1 diabetes in adults.

·     NICE's guideline on chronic heart failure 

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

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Thank you for downloading and welcome. This podcast is intended for healthcare professionals and it brings you medical information about clinical guidelines by the National Institute for Clinical Excellence or NICE from a Primary Care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.

In this episode I am going to tell you about the NICE guidelines on Hypertension in adults: diagnosis and management (NG136 guideline), updated on 18th March 2022.

In this episode I am going to summarise the main body of the guideline and I will provide links in the episode description to other guidance where indicated.

I have also uploaded YouTube videos on this subject and other NICE guidance. A link to access the YouTube channel can be found in the episode description.

As ever, all information is correct at the time of recording and all views and opinions are my own. I hope that you enjoy this episode.

This guideline covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively.

In March 2022, the updated guideline:

• reviewed the evidence and made a new recommendation on blood pressure targets for people who have both hypertension and cardiovascular disease.
• reassessed evidence on antihypertensive drug treatment and made a new recommendation to cover people who have both hypertension and cardiovascular disease.

NICE has also produced a guideline on hypertension in pregnancy and I will put the link to this in the podcast description.

This guideline includes a variety of recommendations including diagnosis, treatment and monitoring.

The recommendations on measuring blood pressure and diagnosing hypertension in this guideline apply to all adults, including those with type 2 diabetes. The recommendations on treatment and monitoring also apply to adults with type 2 diabetes.

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), we need to palpate the radial or brachial pulse before measuring the blood pressure. If pulse irregularity is present, we will need to measure blood pressure manually using direct auscultation over the brachial artery. 

When measuring blood pressure in the clinic or in the home, we need to standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. We will also need to use an appropriate cuff size for the person's arm. 

In people with symptoms of postural hypotension (falls or postural dizziness):

·      first we will measure the blood pressure with the person either supine or seated

·      and then measure the blood pressure again with the person standing for at least 1 minute before measurement. 

Then, If the systolic blood pressure falls by 20 mmHg or more when the person is standing:

·      we will need to review the medication

·      we will measure subsequent blood pressure readings with the person standing

·      and we will consider referral to specialist care if symptoms of postural hypotension persist. 

When considering a diagnosis of hypertension, we will need to measure the blood pressure in both arms and:

·      If the difference in readings between arms is more than 15 mmHg, we will repeat the measurements and

·      If the difference in readings between arms remains more than 15 mmHg on the second measurement, we will measure subsequent blood pressures in the arm with the higher reading. 

If blood pressure measured in the clinic is 180/120 mmHg or higher, we will identify who and how to refer for further investigation and management and a section about this will be addressed later on in this guideline.

If blood pressure measured in the clinic is 140/90 mmHg or higher:

·      We will Take a second measurement during the consultation and.

·      If the second measurement is substantially different from the first, we will take a third measurement.

Then we will Record the lower of the last 2 measurements as the clinic blood pressure. 

Then, If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, we will offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension and

If ABPM is unsuitable or the person is unable to tolerate it, we will offer home blood pressure monitoring (HBPM) to confirm the diagnosis. 

While waiting for confirmation of a diagnosis of hypertension, we will carry out:

·      investigations for target organ damage (there is a section later in this guideline covering this) followed by

·      a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool (there is also a section later in this guideline covering this). 

When using ABPM to confirm a diagnosis of hypertension, we will ensure that at least 2 measurements per hour are taken during the person's usual waking hours (for example, between 08:00 and 22:00) and we will use the average value of at least 14 measurements taken during the person's usual waking hours to confirm a diagnosis of hypertension. 

When using HBPM to confirm a diagnosis of hypertension, we will ensure that:

·      for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and

·      the blood pressure is recorded twice daily, ideally in the morning and evening and

·      the blood pressure recording continues for at least 4 days, ideally for 7 days.

We will Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. 

We will Confirm diagnosis of hypertension in people with a:

·      clinic blood pressure of 140/90 mmHg or higher and

·      ABPM daytime average or HBPM average of 135/85 mmHg or higher. 

If hypertension is not diagnosed but there is evidence of target organ damage, we will consider carrying out investigations for alternative causes of the target organ damage.

If hypertension is not diagnosed, we will measure the person's clinic blood pressure at least every 5 years subsequently, and we will consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90 mmHg. 

We will however Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease.

And we will Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. 

We will use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options and we will estimate the cardiovascular risk in line with the NICE recommendations on identifying and assessing cardiovascular disease risk (I will put the link to this guideline in the episode description). We will use clinic blood pressure measurements to calculate cardiovascular risk. 

For all people with hypertension we will offer investigations for target organ damage which will include all of the following:

·      We will test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and we will test for haematuria using a reagent strip

·      We will take a blood sample to measure glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol

·      We will examine the fundi for the presence of hypertensive retinopathy and

·      We will arrange for a 12‑lead ECG

We will offer lifestyle advice

We will encourage a healthy diet and regular exercise because they can reduce blood pressure.

We will encourage a reduced intake of alcohol if they drink excessively, because this can reduce blood pressure and has broader health benefits.

We will discourage excessive consumption of coffee and other caffeine-rich products. 

We will also encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. We need to be aware that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin II receptor blockers. We will just encourage salt reduction in these groups. 

We will not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure.

And we will offer advice and help to smokers to stop smoking.

NICE has produced a patient decision aid on treatment options for hypertension to help people and their healthcare professionals discuss the different types of treatment and make a decision that is right for each person. A link to this aid is in the episode description.

We will offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension (which is a clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher). We will use our clinical judgement for people of any age with frailty or multimorbidity

We will discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension (which is a clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg) who have 1 or more of the following:

·      target organ damage

·      established cardiovascular disease

·      renal disease

·      diabetes

·      or an estimated 10‑year risk of cardiovascular disease of 10% or more but we will consider the antihypertensive drug treatment if the risk is below 10% bearing in mind that the risk calculation may underestimate the lifetime probability of developing cardiovascular disease.

We will again use clinical judgement for people with frailty or multimorbidity (there is a specific NICE guideline in about this and I will put the link in the episode description) (see also NICE's guideline on multimorbidity). 

We will consider antihypertensive drug treatment for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg and we will use clinical judgement for people with frailty or multimorbidity.

For adults aged under 40 with hypertension, we will consider seeking specialist evaluation of secondary causes of hypertension

For specific recommendations on blood pressure control in people with other conditions or who are pregnant, there is specific guidance for people with CKD, type 1 diabetes and who are pregnant> There is separate guidance for these and I will put links in the episode description. see also the NICE guidelines on chronic kidney disease, type 1 diabetes and hypertension in pregnancy.

We will use clinic blood pressure measurements to monitor the response to treatment and

We will measure standing as well as seated blood pressure in people with hypertension and:

·      with type 2 diabetes or

·      with symptoms of postural hypotension or

·      aged 80 and over.

In people with a significant postural drop or symptoms of postural hypotension, we will treat to a blood pressure target based on standing blood pressure. 

We will consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting), being aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements

When setting Blood pressure targets,

For adults aged under 80, we will reduce the clinic blood pressure to below 140/90 mmHg and

For adults aged 80 and over, we will reduce clinic blood pressure to below 150/90 mmHg, using our clinical judgement for people with frailty or multimorbidity

When using ABPM or HBPM, we will use the average blood pressure level taken during the person's usual waking hours, aiming to reduce it to:

·      below 135/85 mmHg for adults aged under 80

·      below 145/85 mmHg for adults aged 80 and over.

We will use the same blood pressure targets for people with and without cardiovascular disease. 

And we will provide an annual review of care for adults with hypertension.

Finally, when diabetes is diagnosed, we will review the antihypertnsive medication making changes if drug treatment is not appropriate because of microvascular complications or metabolic problems. 

We need to be aware that ACE inhibitors and angiotensin II receptor antagonists should not be used in pregnant or breastfeeding women or women planning pregnancy unless absolutely necessary, in which case the potential risks and benefits should be discussed. There is MHRA guidance in tis respect and I will put the links to this in the episode description. Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, recommendations on how to use for breastfeeding and the related clarification on breastfeeding.

For guidance on choice of hypertensive agent in people with chronic kidney disease or women considering pregnancy or who are pregnant or breastfeeding, we will follow separate guidance specific to this area and links to this guidance will also appear in the episode description. see NICE's guideline on chronic kidney disease.

Whenever possible, we will offer treatment with drugs taken only once a day and we will prescribe generic drugs to minimise the cost. 

We will offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. 

When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, we will consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor. 

For people with cardiovascular disease:

·      we will follow the recommendations for disease-specific indications in the NICE guideline on their condition. Relevant recommendations include acute coronary syndromes, acute and chronic heart failure, stable angina and type 1 diabetes and links to these guidelines will be available in the episode description.

o  drug therapy for secondary prevention in the NICE guideline on acute coronary syndromes

o  treatment after stabilisation in the NICE guideline on acute heart failure

o  treating heart failure with reduced ejection fraction in the NICE guideline on chronic heart failure

o  drugs for secondary prevention of cardiovascular disease in the NICE guideline on stable angina

o  blood pressure management in the NICE guideline on type 1 diabetes in adults.

We will offer an ACE inhibitor or an ARB to adults who:

·      have type 2 diabetes and are of any age or family origin or

·      are aged under 55 but not of Black African or African–Caribbean family origin. 

If an ACE inhibitor is not tolerated, for example because of cough, we will offer an ARB to treat hypertension. 

We will not combine an ACE inhibitor with an ARB to treat hypertension. 

We will offer a calcium-channel blocker (CCB) to adults who:

·      are aged 55 or over and do not have type 2 diabetes or

·      are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). 

If a CCB is not tolerated, for example because of oedema, we will offer a thiazide-like diuretic to treat hypertension. 

If there is evidence of heart failure, we will offer a thiazide-like diuretic and follow the NICE's guideline on chronic heart failure. 

If starting or changing diuretic treatment for hypertension, we will offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. 

However, for adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, we will continue with their current treatment. 

If hypertension is not controlled in adults taking an ACE inhibitor or ARB, we will add 1 of the following drugs:

·      a CCB or

·      a thiazide-like diuretic. 

If hypertension is not controlled in adults taking a CCB, we will add 1 of the following drugs:

·      an ACE inhibitor or

·      an ARB (and this is in preference to ACE inhibitor in adults of Black African or African–Caribbean family origin) or

·      a thiazide-like diuretic. 

If hypertension is not controlled in adults taking step 2 treatment, offer triple therapy as a combination of:

·      an ACE inhibitor or ARB (again, the latter in preference for people of Black African or African–Caribbean family origin) and

·      a CCB and

·      a thiazide-like diuretic. 

If hypertension is not controlled in adults taking triple therapy, we will regard them as having resistant hypertension and

Before considering further treatment:

·      we will confirm the elevated clinic blood pressure measurements using ambulatory or home blood pressure recordings.

·      We will assess for postural hypotension.

·      And we will discuss adherence.

For people with confirmed resistant hypertension, we will consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice. 

When adding a fourth drug, we will consider further diuretic therapy with low-dose spironolactone when the blood potassium level is 4.5 mmol/l or less and we will be particularly cautious in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia. 

When doing this, we will monitor blood sodium and potassium and renal function within 1 month of starting treatment and repeat as needed thereafter. 

We will consider an alpha-blocker or beta-blocker as a fourth drug for those who have a blood potassium level of more than 4.5 mmol/l. 

If blood pressure remains uncontrolled taking 4 drugs, we will seek specialist advice. 

We will refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

·      signs of retinal haemorrhage or papilloedema (which is what we will call accelerated hypertension) or

·      life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

We will also refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

If a person has a clinic blood pressure of 180/120 mmHg or higher, but no symptoms or signs, we will carry out investigations for target organ damage as soon as possible, including all of the following:

·      testing for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and testing for haematuria using a reagent strip

·      taking a blood sample to measure glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol

·      examining the fundi for the presence of hypertensive retinopathy

·      and arranging for a 12‑lead ECG

And then:

·      If target organ damage is identified, we will consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

·      However, if no target organ damage is identified, we will confirm the diagnosis by:

o  repeating clinic blood pressure measurement within 7 days, or

o  considering ABPM (or HBPM if ABPM is not suitable or not tolerated) and we will review within 7 days.

We have come to the end of the actual guideline but it is worth going through the definition of the Terms used by NICE in this guideline, and these are:

Which is defined as a severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (or swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.

Refers to a Medical history of ischaemic heart disease, cerebrovascular disease, peripheral vascular disease, aortic aneurysm or heart failure. Cardiovascular disease is usually associated with a build-up of fatty deposits inside the arteries (or atherosclerosis) and an increased risk of blood clots.

Refers to when Clinic blood pressure measurements are normal (that is, less than 140/90 mmHg), but blood pressure measurements are higher when taken outside the clinic using an ABPM or a HBPM.

Is when the clinic blood pressure ranges from 140/90 mmHg to 159/99 mmHg and subsequent ABPM or HBPM average blood pressure ranges from 135/85 mmHg to 149/94 mmHg.

Is when the clinic blood pressure is 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM or HBPM average blood pressure is 150/95 mmHg or higher.

Is when the clinic systolic blood pressure is 180 mmHg or higher or the clinic diastolic blood pressure of 120 mmHg or higher.

Is defined as damage to organs such as the heart, brain, kidneys and eyes. Examples are left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy or increased urine albumin:creatinine ratio.

Is defined as a discrepancy of more than 20/10 mmHg between clinic and ABPM or HBPM blood pressure measurements at the time of diagnosis.

We have come to the end of this episode. I hope that you have enjoyed it and found it useful and I hope that you will join me in the next one. Thank you for listening and goodbye.

NICE guideline [NG115]Published: 05 December 2018 Last updated: 26 July 2019

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115 guideline), updated on 26th July 2019.

This podcast will be saved on a website.

There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:

https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw

NICE Guideline NG115 can be found here:

https://www.nice.org.uk/guidance/NG115

Other links referred to in this episode: 

·      guideline on antimicrobial prescribing for acute exacerbations of COPD

·      visual summary covering non-pharmacological management and use of inhaled therapies

·      MRC breathlessness scale 1959

·      NICE guideline on asthma

·      visual summary covering non-pharmacological management and use of inhaled therapies

·      asthmatic features/features suggesting steroid responsiveness

·      MHRA safety advice on Respimat and Handihaler inhalers

·      NICE's technology appraisal guidance on roflumilast for treating chronic obstructive pulmonary disease

·      NICE technology appraisals on oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza

·      amantadine, oseltamivir and zanamivir for the treatment of influenza

·      NICE interventional procedures guidance on lung volume reduction surgery, endobronchial valves

·      endobronchial coils

·      British Thoracic Society recommendations

·      NICE guideline on antimicrobial prescribing for acute exacerbations of COPD

·      recommendations on systemic corticosteroids 

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

Thank you for downloading and welcome. This podcast is intended for healthcare professionals and it brings you medical information about clinical guidelines by the National Institute for Clinical Excellence or NICE from a Primary Care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.

In this episode I am going to tell you about the NICE guidelines on Chronic obstructive pulmonary disease in over 16s: diagnosis and management (this is the NG115 guideline). These guidelines were last updated in July 2019. NICE checked this guideline in January 2022 and it was decided that it did not need to be updated at that time.

In this episode I am going to summarise the main body of the guideline. You may be aware that many clinicians and formularies now rely on the management recommendations produced by the Global initiative for obstructive lung disease, also known as GOLD, which some say are more easily applied in practice than the NICE recommendations. The NICE recommendations do not contradict the GOLD report, but there are some who say that they are much more concise in their approach. Considering that the PDF document of this NICE guideline is 72 pages long, that is quite a statement. However, stay tuned because I intend to create another episode in future on the GOLD guidelines.

I have also uploaded YouTube videos on this subject and other NICE guidance. A link to access the YouTube channel can be found in the episode description.

As ever, all information is correct at the time of recording and all views and opinions are my own. I hope that you enjoy this episode.

Right, this guideline covers diagnosing and managing chronic obstructive pulmonary disease or COPD (which includes emphysema and chronic bronchitis) in people aged 16 and older. It aims to help people with COPD to receive a diagnosis earlier so that they can benefit from treatments to reduce symptoms, improve quality of life and keep them healthy for longer.

NICE has also produced a guideline on antimicrobial prescribing for acute exacerbations of COPD and a visual summary covering non-pharmacological management and use of inhaled therapies.  I will put the links to these two in the episode description.

The diagnosis of COPD is suspected on the basis of symptoms and signs and is supported by spirometry.

We will suspect a diagnosis of COPD in people over 35 who have a risk factor (generally smoking or a history of smoking) and who present with 1 or more of the following symptoms:

·      exertional breathlessness

·      chronic cough

·      regular sputum production

·      frequent winter 'bronchitis'

·      or wheeze. 

One of the primary symptoms of COPD is breathlessness. The Medical Research Council (MRC) dyspnoea scale (see table 1) should be used to grade the breathlessness according to the level of exertion required to elicit it. I will put the link to this table in the episode description. The scale goes from 1 to 5 where 1 means minimal breathlessness and 5 disabling breathlessness.

So, In the MRC dyspnoea scale

Grade 1

Means that the person is not troubled by breathlessness except on strenuous exercise

Grade 2

Means that the person is short of breath when hurrying or walking up a slight hill

Grade 3

Is when the person walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace

Grade 4

Is when the person needs to stop for breath after walking about 100 metres or after a few minutes on level ground

And Grade 5

Is when the person is too breathless to leave the house, or is breathless when dressing or undressing

We need to perform spirometry:

·      at diagnosis

·      to reconsider the diagnosis, for people who show an exceptionally good response to treatment

·      to monitor disease progression. 

We will measure post-bronchodilator spirometry to confirm the diagnosis of COPD. An FEV1/FVC ratio below 0.7 is typical in COPD

We will also think about alternative diagnoses or investigations for older people who have an FEV1/FVC ratio below 0.7 but do not have typical symptoms of COPD. 

And we will think about a diagnosis of COPD in younger people who have typical symptoms of COPD, even when their FEV1/FVC ratio is above 0.7. 

We will consider primary care respiratory review and spirometry for people with emphysema or signs of chronic airways disease on a chest X-ray or CT scan. 

If the person is a current smoker, their spirometry results are normal and they have no symptoms or signs of respiratory disease:

·      we will offer smoking cessation advice and treatment

·      we will warn them that they are at higher risk of lung disease

·      we will advise them to return if they develop respiratory symptoms

·      So all this is if the person is a smoker. However

If the person is not a current smoker, their spirometry is normal and they have no symptoms or signs of respiratory disease:

·      We will ask them if they have a personal or family history of lung or liver disease and consider alternative diagnoses, such as alpha‑1 antitrypsin deficiency

·      We will reassure them that their emphysema or chronic airways disease is unlikely to get worse but

·      We will advise them to return if they develop respiratory symptoms

For both situations, smokers and non-smokers, we need to be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer. 

in addition to spirometry all patients should have:

·      a chest X-ray to exclude other pathologies

·      a full blood count to identify anaemia or polycythaemia

·      their body mass index (BMI) calculated. 

·      So these three investigations should always be carried out but

We will perform additional investigations when needed, and these investigations will be

Sputum culture

if sputum is purulent

Serial home peak flow measurements

To exclude asthma if diagnostic doubt remains

ECG and serum natriuretic peptides

To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of:

·      a history of cardiovascular disease, hypertension or hypoxia or

·      clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale

Echocardiogram

To assess cardiac status if cardiac disease or pulmonary hypertension are suspected

CT scan of the thorax

To investigate symptoms that seem disproportionate to the spirometric impairment

To investigate signs that may suggest another lung diagnosis (such as fibrosis or bronchiectasis)

To investigate abnormalities seen on a chest X-ray and

To assess suitability for lung volume reduction procedures

Serum alpha-1 antitrypsin

To assess for deficiency if there is early onset, minimal smoking history or family history

Transfer factor for carbon monoxide (TLCO)

To investigate symptoms that seem disproportionate to the spirometric impairment and

To assess suitability for lung volume reduction procedures

For most people, routine spirometric reversibility testing is not necessary as part of the diagnostic. It may be unhelpful or misleading because:

·      repeated FEV1 measurements can show small spontaneous fluctuations

·      the results of a reversibility test performed on different occasions can be inconsistent and not reproducible

·      over-reliance on a single reversibility test may be misleading unless the change in FEV1 is greater than 400 ml

·      response to long-term therapy is not predicted by acute reversibility testing. 

Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time. Whenever possible, we will use features from the history and examination to differentiate COPD from asthma.

These six Clinical features differentiating COPD and asthma are as follows

For example

COPD

Asthma

1- being a smoker or ex-smoker

Is a feature in almost all COPD patients

Whereas it is only possible in asthma

2- Symptoms under age 35

are Rare in COPD

Whereas they appear often in asthma

3- Chronic productive cough

Is common in COPD

But uncommon in asthma

4- Breathlessness

Is persistent and progressive in COPD

Whereas it is variable in asthma

5- Night time waking with breathlessness and/or wheeze

Is uncommon in COPD

Whereas it is common in asthma

6- Significant diurnal or day-to-day variability of symptoms

Is uncommon in COPD

Whereas it is common in asthma

For more information on diagnosing asthma you can refer to the NICE guideline on asthma and I will put a link to this in the episode description.

In addition to these six features, we can use the regular observation of symptoms or spirometry or peak flow readings to help differentiate COPD from asthma. 

And when diagnostic uncertainty remains, or we suspect that both COPD and asthma are present, we will use the following findings to help identify asthma:

1.    a response to bronchodilators or to 30 mg oral prednisolone daily for 2 weeks of over 400 ml in the FEV1.

2.    Or serial peak flow measurements showing 20% or greater diurnal or day-to-day variability.

In addition, we will conclude that clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy and we will reconsider the diagnosis of COPD for people who report a marked improvement in symptoms in response to inhaled therapy. 

If diagnostic uncertainty remains, we will think about referral for more detailed investigations, including imaging and measurement of transfer factor for carbon monoxide (TLCO). 

For people for whom the FEV1/FVC ratio is <0.7 we will classify the severity of airflow obstruction according to the reduction in FEV1, and this is

Gradation of severity of airflow obstruction

If

FEV1≥ 80% predicted

It will be Stage 1 – Mild

FEV1 50–79% predicted

It will be Stage 2 – Moderate

FEV1 30–49% predicted

It will be Stage 3 – Severe

FEV1 <30% predicted

It will be Stage 4 – Very severe (or FEV1 below 50% with respiratory failure)

We should perform spirometry in people who are over 35, current or ex‑smokers, and have a chronic cough. 

We will consider spirometry in people with chronic bronchitis given that a significant proportion of these people will go on to develop airflow limitation. 

We will refer patients for the following reasons:

If There is diagnostic uncertainty or there is severe COPD or cor pulmonale

In order to Confirm the diagnosis and optimise the therapy

We will also refer For Assessment for oxygen therapy long term nebuliser therapy or corticosteroid therapy

In order to Optimise therapy and measure blood gases

If there is Bullous lung disease, For Assessment for a lung volume reduction procedure and For Assessment for lung transplantation

In order to Identify candidates for intervention

We will also refer If there is A rapid decline in FEV1 and for pulmonary rehabilitation and If the Symptoms are disproportionate to the lung function deficit or if there is Dysfunctional breathing

In order to Look for other explanations

Finally we will refer If there is Onset of symptoms under 40 years or a family history of alpha‑1 antitrypsin deficiency

In order to Identify alpha‑1 antitrypsin deficiency

If there are Frequent infections

In order to Exclude bronchiectasis

If there is Haemoptysis

In order to Exclude carcinoma of the bronchus

NICE has produced a visual summary covering non-pharmacological management and use of inhaled therapies and I will put a link to this in the episode description.

Document an up-to-date smoking history, including pack years smoked (which is the number of cigarettes smoked per day, divided by 20 cigarettes in a pack, multiplied by the number of years smoked)

At every opportunity, we will advise and encourage to stop, and offer them help to do so. 

So, unless contraindicated, we will offer nicotine replacement therapy, varenicline or bupropion as appropriate to people who want to stop smoking, combined with an appropriate support programme

We need to discuss with the person, the risk of side effects (including pneumonia) of inhaled corticosteroids for COPD and

We will not use oral corticosteroid reversibility tests to identify which people should be prescribed inhaled corticosteroids, because they do not predict response to inhaled corticosteroid therapy. 

We will not assess the effectiveness of bronchodilator therapy using lung function alone but we will also include a clinical improvement in symptoms. 

We will offer LAMA+LABA to COPD patients who are on a short-acting bronchodilator if

·      do not have asthmatic features/features suggesting steroid responsiveness such as previous diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation in FEV1 over time ( and of at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%)and

·      remain breathless or have exacerbations despite existing management.

We need to be aware of the MHRA safety advice on Respimat and Handihaler inhalers which basically refers to taking into account the risk of cardiovascular side effects for patients with conditions that may be affected by the anticholinergic action of tiotropium, including MI, cardiac arrythmia and heart failure. I will put a link to this advice in the episode description.

We will consider LABA+ICS for COPD patients who are on a short-acting bronchodilator if

·      they have asthmatic features/features suggesting steroid responsiveness and

·      remain breathless or have exacerbations despite existing management.

For people with COPD who are taking LABA+ICS, we will offer triple therapy with LAMA+LABA+ICS if:

·      their day-to-day symptoms continue to adversely impact their quality of life or

·      they have a severe exacerbation (requiring hospitalisation) or

·      they have 2 moderate exacerbations within a year. 

·      This is because adding the LAMA has a beneficial effect on symptoms and exacerbations

For people with COPD who are taking LAMA+LABA, consider LAMA+LABA+ICS if:

·      they have a severe exacerbation (requiring hospitalisation) or

·      they have 2 moderate exacerbations within a year. 

·      And this is because ICS have a significant impact on exacerbations and not so much on symptoms.

For people with COPD who are taking LAMA+LABA and whose day-to-day symptoms adversely impact their quality of life:

·      we will consider a trial of LAMA+LABA+ICS, lasting for 3 months only

·      And then:

o  if symptoms have not improved, stop LAMA+LABA+ICS and switch back to LAMA+LABA

o  if symptoms have improved, continue with LAMA+LABA+ICS. 

· We will Minimise the number of inhalers and the number of different types of inhaler used by each person as far as possible, using combination inhalers if necessary

We will say that

In most cases bronchodilator therapy is best administered using a hand-held inhaler (including a spacer if appropriate). And we will only prescribe inhalers after people can demonstrate satisfactory inhaler technique

We will provide a spacer that is compatible with the inhaler advising that

·      They should administer the drug by single actuations of the metered-dose inhaler into the spacer, inhaling after each actuation

·      And ensuring that there should be minimal delay between inhaler actuation and inhalation and being aware that

·      normal tidal breathing can be used as it is as effective as single breaths

In respect of spacer cleaning, we will advise:

·      not to clean the spacer more than monthly, because more frequent cleaning affects their performance (because of a build-up of static)

·      to hand wash using warm water and washing-up liquid, and allow the spacer to air dry. 

We will think about nebuliser therapy for people with distressing or disabling breathlessness despite maximal therapy using inhalers. 

And we will not continue it unless there is an objective or subjective improvement.

We will offer people a choice between a facemask and a mouthpiece to administer their nebulised therapy, unless the drug specifically requires a mouthpiece (for example, anticholinergic drugs). 

We will say that the long-term use of oral corticosteroid therapy in COPD is not normally recommended. Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. In these cases, the dose of oral corticosteroids should be kept as low as possible. 

And we will monitor people who are having long-term oral corticosteroid therapy for osteoporosis, and give them appropriate prophylaxis. Prophylaxis should be started without monitoring for people over 65. 

We will say that

slow-release Theophylline should only be used after a trial of short-acting bronchodilators and long-acting bronchodilators, or for people who are unable to use inhaled therapy, as plasma levels and interactions need to be monitored. 

We will take particular caution when using theophylline in older people, because of differences in pharmacokinetics, the increased likelihood of comorbidities and the use of other medications. 

And we will reduce the dose of theophylline for people who are having an exacerbation if they are prescribed macrolide or fluoroquinolone antibiotics (or other drugs known to interact). 

We will consider it for people with a chronic cough productive of sputum. And we will only continue it if there is symptomatic improvement. However, we will not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD. 

We will consider azithromycin (usually 250 mg 3 times a week) for people with COPD if they:

·      do not smoke and

·      have optimised management and

·      continue to have either:

o  frequent exacerbations with sputum production (typically 4 or more per year)

o  prolonged exacerbations with sputum production or

o  exacerbations resulting in hospitalisation. 

Before offering prophylactic antibiotics, we need to ensure that the person has had:

·      sputum culture and sensitivity (including tuberculosis culture), to identify other possible causes of persistent or recurrent infection that may need specific treatment (for example, antibiotic-resistant organisms, atypical mycobacteria or Pseudomonas aeruginosa)

·      also training in airway clearance techniques to optimise sputum clearance

·      and a CT scan of the thorax to rule out bronchiectasis and other lung pathologies. 

In addition, before starting azithromycin, we need to ensure the person has had:

·      an electrocardiogram (ECG) to rule out prolonged QT interval and

·      baseline liver function tests. 

When prescribing azithromycin, we will advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs. 

We will review prophylactic azithromycin after the first 3 months, and then at least every 6 months and

We will only continue treatment if the continued benefits outweigh the risks. This is because there are no long-term studies on the use of prophylactic antibiotics in people with COPD. 

For people who are taking prophylactic azithromycin and are still at risk of exacerbations, we will provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan, telling the patient that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD. 

We will say that for treating severe COPD with roflumilast, there is separate NICE guidance which is really outside the scope of this podcast. However, if you are interested, I will put the link to this guidance in the episode description. 

We need to be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression. 

We need to assess the need for oxygen therapy in people with:

·      very severe airflow obstruction (FEV1 below 30% predicted)

·      cyanosis

·      polycythaemia

·      peripheral oedema

·      a raised jugular venous pressure

·      oxygen saturations of 92% or less on air.

And we will also consider it for people with severe airflow obstruction (FEV1 30–49% predicted). 

We will make the assessment by measuring arterial blood gases on 2 occasions at least 3 weeks apart and we will consider long-term oxygen therapy for people who do not smoke and who:

·      have a partial pressure of oxygen in arterial blood (PaO2) below 7.3 kPa when stable or

·      have a partial pressure of oxygen in arterial blood (PaO2) between 7.3 and 8 kPa when stable, if they also have 1 or more of the following:

o  secondary polycythaemia

o  peripheral oedema and / or

o  pulmonary hypertension.

We will also conduct and document a structured risk assessment for people being assessed for long-term oxygen therapy. As part of the risk assessment, we will consider:

·      the risks of falls from tripping over the equipment

· the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e‑cigarettes).

For people who smoke or live with people who smoke, we will ensure the person who smokes is offered advice and support to stop. However, we will not offer long-term oxygen therapy to people who continue to smoke despite these efforts.

We should advise people who are having long-term oxygen therapy that they should use it for a minimum of 15 hours per day. 

We will not offer long-term oxygen therapy to treat isolated nocturnal hypoxaemia caused by COPD. 

Oxygen concentrators should be used to provide the fixed supply at home.

People on long-term oxygen therapy should be reviewed at least once per year

We will consider ambulatory oxygen in COPD if there is exercise desaturation and are shown to improve with oxygen

We will prescribe ambulatory oxygen to people who are already on long-term oxygen therapy, who wish to continue oxygen therapy outside the home, but we will only prescribe it after an assessment by a specialist. The purpose of the assessment is to assess the extent of desaturation, the improvement in exercise capacity with supplemental oxygen, and the oxygen flow rate needed to correct desaturation. 

We will use small light-weight cylinders, oxygen-conserving devices and portable liquid oxygen systems depending on the hours of ambulatory oxygen use and oxygen flow rate needed. 

We will not offer Short-burst oxygen therapy to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. 

We will say that In this guideline ‘cor pulmonale’ is defined as a clinical condition that is identified and managed on the basis of clinical features. It includes people who have right heart failure secondary to lung disease and people whose primary pathology is salt and water retention, leading to the development of peripheral oedema.

We will suspect a diagnosis of cor pulmonale for people with:

·      peripheral oedema

·      a raised venous pressure

·      a systolic parasternal heave and

·      a loud pulmonary second heart sound. 

And it is recommended that the diagnosis of cor pulmonale is made clinically.

We will not offer solely to manage pulmonary hypertension caused by COPD, any the following treatments:

·      bosentan, losartan, nifedipine

·      nitric oxide, pentoxifylline

·      phosphodiesterase-5 inhibitors

·      statins. 

caused by COPD we will ensure that patients are offered optimal COPD treatment, including stop smoking and oxygen therapy if there is hypoxia

Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy. 

We will not use any of the following to treat cor pulmonale caused by COPD:

·      alpha-blockers

·      angiotensin-converting enzyme inhibitors

·      calcium channel blockers or

·      digoxin (unless there is atrial fibrillation). 

We will offer pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above), including people who have had a recent hospitalisation for an acute exacerbation. Pulmonary rehabilitation is not suitable for people who are unable to walk, who have unstable angina or who have had a recent myocardial infarction. 

The rehabilitation process should incorporate a programme of physical training, disease education, and nutritional, psychological and behavioural intervention. 

We will offer pneumococcal vaccination and an annual flu vaccination to all people with COPD.

There is separate guidance on preventing and treating flu using antivirals, and I will put the links to this guidance in the podcast description. 

But being such a specialised area, I will not say much about this. Only that it applies only to the most severe forms of COPD, that it can involve lung volume reduction surgery, bullectomy, endobronchial valves and coils and lung transplantation and that careful investigations including imaging of the lungs will be required for this. I will put links to this specific guidance in the episode description.

We will also say that Alpha‑1 antitrypsin replacement therapy is not recommended  in Alpha‑1 antitrypsin deficiency

We will say that COPD care should be delivered by a multidisciplinary team including:

We need to develop an individualised self-management plan in collaboration with each person with COPD and their family members or carers (as appropriate), including an individualised exacerbation action plan. We will also offer people a short course of oral corticosteroids and a short course of oral antibiotics to keep at home as part of their exacerbation action plan if:

·      they have had an exacerbation within the last year, and remain at risk of exacerbations

·      they understand and are confident about when and how to take these medicines, and the associated benefits and harms

·      they know to tell their healthcare professional when they have used the medicines, and to ask for replacements. 

There is separate NICE guidance on the choice of antibiotics and I will put the link to this in the episode description. In summary the choice of antibiotics will be:

·      as first line amoxicillin, doxycycline or clarithromycin.

·      As second line if the first line antibiotic has failed, we will use an alternative first choice, preferably from a different class

·      Finally an Alternative choice antibiotic if person at higher risk of treatment failure would be co-amoxiclav, cotrimoxazole and levofloxacine

For people who have used 3 or more courses of oral corticosteroids and/or oral antibiotics in the last year, we should investigate the possible reasons for this. 

There is also separate guidance on the recommendations on systemic corticosteroids for more guidance on oral corticosteroids and the link will also be in the podcast description.

We will encourage people with COPD to respond promptly to exacerbation symptoms by following their action plan, which may include:

·      adjusting their short-acting bronchodilator therapy to treat their symptoms

·      taking a short course of oral corticosteroids if their increased breathlessness interferes with activities of daily living

·      adding oral antibiotics if their sputum changes colour and increases in volume or thickness beyond their normal day-to-day variation

·      telling their healthcare professional. 

· apart from offering the usual advice and treatment we will record the opportunistic measurement of spirometric parameters and if there is a loss of 500 ml or more over 5 years, this will show rapidly progressing disease and may need referral to specialist treatment and investigation. 

· We will review people with mild to severe COPD (stages 1 to 3) at least once per year and those with very severe COPD (or stage 4) should be seen at least twice per year in primary care

· A review should include:

o  Smoking status and advice,

o  symptoms and complications including cor pulmonale

o  response to treatment, including inhaler technique, pulmonary rehabilitation and long-term oxygen therapy

o  and measure FEV1 and FVC, BMI and the MRC dyspnoea score. We should also check oxygen saturation in patients with very severe COPD

We will define an exacerbation as a sustained worsening of the patient's symptoms which is beyond normal day-to-day variations. The change in these symptoms often necessitates a change in medication.

·      a mild exacerbation requires increasing their medication in their own normal environment

·      a moderate exacerbation, requires treatment with systemic corticosteroids and/or antibiotics

·      a severe exacerbation, requires hospitalisation.

According to the patient’s symptoms and social circumstances as well as objective measurements. In particular significant changes on a chest x-ray and an oxygen saturation of less than 90% is likely to indicate the need for hospital treatment, as well as arterial blood gases showing a PH less than 7.35 or the partial pressure of oxygen in arterial blood is less than 7 kilopascals

sending sputum samples for culture is not recommended routinely for people who have their exacerbation managed in primary care but pulse oximetry can be of value

·      a chest X-ray

·      arterial blood gases

·      an ECG

·      a full blood count and urea and electrolyte

·      a theophylline level for people taking theophylline

·      a sputum culture if the sputum is purulent

·      and blood cultures if there is a fever

Hospital-at-home and assisted-discharge schemes are safe and can also be used as an alternative

We can use both nebulisers and inhalers but we will change people to inhalers as soon as their condition has stabilised, because this may allow them to be discharged from hospital earlier. 

If a person with COPD is hypercapnic or acidotic the nebuliser should be driven by compressed air rather than oxygen to avoid worsening hypercapnia. If oxygen therapy is needed, we should administer it simultaneously by nasal cannulae. 

In the absence of significant contraindications, we will use oral corticosteroids, to people having an exacerbation, offering 30 mg of oral prednisolone daily for 5 days and we will think about osteoporosis prophylaxis for people who need frequent courses of oral corticosteroids. 

For guidance on using antibiotics to treat COPD exacerbations, there is separate guidance and I will put the link in the episode description. It is basically:

·      amoxicillin, doxycycline or clarithromycin as first line.

·      As second line if the first line antibiotics has failed, we will use an alternative first choice, preferably from a different class

·      Alternative choice oral antibiotics (if person at higher risk of treatment failure would be co-amoxiclav, cotrimoxazole and levofloxacine

We will only use intravenous theophylline with careful monitoring as an adjunct to exacerbation management if there is an inadequate response to nebulised bronchodilators. 

Respiratory stimulants such as doxapram should be used only when non-invasive ventilation is either unavailable or inappropriate. 

We will measure oxygen saturation if there are no facilities to measure arterial blood gases and if necessary, prescribe oxygen to keep the oxygen saturation of arterial blood within the individualised target range. 

Pulse oximetry gives no information about the partial pressure of CO2 in arterial blood 2 or pH so we will measure arterial blood gases in all people who arrive at hospital with an exacerbation of COPD.

We will use Non-Invasive Ventilation as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy. 

We will treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary. 

We will also consider physiotherapy using positive expiratory pressure devices for selected people with exacerbations of COPD, to help with clearing sputum. 

We will do regular clinical assessments, use pulse oximetry and for people who are hypercapnic or acidotic , we will measure intermittent arterial blood gases until they are stable.

We will not, however, routinely perform daily monitoring of peak expiratory flow or FEV1 because the magnitude of changes is small compared with the variability of the measurement. 

We have come to the end of this episode. I hope that you have enjoyed it and I hope that you will join me in the next one. Thank you for listening and goodbye.

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the updated NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline), updated on 31st March 2022. The podcast focuses in the new drug treatment recommendations in blood glucose management in adults with Type 2 Diabetes.

This podcast will be saved on a website.

There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:

https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw 

This podcast also appears in the Diabetes in Primary Care podcast which can be found here:

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

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

·      Apple podcasts: https://podcasts.apple.com/us/podcast/diabetes-in-primary-care/id1562910252

NICE Guideline NG28 can be found here:

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

Other links referred to in this episode: 

·      visual summary to provide an overview of the recommendations and additional information to support medicines choice

·      visual summary on first-line drug treatment

·      recommendations on using risk scores and QRISK2 to assess cardiovascular disease risk in adults with type 2 diabetes in NICE's guideline on cardiovascular disease: risk assessment and reduction, including lipid modification

·      NICE's technology appraisal guidance on dapagliflozin for treating chronic kidney disease

·      visual summary on treatment options if further interventions are needed

·      section on insulin delivery in the NICE guideline on type 1 diabetes 

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

Music provided by Audio Library Plus

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Thank you for downloading and welcome. This podcast is intended for healthcare professionals bringing you medical information about the management of diabetes from a Primary Care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.

In this episode I am going to tell you about the updated NICE guidelines in the management of type 2 diabetes in adults or guideline NG28. These guidelines were last updated on 31st March 2022. In this episode I am only going to refer to the drug management of blood glucose rather than the full guideline. The other recommendations have not really changed significantly and, if you are interested in them, you can listen to the previous podcasts that I have uploaded on the subject. You will be able to find links to them in the podcast description. I have also uploaded YouTube videos on this subject and other NICE guidance. A link to access the channel can be found in the podcast description.

As ever, all information is correct at the time of recording and all views and opinions are my own. I hope that you enjoy this episode.

You may be aware that until the publication of this NICE guideline update, there has been quite a disparity between the advice given by NICE and other international guidelines such as those of the American Diabetes Association or the European Association for the Study of Diabetes, amongst many others. This is because of the funding of the British National Health System which expects NICE to assess not only the clinical merits of each medical intervention, including drugs, but also their cost effectiveness. After this update, the NICE guidelines are now more similar to the American and European guidelines when considering SGLT2 inhibitors but they still differ very significantly when it comes to GLP mimetics. This is because NICE, at this stage, does not consider them to be cost effective except in some very specific circumstances.

You must know that there is a visual summary to provide an overview of the recommendations and additional information to support medicines choice and a link will be placed in the podcast description.

Now, when it comes to Choosing drug treatments

and before we start any medication, we will need to discuss with adults with type 2 diabetes the benefits and risks of drug treatment and the options available and base the choice of drug treatments on:

·      the person's individual clinical circumstances, preferences and needs

·      the effectiveness of the drug treatments in terms of metabolic response and cardiovascular and renal protection

·      safety and tolerability of the drug treatment

·      monitoring requirements

·      the licensed indications or combinations available

·      cost (if 2 drugs in the same class are appropriate, choose the option with the lowest acquisition cost). 

We just need to be aware that there are separate guidelines for the drug treatment during pregnancy and the pre-pregnancy period.

IN terms of Rescue therapy at any phase of treatment

If an adult with type 2 diabetes is symptomatically hyperglycaemic, we need to consider insulin or a sulfonylurea, and review treatment when blood glucose control has been achieved. 

Now, when it comes to First-line drug treatment

There is a visual summary on first-line drug treatment that offers an overview of the recommendations. I will also put a link to this in the podcast description.

We will basically start by offering standard-release metformin as first-line drug treatment to adults with type 2 diabetes. 

We will then assess the person's cardiovascular status and risk to determine whether they have chronic heart failure or established atherosclerotic cardiovascular disease or are at high risk of developing cardiovascular disease.

Because SGLT2 inhibitors can improve cardiovascular outcomes, we will do the following:

·      If they have chronic heart failure or established atherosclerotic cardiovascular disease, we will offer an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.

·      If they are at high risk of developing cardiovascular disease, we will consider an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin. 

To assess whether people are at high risk of developing cardiovascular disease, it is recommended to use the QRISK2 tool for adults with type 2 diabetes. We need to be aware that lifetime cardiovascular risk may be underestimated in people aged under 40 using this tool, so we need to consider other risk factors too.

There are recommendations on using risk scores and QRISK2 to assess cardiovascular disease risk in adults with type 2 diabetes in NICE's guideline on cardiovascular disease: risk assessment and reduction, including lipid modification- I will put a link to these guideline in the podcast description.

The evidence shows that SGLT2 inhibitors as a class of drugs are most likely to be cost effective in combination with metformin and there are also varying levels of certainty in the clinical trials and the meta-analyses about:

·      which individual SGLT2 inhibitors were effective at improving cardiovascular outcomes

·      whether there were real differences in cardiovascular benefits between the different SGLT2 inhibitors.

For example, for hospitalisation for heart failure, empagliflozin, canagliflozin, ertugliflozin and dapagliflozin produced a clinically meaningful reduction. However, the network meta-analysis could not differentiate between the SGLT2 inhibitors.

When starting an adult with type 2 diabetes on dual therapy with metformin and an SGLT2 inhibitor as first-line therapy, we will introduce the drugs sequentially, starting with metformin and checking tolerability. We will then start the SGLT2 inhibitor as soon as metformin tolerability is confirmed. 

We will gradually increase the dose of standard-release metformin over several weeks to minimise the risk of gastrointestinal side effects in adults with type 2 diabetes. 

If an adult with type 2 diabetes experiences gastrointestinal side effects with standard‑release metformin, we should consider a trial of modified‑release metformin. 

However, if metformin is contraindicated or not tolerated, for first-line drug treatment we will consider the following:

·      If they have chronic heart failure or established atherosclerotic cardiovascular disease, we will offer an SGLT2 inhibitor with proven cardiovascular benefit.

·      And If they are at high risk of developing cardiovascular disease, then we will consider it. 

For first-line drug treatment in adults with type 2 diabetes who are not in either of these groups, if metformin is contraindicated or not tolerated and we will consider:

·      a DPP‑4 inhibitor or

·      pioglitazone or

·      a sulfonylurea although

·      an SGLT2 inhibitor can be prescribed for people for whom

• a sulfonylurea or pioglitazone is not appropriate and
• a DPP‑4 inhibitor would otherwise be prescribed

There have been multiple instances of avoidable diabetic ketoacidosis (DKA) associated to SGLT2 inhibitors and addressing modifiable risk factors before starting an SGLT2 inhibitor could reduce the risk of DKA and make the drug safer for the person with type 2 diabetes.

Therefore, before starting an SGLT2 inhibitor, we must check whether the person may be at increased risk of diabetic ketoacidosis (DKA), for example if:

·      they have had a previous episode

·      they are unwell with intercurrent illness

·      they are following a very low carbohydrate or ketogenic diet. 

And we will address modifiable risks for DKA before starting an SGLT2 inhibitor. For example, for people who are following a very low carbohydrate or ketogenic diet, they may need to delay treatment until they have changed their diet. 

Adults with type 2 diabetes who are overweight or obese may wish to try a ketogenic diet to reverse or reduce the severity of their diabetes or induce remission. However, because there may be an increased risk of DKA associated with SGLT2 inhibitors and such diets, it is important to tell people about these risks and to advise them to discuss any planned change to a very low carbohydrate or ketogenic diet with their healthcare professional first.

Therefore we will advise adults with type 2 diabetes who are taking an SGLT2 inhibitor about the need to minimise their risk of DKA by not starting a very low carbohydrate or ketogenic diet without discussing it with their healthcare professional, because they may need to suspend SGLT2 inhibitor treatment. 

When it comes to patients with type 2 diabetes and chronic kidney disease, there are recommendations on SGLT2 inhibitors in a separate section in this guideline. These are as follows:

For adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor (titrated to the highest tolerated dose) we will:

·      offer an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if the ACR is over 30 mg/mmol and

·      consider an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if the ACR is between 3 and 30 mg/mmol

·      however, because some of the SGLT2 inhibitors cannot be prescribed when the eGFR levels are too low, we will need to ensure that the eGFR thresholds are met.

We must note that not all SGLT2 inhibitors have been licensed for the indication of CKD, although this is likely to change over time. Dapaglifozin is definitely one of the licensed ones. This is because clinical trial evidence suggests that dapagliflozin plus standard care is more effective than standard care alone in slowing disease progression.

There is separate NICE guidance for it which I will also put in the podcast description.

(This dapaglifozin in CKD guidance broadly says the same as what has just been stated although the ACR threshold is 22.6 or more:

·      Dapagliflozin is recommended as an option for treating chronic kidney disease (CKD) in people with diabetes:

•  only as an add-on to optimised standard care including the highest tolerated licensed dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), unless these are contraindicated, and

§ eGFR is between 25 and 75 at the start of treatment and

§ ACR is 22.6 mg/mmol or more.)

When reviewing or considering changing treatments for adults with type 2 diabetes, we should think about and discuss the following:

·      We need to take into account factors such as adverse effects, adherence to existing medicines, advice about diet and lifestyle and prescribed doses and formulations

·      We also need to consider stopping medicines that have had no impact on glycaemic control or weight, unless there is an additional clinical benefit, such as cardiovascular or renal protection

·      We will also consider whether switching rather than adding drugs could be effective

·      Plus we will take into account all the considerations about treatment choice described earlier – such as individual clinical circumstances, individual preferences and needs, the effectiveness, safety and tolerability of the drug etc

When considering adding an SGLT2 inhibitor at any stage after first-line treatment, there are some considerations to consider and these are that

·      If they have or develop chronic heart failure or established atherosclerotic cardiovascular disease, we need to offer an SGLT2 inhibitor or replace an existing drug with the SGLT2 inhibitor.

·      If they are or become at high risk of developing cardiovascular disease, we will have to consider doing this, that is, either adding an SGLT2 inhibitor or replacing an existing drug with the SGLT2 inhibitor.

When it comes to Treatment options if further interventions are needed

There is a visual summary on treatment options if further interventions are needed and I will put a link to this in the podcast description.

First of all, we need to introduce drugs used in combination therapy in a stepwise manner, checking for tolerability and effectiveness of each drug. 

As we have already mentioned, if monotherapy has not controlled HbA1c we will consider adding a second drug, that is an SGLT2 inhibitor for people who meet the cardiovascular criteria or, otherwise, a DPP‑4 inhibitor or pioglitazone or a sulfonylurea 

If dual therapy with metformin and another oral drug has not continued to control HbA1c we will consider either:

·      triple therapy, by Switching or adding treatments from different drug classes up to triple therapy including combinations of Metformin, sulphonylureas, DPP‑4 inhibitors and, for people who meet the cardiovascular criteria, SGLT2 inhibitors.

·      Or we could consider going directly from dual therapy to starting insulin

However, if metformin is contraindicated or not tolerated and dual therapy with 2 oral drugs has not controlled HbA1c, then we will need to consider going directly to insulin treatment

Finally, if triple therapy with metformin and 2 other oral drugs is not effective, not tolerated or contraindicated, we will consider triple therapy by switching one drug for a GLP‑1 mimetic only if certain strict conditions are met. These are:

·      If the body mass index (BMI) of 35 kg/m2 or higher (adjusting accordingly for people from Black, Asian and other minority ethnic groups) and there are specific psychological or other medical problems associated with obesity or

·      If they have a BMI lower than 35 kg/m2 and:

o  for whom insulin therapy would have significant occupational implications or

o  weight loss would benefit other significant obesity-related comorbidities. 

We will only continue GLP‑1 mimetic therapy if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and weight loss of at least 3% of initial body weight in 6 months). 

When considering Insulin-based treatments

Patients should receive a structured programme using active insulin dose titration that encompasses full training and support as well as appropriate driving advice.

When starting insulin, we should continue to offer metformin for people without contraindications or intolerance but we will review the continued need for other blood glucose lowering therapies. 

In general, combination therapy with a GLP‑1 mimetic and insulin should only be considered along with specialist care advice and ongoing support from a consultant-led multidisciplinary team. 

Insulin in combination with other oral hypoglycaemic agents, including SGLT2 inhibitors can be an option for treating type 2 diabetes

When it comes to managing their therapy,

We will start insulin from a choice of the following insulin types and regimens:

·      First, we will offer NPH insulin injected once or twice daily according to need.

·      But we will consider starting both NPH and short‑acting insulin (particularly if the person's HbA1c is 75 mmol/mol [9.0%] or higher), administered either:

o  separately or

o  as a pre-mixed (biphasic) human insulin preparation.

·      We will also consider, as an alternative to NPH insulin, using insulin detemir or insulin glargine if:

o  the person needs help from someone else to inject insulin, and use of insulin detemir or insulin glargine would reduce the frequency of injections from twice to once daily or

o  the person is restricted by recurrent symptomatic hypoglycaemic episodes or

o  the person would otherwise need twice‑daily NPH insulin injections in combination with oral glucose‑lowering drugs.

·      We will consider pre-mixed (biphasic) preparations that include short‑acting insulin analogues, rather than pre‑mixed (biphasic) preparations that include short‑acting human insulin preparations, if:

o  the person prefers injecting insulin immediately before a meal or

o  hypoglycaemia is a problem or

o  blood glucose levels rise markedly after meals. 

We will consider switching to insulin detemir or insulin glargine from NPH insulin if there are issues with NPH such as not reaching their target HbA1c because of significant hypoglycaemia or who experience significant hypoglycaemia or who cannot use the device needed to inject NPH or who need help from someone else to administer insulin injections and for whom switching to one of the long‑acting insulin analogues would reduce the number of daily injections. 

We will monitor adults with type 2 diabetes who are on a basal insulin regimen (NPH insulin, insulin detemir or insulin glargine) for the need for short‑acting insulin before meals (or a pre‑mixed [biphasic] insulin preparation). 

We will monitor adults with type 2 diabetes who are on pre‑mixed (biphasic) insulin for the need for a further injection of short‑acting insulin before meals or for a change to a basal-bolus regimen

When starting an insulin for which a biosimilar is available, we will use the product with the lowest acquisition cost. 

Insulin delivery

I will not say much about the guidance on insulin delivery for adults with type 2 diabetes, but you can see the section on insulin delivery in the NICE guideline on type 1 diabetes, and I will put a link in the podcast description to access it.

This is the end of this episode. I hope that you have enjoyed it and I hope that you will join me in the next one. Thank you for listening

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through a section of the NICE guideline NG12 “Suspected cancer recognition and referral”, last updated in December 2021. This episode will summarise the section “recommendations by site of cancer” covering skin cancer, head and neck cancers, haematological cancers, nervous system cancers, sarcoma and childhood cancers as well as other non-site specific symptoms of concern..

This podcast will be saved on a website.

NICE guideline NG12 can be found here:

https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer

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

Welcome to a new episode of the Clinical Guidelines in Primary Care podcast. My name is Fernando Florido and I am a GP in the United Kingdom. This is the third episode of the cancer guidelines series and is the last one reviewing the section “recommendations by site of cancer” of the NICE guideline NG12 “Suspected cancer recognition and referral”. In this podcast, I will cover skin cancer, head and neck cancers, haematological cancers, nervous system cancers sarcoma and childhood cancers as well as other non-site specific symptoms of concern. I hope that you enjoy the episode.

We will start with Skin cancers and the first ones to consider will be

Malignant melanoma and squamous cell carcinoma of the skin. For this,

We need to consider a cancer referral for melanoma in people with a pigmented or non‑pigmented skin lesion that suggests clinically the possibility of nodular melanoma or squamous cell carcinoma. This includes the use of dermoscopy

We must also refer people using a suspected cancer pathway referral to exclude melanoma if they have a suspicious pigmented skin lesion with a weighted 7‑point checklist score of 3 

We will quickly go through the Weighted 7‑point checklist which lists

Major features of the lesions (scoring 2 points each): 

·      change in size

·      irregular shape

·      irregular colour.

And Minor features of the lesions (scoring 1 point each): 

·      largest diameter 7 mm or more

·      inflammation

·      oozing

·      change in sensation.

In respect of Basal cell carcinomas

We should only consider a suspected cancer pathway referral for a basal cell carcinoma if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size. 

Otherwise it should be a routine referral.

We are now going t move to Head and neck cancers and the first one to look at is

Laryngeal cancer

For this we need to consider a suspected cancer pathway referral in people aged 45 and over with:

·      persistent unexplained hoarseness or

·      an unexplained lump in the neck. 

For Oral cancers

We need to consider a suspected cancer pathway referral in people with either:

·      an unexplained ulceration in the oral cavity lasting for more than 3 weeks or

·      a persistent and unexplained lump in the neck. 

We also need to consider an urgent referral to a dentist (for an appointment within 2 weeks) for assessment for possible oral cancer in people who have either:

·      a lump on the lip or in the oral cavity or

·      a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. 

Then the dentist will decide whether these patients get referred through a full

For Thyroid cancers

We need to consider a cancer referral in people with an unexplained thyroid lump. 

The next section is Brain and central nervous system cancers

And the recommendations are different depending if the suspicion refers to adults or children and young people.

In Adults

We need to consider an urgent, direct access, MRI scan of the brain (or CT scan if MRI is contraindicated; to be done within 2 weeks) in adults with progressive, sub‑acute loss of central neurological function. That is, to be done within 2 weeks if there is progressive, sub‑acute loss of central neurological function. 

However, in Children and young people

We need to consider a very urgent referral (which means an appointment within 48 hours) in children and young people with newly abnormal cerebellar or other central neurological function. This is straightforward and simple, to be seen within 48 hours if there is newly abnormal cerebellar or other central neurological function. 

We will nnow look at the Haematological cancers

And for Leukaemia in adults

We need to consider a very urgent full blood count (which is to be done within 48 hours) with any of the following:

·      pallor

·      persistent fatigue

·      unexplained fever

·      unexplained persistent or recurrent infection

·      generalised lymphadenopathy

·      unexplained bruising

·      unexplained bleeding

·      unexplained petechiae

·      hepatosplenomegaly. 

To say this again, do a FBC within 48 hours if there is:

·      pallor

·      persistent fatigue

·      unexplained fever

·      unexplained persistent or recurrent infection

·      generalised lymphadenopathy

·      unexplained bruising

·      unexplained bleeding

·      unexplained petechiae

·      hepatosplenomegaly. 

In terms of Leukaemia in children and young people

Firstly, We need to Refer children and young people for immediate specialist assessment for leukaemia if they have unexplained petechiae or hepatosplenomegaly. 

Also, similarly to adults, we must offer a very urgent full blood count (within 48 hours) in children and young people with any of the following:

·      pallor

·      persistent fatigue

·      unexplained fever

·      unexplained persistent infection

·      generalised lymphadenopathy

·      persistent or unexplained bone pain

·      unexplained bruising

·      unexplained bleeding. 

For Myeloma

We need to offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate in people aged 60 and over with persistent bone pain, particularly back pain, or unexplained fracture. 

And then We need to offer very urgent protein electrophoresis and a Bence–Jones protein urine test (that is within 48 hours) in people aged 60 and over with hypercalcaemia or leukopenia or if the ESR or plasma viscosity are abnormal and the presentation is consistent with possible myeloma. Obviously we will refer people using a suspected cancer pathway referral if the results of protein electrophoresis or a Bence–Jones protein urine test suggest myeloma. 

Finally, the recommendations are the same for Hodgkin’s and Non-Hodgkin's lymphoma but Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways.

For adults Adults

We need to consider a suspected cancer pathway referral in adults presenting with unexplained lymphadenopathy or splenomegaly. When considering the referral, we will take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss or, in the case of Hodgkin’s lymphoma, if there is alcohol‑induced lymph node pain. [. 

For Children and young people

We need to consider a very urgent referral (, that is, for an appointment within 48 hours) for specialist assessment in children and young people presenting with unexplained lymphadenopathy or splenomegaly. Equally, when considering the referral, we will take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss. 

In respect of Sarcomas

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways.

In terms of Bone sarcoma in adults 

We need to consider a suspected cancer pathway referral for adults if an X‑ray suggests the possibility of bone sarcoma. 

For Bone sarcoma in children and young people

We need to consider a very urgent direct access X‑ray (to be done within 48 hours) in children and young people with unexplained bone swelling or pain. 

And then we need to consider a very urgent referral (for an appointment within 48 hours) for specialist assessment if an X‑ray suggests the possibility of bone sarcoma. 

In respect of Soft tissue sarcoma in adults

We need to consider an urgent direct access ultrasound scan (to be done within 2 weeks) in adults with an unexplained lump that is increasing in size. 

And then we need to consider a suspected cancer pathway referral (also for an appointment within 2 weeks) for adults if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists. 

Now, for Soft tissue sarcoma in children and young people the recommendations are exactly the same a for adults with the exception of where we said to be done or seen within 2 weeks it is now 48 hours. So, for children

We need to consider a very urgent direct access ultrasound scan (to be done within 48 hours) to assess for soft tissue sarcoma in children and young people with an unexplained lump that is increasing in size. 

And then we need to consider a very urgent referral (for an appointment within 48 hours) for children and young people if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists. 

We are now going to look at three types of Childhood cancers

And the first one is Neuroblastoma. For this

We need to consider very urgent referral (for an appointment within 48 hours) for specialist assessment for neuroblastoma in children with a palpable abdominal mass or unexplained enlarged abdominal organ. 

For Retinoblastoma

We need to consider urgent referral (for an appointment within 2 weeks) for ophthalmological assessment for retinoblastoma in children with an absent red reflex.

For Wilms' tumour

We need to consider very urgent referral (for an appointment within 48 hours) for specialist assessment in children with any of the following:

·      a palpable abdominal mass

·      an unexplained enlarged abdominal organ

·      unexplained visible haematuria. 

Finally, for Non-site-specific cancer symptoms

We need to say that Some symptoms or symptom combinations may be features of several different cancers. For some of these symptoms, the risk for each individual cancer may be low but the total risk of cancer of any type may be higher. This section includes recommendations for these symptoms.

Firstly we will look at Symptoms of concern in children and young people

We need to consider referral for children if their parent or carer has persistent concern or anxiety about the child's symptoms, even if the symptoms are most likely to have a benign cause. 

Lastly, in respect of Symptoms of concern in adults we will say the following:

For people with either unexplained weight loss, unexplained appetite loss and deep vein thrombosis , all of which can be a symptom of several cancers:

·      we must carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely and

·      then offer urgent investigation or a suspected cancer pathway referral depending on our clinical judgement

This is the end of this episode of the Clinical Guidelines in Primary Care podcast. I hope that you have enjoyed this episode and I hope that you will join me in the next one. Thank you for listening

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through a section of the NICE guideline NG12 “Suspected cancer recognition and referral”, last updated in December 2021. This episode will summarise the section “recommendations by site of cancer” covering breast cancer as well as gynaecological and urological cancers.

This podcast will be saved on a website.

NICE guideline NG12 can be found here:

https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer

Age specific PSA threshold table:

Table 1 Age-specific PSA thresholds for people with possible symptoms of prostate cancer

Age (years) Prostate-specific antigen threshold (micrograms/litre)

Below 40 Use clinical judgement

40 to 49 More than 2.5

50 to 59 More than 3.5

60 to 69 More than 4.5

70 to 79 More than 6.5

Above 79 Use clinical judgement

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

Music provided by Audio Library Plus

Watch: https://youtu.be/aBGk6aJM3IU

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

Welcome to a new episode of the Clinical Guidelines in Primary Care podcast. My name is Fernando Florido and I am a GP in the United Kingdom. This is the second episode of the cancer guidelines series. This episode will summarise the section “recommendations by site of cancer” of the NICE guideline NG12 “Suspected cancer recognition and referral”. In this podcast, I will cover breast cancer as well as gynaecological and urological cancers. I hope that you enjoy the episode.

Starting with Breast cancer

We must refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

·      aged 30 and over and have an unexplained breast lump with or without pain or

·      aged 50 and over with any of the following symptoms in one nipple only:

o  discharge 

o  retraction 

·      other changes of concern. This has been left particularly vague so we must use our clinical judgment here.

We should also consider a suspected cancer pathway referral in people:

·      with skin changes that suggest breast cancer or

·      aged 30 and over with an unexplained lump in the axilla.

Finally, we should consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain. However, breast cancer can happen in patients under 30 so you are particularly worried for any reason, you can always upgrade the referral to urgent.

Now we are going to move to Gynaecological cancers and the first one to consider is

Ovarian cancer

and these recommendations apply to women aged 18 and over.

We need to make an urgent referral to a gynaecological cancer service if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids). 

We must carry out tests in primary care, particularly the measurement of serum CA125  if a woman, especially if aged 50 or over, reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month:

·      persistent abdominal distension (often referred to as 'bloating')

·      feeling full and/or loss of appetite

·      pelvic or abdominal pain

·      increased urinary urgency and/or frequency. 

We must also measure CA125 if a woman experiences symptoms within the last 12 months that suggest irritable bowel syndrome or IBS, because IBS rarely presents for the first time in women of this age.

We should consider carrying out tests in primary care, particularly the measurement of serum CA125  if a woman reports unexplained weight loss, fatigue or changes in bowel habit. 

Once the CA125 has been measured as per these recommendations, we must do the following:

If the value is 35 IU/ml or greater, we must arrange an ultrasound scan of the abdomen and pelvis. 

And, if the ultrasound suggests ovarian cancer, we will obviously need make an urgent referral to a gynaecological cancer service. 

However, for any woman who has a serum CA125 which is less than 35 IU/ml, or CA125 of 35 IU/ml or greater but a normal ultrasound:

·      we will need to assess her carefully for other clinical causes of her symptoms and investigate if appropriate

·      and, if no other clinical cause is apparent, we will need to advise her to return to primary care if her symptoms become more frequent and/or persistent. 

In summary:

We must do an urgent cancer referral there is ascites or a pelvic or abdominal mass. 

We must measure CA125  if a woman, especially if aged 50 or over, reports frequent or persistent symptoms such as:

·      'bloating'

·      feeling full or loss of appetite

·      pelvic or abdominal pain

·      increased urinary urgency and/or frequency. 

·      Or if IBS symptoms have developed within the last 12 months.

In addition we should consider CA125 if there is:

·      Weight loss

·      Fatigue

·      Changes in bowel habit

If the value is 35 or greater, we must arrange an ultrasound scan and act accordingly if abnormal. 

If the CA125 is less than 35 or is greater with a normal ultrasound we must continue to investigate or monitor the patient until the cause if found

The next cancer to consider is Endometrial cancer

We must refer women using a suspected cancer pathway referral if they are aged 55 and over with post‑menopausal bleeding (or unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause), although we should also consider in women aged under 55.

We need to consider a direct access ultrasound scan in women aged 55 and over with:

·      unexplained vaginal discharge who:

o  are presenting with these symptoms for the first time or

o  have thrombocytosis or

o  report haematuria, or

·      visible haematuria and:

o  low haemoglobin levels or

o  thrombocytosis, or

o  high blood glucose levels. This is because there is a link between hyperglycaemia and endometrial cancer and hyperglycaemia is considered an independent risk factor for this type of cancer.

In summary, do a cancer referral if there is postmenopausal bleeding and do an USS if the women is over 55 and have a vaginal discharge or haematuria with other symptoms such as thrombocytosis, low haemoglobin or hyperglycaemia.

For Cervical cancer it is very straightforward.

We need to consider a suspected cancer pathway referral if, on examination, the appearance of their cervix is consistent with cervical cancer. 

In terms of Vulval and vaginal cancer

We need to consider a suspected cancer pathway referral for vulval cancer in women with an unexplained vulval lump, ulceration or bleeding and  for vaginal cancer if there is an unexplained palpable mass in or at the entrance to the vagina. 

We will now move to the Urological cancers

In terms of Prostate cancer

We must refer men using a suspected cancer pathway referral if their prostate feels malignant on digital rectal examination. 

We need to consider a prostate‑specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in men with:

·      any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or

·      erectile dysfunction or

·      visible haematuria. 

And we need to consider referring using a suspected cancer pathway referral if their PSA levels are above the threshold for their age. I have put a table with these values in the podcast description. The summary of this table is that for men under 40 and or 80 or over we need to use our clinical judgement when assessing the PSA. For the remainder, the PSA threshold is 2.5 for men in their 40’s, 3.5 in their 50’s is, 4.5 in their 60’s and 6.5 in their 70’s. That means consider referring men whose result is above those limits.



When it come to Bladder cancer

We must refer people using a suspected cancer pathway referral if they are:

·      aged 45 and over and have:

o  unexplained visible haematuria without urinary tract infection or

o  visible haematuria that persists or recurs after successful treatment of urinary tract infection, or

·      aged 60 and over and have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test. 

We should also consider non-urgent referral in people aged 60 and over with recurrent or persistent unexplained urinary tract infection. 

Renal cancer

We must refer people using a suspected cancer pathway referral if, like in bladder cancer, they are aged 45 and over and have:

·      unexplained visible haematuria without urinary tract infection or

·      visible haematuria that persists or recurs after successful treatment of urinary tract infection. 

For Testicular cancer

We need to consider a suspected cancer pathway referral in men if they have a non‑painful enlargement or change in shape or texture of the testis. 

And we should consider a direct access ultrasound scan in men with unexplained or persistent testicular symptoms. 

For Penile cancer

We need to consider a suspected cancer pathway referral in men if they have:

·      a penile mass or ulcerated lesion, when a sexually transmitted infection has been excluded as a cause, or

·      a persistent penile lesion after treatment for a sexually transmitted infection has been completed. 

We should also consider a cancer referral in men with unexplained or persistent symptoms affecting the foreskin or glans. 

This is the end of this episode of the Clinical Guidelines in Primary Care podcast. I hope that you have enjoyed this episode and I hope that you will join me in the next one. Thank you for listening

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through a section of the NICE guideline NG12 “Suspected cancer recognition and referral”, last updated in December 2021. This episode will summarise the section “recommendations by site of cancer” covering lung and pleural cancers as well as upper and lower gastrointestinal tract cancers.

This podcast will be saved on a website.

NICE guideline NG12 can be found here:

https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer

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Transcript

Welcome to a new episode of the Clinical Guidelines in Primary Care podcast. My name is Fernando Florido and I am a GP in the United Kingdom. Now think. After seeing a patient, have you ever found yourself wondering whether you may have missed an important diagnosis? And what if it is cancer? Are you sometimes unsure about cancer red flags and how you should manage those patients? I know that I have and, if you have too, then you are in the right place because with this episode we are starting a new cancer series that will help you in this respect. In this episode I will go through a section of the NICE guideline NG12 which is “Suspected cancer recognition and referral” which was published in June 2015 and was last updated in December 2021. This episode will cover lung cancer and mesothelioma as well as all gastrointestinal tract cancers. I hope that you enjoy the episode.

We are going to start with the respiratory cancers, that is, Lung cancer and mesothelioma.

The recommendations in respect of Lung cancer and mesothelioma are described separately in the NICE guideline. However, as it can be expected, there is a significant overlap between the red flags for the two conditions and therefore, for simplicity and the avoidance of repetition, I have amalgamated both recommendations into one. These recommendations say the following:

We must refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer or mesothelioma if they:

·      have chest X‑ray findings that suggest lung cancer or mesothelioma or

·      are aged 40 and over with unexplained haemoptysis. I understand this to be that we would need to refer someone over 40 with unexplained haemoptysis even before doing a chest x-ray or, if it has already been done, even if it is normal

We must offer an urgent chest X‑ray (to be done within 2 weeks) to assess for lung cancer or mesothelioma in people aged 40 and over if:

·      they have 2 or more of the following unexplained symptoms, or

·      they have 1 or more of the following unexplained symptoms and have ever smoked, or

·      they have 1 or more of the following unexplained symptoms and have been exposed to asbestos:

·      cough

·      shortness of breath

·      chest pain

·      fatigue

·      weight loss

·      appetite loss. 

·      That it, while the first three (cough, SOB and chest pain) may appear evident, the last three (fatigue, weight loss and appetite loss) may not always prompt us to think about lung cancer.

·      These are the cases where we must refer for a CXR. However:

We need to “consider” ( as opposed to “must”) an urgent chest X‑ray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following:

·      persistent or recurrent chest infection 

·      finger clubbing 

·      supraclavicular lymphadenopathy or persistent cervical lymphadenopathy 

·      chest signs consistent with lung cancer or pleural disease

·      thrombocytosis. 

Now we are going to move to the gastrointestinal tract cancers, both upper and lower parts of the gastrointestinal tract.

In terms of Oesophageal and stomach cancers

Obviously we must consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with an upper abdominal mass consistent with stomach cancer. 

We must offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) to assess for oesophageal and stomach cancer in people:

·      with dysphagia or

·      aged 55 and over with weight loss and any of the following: 

o  upper abdominal pain 

o  reflux

o  dyspepsia. 

We need to consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal or stomach cancer in people with haematemesis. Obviously I understand that the urgency of the referral will be guided by our clinical judgement depending on the severity of the haematemesis.

We also need to consider non‑urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:

·      treatment‑resistant dyspepsia or

·      upper abdominal pain with low haemoglobin levels or

·      raised platelet count with any of the following:

o  nausea

o  vomiting

o  weight loss

o  reflux

o  dyspepsia

o  upper abdominal pain, or

·      nausea or vomiting with any of the following:

o  weight loss

o  reflux

o  dyspepsia

o  upper abdominal pain. 

When it comes to Pancreatic cancers

We must refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for pancreatic cancer if they are aged 40 and over and have jaundice. 

We need to consider an urgent direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following: 

·      diarrhoea

·      back pain

·      abdominal pain

·      nausea

·      vomiting

·      constipation

·      new‑onset diabetes. 

·      I would personally say that if you do not have direct access to CT scan, you should not be entirely reassured by just an ultrasound and perhaps a referral for further investigations should be in order if the symptoms are significant.

In terms of Gall bladder and liver cancers

We need to consider an urgent direct access ultrasound scan (to be done within 2 weeks) to assess for gall bladder or liver cancer in people with an upper abdominal mass consistent with an enlarged gall bladder or liver.

When it comes to Colorectal cancer

We must refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer if:

·      they are aged 40 and over with unexplained weight loss and abdominal pain or

·      they are aged 50 and over with unexplained rectal bleeding or

·      they are aged 60 and over with:

o  iron‑deficiency anaemia or

o  changes in their bowel habit, or

·      tests show occult blood in their faeces (and it seems that the guideline indicates this irrespective of age).

·      These are when we “must” refer. However:

We need to consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults with a rectal or abdominal mass. And

We also need to consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings:

·      abdominal pain

·      change in bowel habit

·      weight loss

·      iron‑deficiency anaemia. 

·      This means that for any other patient not meeting the age requirements:

We can offer testing with quantitative faecal immunochemical tests to assess for colorectal cancer in adults without rectal bleeding who:

·      are aged 50 and over with unexplained:

o  abdominal pain or

o  weight loss, or

·      are aged under 60 with:

o  changes in their bowel habit or

o  iron-deficiency anaemia, or

·      are aged 60 and over and have anaemia even in the absence of iron deficiency. 

Finally, in terms of Anal cancer

We need to consider a suspected cancer pathway referral (for an appointment within 2 weeks) for anal cancer in people with an unexplained anal mass or unexplained anal ulceration. 

This is the end of this episode of the Clinical Guidelines in Primary Care podcast. I hope that you have enjoyed this episode and I hope that you will join me in the next one. Thank you for listening