Primary Care Guidelines

The video version of this podcast can be found here:

·      https://youtu.be/IzuigE4BNVM

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

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in October 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The Full NICE News bulletin for October 2025 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2025-10-01&to=2025-10-31&ndt=Guidance&ndt=Quality+standard

The updated Quality standard on head injury [QS74] can be found here:

·      https://www.nice.org.uk/guidance/qs74

Transcript

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

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in October 2025, focusing on what is relevant in Primary Care only.

And this time there hasn’t been an awful lot that is relevant to Primary care, only an update to the quality standard on head injury.  

Right, let’s jump into it.

The updated quality standard on head injury covers the assessment, management and rehabilitation after a head injury. While much of it applies to secondary care, there are important areas where we play an important role in general practice

This updated quality standard focuses on the NICE guideline on head injury and rehabilitation for chronic neurological disorders.

For GPs, the main message is on recognition and referral. When a patient presents after a head injury, the standard reinforces the importance of same-day assessment and appropriate referral for imaging. The thresholds for CT scans are unchanged, but we should ensure rapid referral if the criteria are met.

But what exactly are these referral criteria? Let’s have a look at them.

The criteria can be divided between emergency referrals and urgent referrals, depending on whether imaging should be done within 1 hour or within 8 hours.

Let’s look at the emergency referral criteria first. They may appear fairly obvious but it is still worthwhile going through them:

• For those aged 16 and over, we need to do a CT head scan within 1 hour if any of the following risk factors are present:
• a Glasgow Coma Scale (GCS) score of 12 or less on initial assessment
• a GCS score of less than 15 at 2 hours after injury
• a suspected skull fracture
• A post-traumatic seizure
• a focal neurological deficit
• more than one episode of vomiting and
• any worrying signs of a basal skull fracture such as haemotympanum, “panda” eyes, cerebrospinal fluid leakage from the ear or nose and bruising over the mastoid process, also known as Battle’s sign
• For children under 16, in addition to what has already been mentioned, we also need to do a CT scan of the head within 1 hour if any of the following apply:
• a suspicion of non-accidental injury
• GCS < 14 or < 15 for babies on initial assessment
• GCS < 15 at 2 h
• a tense fontanelle and
• for babies under 1 year also a head swelling or laceration > 5 cm
• Additionally, a CT should be done within 1 hour if children have more than one of the following risk factors:
• witnessed loss of consciousness >5 minutes
• abnormal drowsiness
• 3 or more episodes of vomiting
• dangerous mechanism of injury
• amnesia >5 minutes and
• any bleeding disorder

Now, let’s look at the urgent referral criteria, that is, when a CT head scan should be done within 8 hours:

• For adults we will do a CT head scan within 8 hours of the head injury, or within one hour if they present more than 8 hours after the injury, if they have had loss of consciousness or amnesia and they also have any of the following factors:
• age 65 or over
• any bleeding or clotting disorder (including anticoagulants) and
• a dangerous mechanism of injury, for example, a pedestrian/cyclist being hit by car, a fall from >1 m or >5 stairs, or more than 30 minutes’ retrograde amnesia before the injury
• Additionally, even if there is no other indication, we should consider a CT head scan within 8 hours of injury (or within 1 hour if presenting >8 hours after injury) for anyone on anticoagulant treatment. This includes warfarin, DOACs, heparin, and antiplatelet treatment excluding aspirin monotherapy

In practice this means that if a patient comes with head trauma, we will need to identify if any of these thresholds are met and refer them appropriately via A&E for imaging. Our role is not to decide whether a CT is indicated or not, but to pick up risk factors, and expedite referral.

Now, going back to the quality statements, the rest of them simply emphasise the role of rehabilitation. In this respect in Primary Care, we should ensure that referral to community neuro-rehabilitation or therapy services happens in a timely fashion and that rehabilitation plans, and shared care arrangements are in place.

In summary: the update doesn’t change the imaging thresholds but for us, it emphasises follow-up, rehabilitation, and long-term management after a head injury.

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

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/30qLbVnKHW8

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I give a brief overview of the mechanism of action of sacubitril valsartan for heart failure.

The NICE guidance on Chronic Heart Failure is covered in these episodes:

Part 1- Diagnosis: https://youtu.be/hjKE4JAQM6c

Part 2 – Drug management: https://youtu.be/UGD7-osSlv0

Part 3 – Additional management: https://youtu.be/i0L-Nv4bJzs

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here: 

·      https://www.nice.org.uk/guidance/ng106

Additional information on ARNIs can be found here:

·      https://www.ncbi.nlm.nih.gov/books/NBK507904/#:~:text=Mechanism%20of%20Action,-The%20pathophysiology%20of&text=Valsartan%20is%20an%20angiotensin%20receptor,neprilysin%20will%20accumulate%20angiotensin%20II

Transcript

Hello and welcome! I’m Fernando, a GP in the UK.

What are Angiotensin receptor–neprilysin inhibitors? They are a relatively new class of medications used specifically in the management of heart failure with reduced ejection fraction. At present, the only available one is sacubitril/valsartan.

If you are interested in learning how Sacubitril/valsartan works, here is some background information.

The first thing to understand is that the pathophysiology of heart failure involves an abnormal activation of the renin-angiotensin-aldosterone system (RAAS). This leads to vasoconstriction, hypertension, increased aldosterone levels, increased sympathetic tone, and eventually, cardiac remodelling, all of which worsen the disease over time. ACEIs or ARBs play a major role in reducing HF morbidity and mortality by blocking this abnormal activation

At the same time that the renin-angiotensin-aldosterone system is activated, the natriuretic peptide system is also activated, hence the elevated BNP and NT-pro BNP seen in heart failure. This compensatory mechanism leads to vasodilation, natriuresis, and diuresis. As a result, the natriuretic peptide system decreases blood pressure, lowers the sympathetic tone, and reduces aldosterone levels. The natriuretic peptide system functions antagonistically to the renin-angiotensin-aldosterone system and has favourable impact on heart failure. Natriuretic peptides are broken down by an enzyme called neprilysin.

Sacubitril/valsartan is a combination product. Sacubitril is a pro-drug that, upon activation, acts as a neprilysin inhibitor. So, it works by blocking the action of neprilysin, thus preventing the breakdown of natriuretic peptides, which leads to a prolonged duration of the favourable effects of these peptides.

However, because neprilysin also breaks down angiotensin II, inhibiting neprilysin will accumulate angiotensin II. For this reason, a neprilysin inhibitor cannot be used alone; it must always be combined with an ARB to block the effect of the excess angiotensin II. This is why Valsartan is used.

Another important substance broken down by neprilysin is bradykinin; neprilysin inhibition will also cause a build-up of bradykinin. Therefore, sacubitril cannot be used with an ACEI due to an increased risk of angioedema if both these drugs are combines or given in a short timeframe. And this is why when switching between ACEI and sacubitril/valsartan, the patient must undergo a 36-hour washout period to lower the risk of angioedema.

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/i0L-Nv4bJzs

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

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the additional management of heart failure.

In previous episodes we covered the initial assessment and diagnosis and the drug management of the different subtypes of heart failure.

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here:

·      https://www.nice.org.uk/guidance/ng106

Additional information on ARNIs can be found here:

·      https://www.ncbi.nlm.nih.gov/books/NBK507904/#:~:text=Mechanism%20of%20Action,-The%20pathophysiology%20of&text=Valsartan%20is%20an%20angiotensin%20receptor,neprilysin%20will%20accumulate%20angiotensin%20II

Transcript

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

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure, which was last updated in September 2025.

Today’s episode focuses on the additional management of heart failure.

If you haven’t already, I recommend that you check the previous episodes where we covered heart failure diagnosis and the drug management of the different subtypes of heart failure.

Right, let’s jump into it.

And as we have just said, today we’re going to focus on the additional management of heart failure.

Now let’s start by looking at how to initiate and monitor medication use.

When tailoring treatment, we should use the person’s medical history, frailty status, and prognosis to decide which specific medicine combinations to use and how to introduce them.

In primary care, we should seek the advice from a heart failure specialist before starting someone on an angiotensin receptor–neprilysin inhibitor, that is, sacubitril/ valsartan.

Before prescribing an ACE inhibitor, ARB, angiotensin receptor-neprilysin inhibitor (ARNI), or mineralocorticoid receptor antagonist, we will measure renal function and electrolytes.

Once these drugs have been started, we should measure renal function and electrolytes:

• one to two weeks after starting treatment,
• one to two weeks after each dose increment,
• every three to six months once the maximum tolerated dose has been established,
• and at any time renal function may be compromised.

If the serum creatinine increases by more than 50%, or potassium rises above 5.5 millimoles per litre, we will follow local guidelines.

We will measure blood pressure, or ask the person to measure it themselves, before and after each dose increment. For people with symptoms of postural hypotension, we will measure blood pressure according to the NICE hypertension guideline, which essentially recommends ideally checking the initial blood pressure in the supine position, and then again after standing for at least 1 minute, in order to check for a drop in systolic blood pressure of 20 mmHg or more. Although checking the BP in a seated position can also be acceptable, we need to remember that measuring blood pressures from sitting to standing may miss some cases of postural hypotension, especially in older or frail people, and that measuring from lying to standing is more accurate for detecting a significant postural drop.

When prescribing beta-blockers, we should not withhold treatment solely because of age, or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease, or COPD.

We will assess heart rhythm, heart rate, and conduction abnormalities using a 12-lead ECG before deciding whether to prescribe a beta-blocker.

We will not offer a beta-blocker to people with second-degree or third-degree heart block who do not have a pacemaker, or to those with bradycardia, that is, a heart rate below 50 beats per minute.

We will assess heart rate and clinical status after each betablocker dose increment, and for people with symptoms and bradycardia, we will consider repeating a 12-lead ECG after each dose increment.

For digoxin, we will not routinely monitor serum digoxin concentrations. But we should be aware that a digoxin level measured within 8 to 12 hours of the last dose may help confirm toxicity or non-adherence, but we must interpret results in the clinical context, since toxicity may occur even when the concentration is within the therapeutic range.

Now, let us move on to clinical review.

We will monitor all people with heart failure and provide:

·      a clinical general assessment including cardiac rhythm

·      a medication review checking for any necessary changes or side effects,

·      An assessment of renal function, and

·      Measurement of iron status and haemoglobin.

This is just the very minimum, Additionally, we should provide more detailed monitoring for people with significant comorbidities, co-prescribed medications, or recent deterioration. The frequency of monitoring will depend on the clinical situation and the stability of the patient’s condition.

If the clinical condition or medication has changed, we should monitor the patient more frequently — from days to every two weeks. For stable people with proven heart failure, we will monitor at least every six months.

For people under 75 years old with heart failure with reduced ejection fraction and normal renal function — that is, an eGFR greater than 60— we can consider measuring NT-proBNP levels to monitor and optimise treatment.

Now let’s look at other treatments and advice relevant to all types of heart failure.

We will use diuretics to relieve congestive symptoms and fluid retention, and we will titrate the dose up or down as needed, always using the lowest effective dose.

Amiodarone, should be started under specialist supervision and we will review the need to continue it every six months, and at each review, we will check liver and thyroid function tests and assess for side effects.

For people with heart failure and atrial fibrillation, we will follow the NICE recommendations on anticoagulation for stroke prevention. For people in sinus rhythm, we will consider anticoagulation if there is a history of thromboembolism, left ventricular aneurysm, or intracardiac thrombus.

We should offer annual influenza vaccination and a one-time pneumococcal vaccination to all people with heart failure.

For people of childbearing potential, we should discuss contraception and pregnancy. If pregnancy is being contemplated or occurs, we will seek specialist advice from both cardiology and obstetrics.

We will not routinely advise people with heart failure to restrict sodium or fluid intake. However, we should ask about salt and fluid consumption and provide advice when necessary, for example, by restricting fluids for dilutional hyponatraemia or by reducing intake for those with high salt or fluid consumption. Additionally, we will advise people to avoid salt substitutes that contain potassium in order to minimise the risk of hyperkalaemia.

In terms of air travel, we can advise that it will be possible for most people, depending on their clinical condition at the time.

Regarding driving, we will simply follow DVLA guidelines.

We should offer people with heart failure a personalised, exercise-based cardiac rehabilitation programme which should include psychological and educational components.

Finally, in terms of palliative care, we should not offer long-term home oxygen therapy solely for advanced heart failure. However, we should be aware that long-term oxygen may be offered for comorbidities such as COPD.

If symptoms are worsening despite optimal specialist treatment, we will refer to palliative care in discussion with the heart failure multidisciplinary team

So that is it, a review of the additional management of heart failure.

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/UGD7-osSlv0

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

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the drug management of the different subtypes of heart failure.

The guidance on the remaining aspects of heart failure management will be covered in other episodes. In the previous episode we covered the initial assessment and diagnosis.

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here:

·      https://www.nice.org.uk/guidance/ng106

Additional information on ARNIs can be found here:

·      https://www.ncbi.nlm.nih.gov/books/NBK507904/#:~:text=Mechanism%20of%20Action,-The%20pathophysiology%20of&text=Valsartan%20is%20an%20angiotensin%20receptor,neprilysin%20will%20accumulate%20angiotensin%20II

Transcript

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

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure in adults, which was last updated in September 2025.

Today’s episode focuses on the drug management of the different subtypes of heart failure.

If you haven’t already, I recommend that you check the previous episode on heart failure diagnosis.

The guidance on the remaining aspects of heart failure management will be covered in the next episode, so stay tuned.

Right, let’s jump into it.

And as we have just said, today we’re going to focus on the specific drug treatment for heart failure.

Also, as we said in the previous episode, echocardiograms assess both systolic and diastolic function of the left ventricle.

Categorising cardiac function is crucial because the treatment of heart failure will be different depending on the ejection fraction.

We classify heart failure as follows:

• Heart failure with reduced ejection fraction, when the ejection fraction is 40% or below.
• Heart failure with mildly reduced ejection fraction, when it is between 41 and 49%.
• And Heart failure with preserved ejection fraction, when it is 50% or higher.

So let’s have look at the treatment of each of these subtypes

For people with heart failure with reduced ejection fraction, we will offer a combination of four medicines:

·      an ACE inhibitor,

·      a beta-blocker,

·      a mineralocorticoid receptor antagonist, and

·      an SGLT-2 inhibitor.

For people who are on the maximum tolerated dose of each of these four medicines but continue to have symptoms of heart failure, we should consider switching the ACE inhibitor to an angiotensin receptor–neprilysin inhibitor.

What are Angiotensin receptor–neprilysin inhibitors? They are a relatively new class of medications used specifically in the management of heart failure with reduced ejection fraction. At present, the only available one is sacubitril/valsartan, which combines two mechanisms of action:

Sacubitril, which inhibits neprilysin — an enzyme that breaks down beneficial natriuretic peptides. By blocking neprilysin, sacubitril helps with vasodilation, sodium excretion, and reduced cardiac remodelling.

And then we have Valsartan, an angiotensin II receptor blocker (ARB), which helps counteract the harmful effects of the renin–angiotensin–aldosterone system by reducing vasoconstriction, sodium retention, and aldosterone secretion.

Together, the combination of sacubitril and valsartan improves cardiac function, reduces hospitalisations, and lowers mortality in patients with heart failure with reduced ejection fraction.

OK, let’s go back to the general management of heart failure with reduced ejection fraction.

And we need to note that if certain medicines are not tolerated, there are alternative treatment combinations that we should consider.

For example, for people who have had angioedema after taking an ACE inhibitor, we will still offer a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor, and we should also consider an angiotensin receptor blocker, or ARB instead of the ACEI. This is because the risk of angioedema is lower with ARBs than with ACE inhibitors, although it is not zero so we should use caution and monitor the patient accordingly. An important safety add-on is that we should not use sacubitril/valsartan in anyone with a history of angioedema, as this is listed as a contraindication.

People with heart failure with reduced ejection fraction who have symptoms of intolerance to ACE inhibitors, other than angioedema, should have a beta-blocker, an MRA, an SGLT2 inhibitor and sacubitril/valsartan. The initiation of sacubitril valsartan should be guided by a heart failure specialist

Additionally, in people with heart failure with reduced ejection fraction, we should assess iron status and check for anaemia using:

·      transferrin saturation (TSAT),

·      serum ferritin, and

·      haemoglobin.

For people with heart failure with reduced ejection fraction and haemoglobin less than 150 grams per litre, and iron deficiency, that is, a TSAT less than 20% or serum ferritin less than 100, we should offer intravenous iron therapy. This is because trial evidence shows that IV iron improves symptoms and quality of life and reduces HF hospitalizations in several settings, especially in patients with symptomatic heart failure with reduced ejection fraction.

If iron deficiency anaemia is identified, we should not assume it is related to the person’s heart failure, and we should consider investigating for alternative causes.

There are other drugs that can be initiated in a specialist setting. I will not cover them in detail, but specialist treatments options include ivabradine, hydralazine in combination with a nitrate, and digoxin.

Additionally, in heart failure with reduced ejection fraction we should avoid verapamil, diltiazem, and short-acting dihydropyridine calcium-channel blockers. The “why” boils down to hemodynamics and outcomes:

• Verapamil & diltiazem are negative inotropes and slow AV conduction. In heart failure with reduced ejection fraction that can worsen cardiac function and precipitate decompensation.
• Then Short-acting dihydropyridines (like immediate-release nifedipine) cause rapid vasodilation and reflex tachycardia and hypotension, which has been linked to increased mortality, so it is considered unsafe in HF

For people with heart failure with mildly reduced ejection fraction, we should also consider treatment with the same four drugs as the reduced ejection fraction subtype, that is, an ACE inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor.

For those who have symptoms of intolerance to ACE inhibitors, we should consider an ARB, a beta-blocker, an MRA, and an SGLT2 inhibitor. But we need to note that an angiotensin receptor–neprilysin inhibitor, that is, sacubitril/valsartan, is not recommended in heart failure with mildly reduced ejection fraction. It is recommended only in heart failure with reduced ejection fraction.

SGLT2 inhibitors specifically recommended by NICE for heart failure with mildly reduced ejection fraction, are empagliflozin and dapagliflozin, for which we have specific NICE recommendations.

Finally, for people with heart failure with preserved ejection fraction, ACE inhibitors and betablockers are not specifically recommended, but we should consider a mineralocorticoid receptor antagonist and an SGLT2 inhibitor, again with specific guidance on empagliflozin and dapagliflozin as the preferred SGLT2 inhibitors in this subtype.

When treating heart failure in people with chronic kidney disease, if the eGFR is 45 or less, we should consider using lower starting doses and smaller dose increments for the medicine combinations already mentioned.

If the person’s eGFR is below 30, the advice of a renal physician should be sought.

So that is it, a review of the drug management of the different subtypes of heart failure.

In the next episode, I will cover additional details and further management recommendations.

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/hjKE4JAQM6c

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

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the initial assessment and diagnosis.

The guidance on the remaining aspects of heart failure management will be covered in future episodes.

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here:

·      https://www.nice.org.uk/guidance/ng106

Additional information on ARNIs can be found here: 

·      https://www.ncbi.nlm.nih.gov/books/NBK507904/#:~:text=Mechanism%20of%20Action,-The%20pathophysiology%20of&text=Valsartan%20is%20an%20angiotensin%20receptor,neprilysin%20will%20accumulate%20angiotensin%20II

Transcript

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

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure in adults, which was last updated in September 2025.

Today’s episode focuses on the initial assessment and diagnosis.

The guidance on the remaining aspects of heart failure management will be covered over forthcoming episodes so stay tuned.

Right, let’s jump into it.

And as we have just said, today we’re going to focus on how we diagnose heart failure.

We will obviously begin by taking a thorough history, performing a clinical examination, and arranging appropriate tests to confirm the diagnosis.

And we should start by measuring N-terminal pro-B-type natriuretic peptide, or NT-proBNP, in anyone with suspected heart failure. Because very high levels of NT-proBNP carry a poor prognosis, we will refer people with suspected heart failure and an NT-proBNP level above 2,000 nanograms per litre — or 236 picomoles per litre — urgently, for specialist assessment and an echocardiogram within two weeks.

We should refer people with suspected heart failure and lower NT-proBNP levels, between 400 and 2,000 nanograms per litre — that’s 47 to 236 picomoles per litre — for specialist assessment and an echocardiogram but this time to be seen within six weeks.

We need to be aware that an NT-proBNP level below 400 nanograms per litre, or 47 picomoles per litre, in an untreated person makes a diagnosis of heart failure less likely. We also need to remember that the level of serum natriuretic peptide does not differentiate between heart failure with preserved, mildly reduced, or reduced ejection fraction.

When NT-proBNP levels are below 400 nanograms per litre, we should consider alternative causes for the symptoms. If there’s still concern that the symptoms might be related to heart failure, we should discuss the case with a heart failure specialist.

We also need to be aware that there are factors that can affect the NT-proBNP level. Examples of factors that can reduce the level are:

·      Obesity

·      African or African–Caribbean ethnic background, or

·      Treatment with certain medications. These include:

o  Diuretics,

o  Beta-blockers

o  Mineralocorticoid receptor antagonists

o  ACE inhibitors, ARBs and

o  Angiotensin receptor-neprilysin inhibitors. And let’s just quickly say that Angiotensin receptor–neprilysin inhibitors, or ARNIs, are a relatively new class of medications used in the management of heart failure with reduced ejection fraction. At present, the only available one is sacubitril/valsartan which combines two mechanisms of action:

§ Sacubitril, which inhibits neprilysin — an enzyme that breaks down beneficial natriuretic peptides. By blocking neprilysin, sacubitril helps with vasodilation, sodium excretion, and reduced cardiac remodelling.

§ And then we have Valsartan, an angiotensin II receptor blocker (ARB), which helps counteract the harmful effects of the renin–angiotensin–aldosterone system by reducing vasoconstriction, sodium retention, and aldosterone secretion. Together, this combination of sacubitril and valsartan improves outcomes in patients with heart failure with reduced ejection fraction.

Ok, going back to the factors that can affect NT-proBNP levels, we should remember that high levels can have causes other than heart failure — for example, pulmonary, renal, liver, or systemic disease, sepsis, COPD, diabetes, or liver cirrhosis.

As we can see, the main tools to diagnose heart failure are the NT-proBNP blood test followed by a transthoracic echocardiogram. The purpose for performing transthoracic echocardiography is to exclude important valve disease, detect intracardiac shunts and assess both systolic and diastolic function of the left ventricle.

Categorising cardiac function is important because the treatment of heart failure will be different depending on the ejection fraction.

We classify heart failure as follows:

• Heart failure with reduced ejection fraction, when the ejection fraction is 40% or below.
• Heart failure with mildly reduced ejection fraction, when it is between 41 and 49%.
• And Heart failure with preserved ejection fraction, when it is 50% or higher.

We will look at the specific drug treatment of each of these subtypes of heart failure in the next episode.

And going back to the diagnosis, although transthoracic echocardiography is our first-line imaging option, if image quality is poor, alternative imaging methods such as radionuclide angiography, cardiac MRI, or transoesophageal echocardiography should be considered.

Also, although NT-proBNP and echocardiography are the cornerstone of the diagnosis of heart failure, we should also consider further investigations to assess possible aggravating factors or alternative diagnoses. These include:

·      An ECG

·      A chest X-ray

·      Blood tests including renal, liver and thyroid function tests, a lipid profile, HbA1c, and a full blood count

·      And we will also do Urinalysis, and

·      Peak flow or spirometry.

We do this because we should always try to exclude other disorders that may present in a similar manner.

Once a diagnosis of heart failure has been made, we will assess its severity, causes, precipitating factors, type of cardiac dysfunction, and any correctable causes, and, in particular, for people with heart failure caused by valve disease, we will refer them for specialist assessment and advice.

We should also review patients with a historical diagnosis of heart failure, and manage them according to the NICE guideline only if the diagnosis has been confirmed with an echocardiogram. If heart failure is still suspected but no underlying cardiac abnormality has been identified on imaging, we will refer to a heart failure specialist.

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

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/qZPisPCp4eQ

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

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in September 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The Full NICE News bulletin for September 2025 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2025-09-01&to=2025-09-30&ndt=Guidance&ndt=Quality+standard

The updated Clinical guideline CG57 on Atopic eczema in under 12s: diagnosis and management can be found here:

·      https://www.nice.org.uk/guidance/cg57

The updated NICE guideline on Chronic heart failure in adults: diagnosis and management NG106 can be found here:

·      https://www.nice.org.uk/guidance/ng106

The updated Quality standard on Chronic heart failure in adults QS9 can be found here:

·      https://www.nice.org.uk/guidance/qs9

The new NICE guideline on Pneumonia: diagnosis and management NG250 can be found here:

·      https://www.nice.org.uk/guidance/ng250

The updated Quality standard on Pneumonia: diagnosis and management QS110 can be found here:

·      https://www.nice.org.uk/guidance/qs110

The updated NICE guideline on Suspected acute respiratory infection in over 16s: assessment at first presentation and initial management NG237 can be found here:

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

The updated Clinical guideline on Bipolar disorder: assessment and management CG185 can be found here:

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

The updated technology appraisal guidance on Tirzepatide for treating type 2 diabetes TA924 can be found here:

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

The updated Technology appraisal guidance on Tirzepatide for managing overweight and obesity TA1026 can be found here:

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

Transcript

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

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in September 2025, focusing on what is relevant in Primary Care only.

In recent months, there hasn’t been much in the way of updates that directly affect us in General Practice. But September is very different — there’s a lot we need to pay attention to. These updates cover eczema, respiratory infections, pneumonia, bipolar disorder, tirzepatide, and, importantly, a new updated guideline on chronic heart failure.

Right, let’s jump into it.

The updated NICE guideline on atopic eczema in children under 12 has revised the section on complementary therapies, washing, and clothing. The new wording makes it clear that children with atopic eczema may bathe or shower once daily. Bathing can help remove crusts and skin debris and improve comfort, but it should always be followed by emollient application to prevent the skin from drying out.

The update also clarifies that water softeners and silk garments do not improve eczema severity and therefore should not be recommended.

So, in summary: daily bathing is acceptable and can be beneficial if followed by emollient use, and water softeners or silk clothing should not be recommended because they provide no proven benefit.

The next section is on Chronic Heart failure. The updated NICE guideline has introduced substantial changes, particularly to how we treat and monitor different categories of heart failure. This is such an important area that I’ll only cover the highlights today, as I will cover it in more detail in a future episode.

The main focus of the update was the drug management of the three subtypes of heart failure, that is, heart failure with reduced ejection fraction, mildly reduced ejection fraction, and preserved ejection fraction.

For heart failure with reduced ejection fraction, that is, an ejection fraction 40% or less, the recommendations now reflect strong evidence for SGLT-2 inhibitors, which consistently reduce hospitalisations for heart failure and improve survival regardless of diabetes status. These drugs are now embedded alongside established treatments such as ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists.

For heart failure with mildly reduced ejection fraction — that is, an ejection fraction between 41% and 49% — NICE issues new recommendations for the first time. This group used to be a bit of a grey area. The update highlights evidence that people with mildly reduced EF may benefit from SGLT-2 inhibitors in much the same way as those with reduced EF, and the guidance now advises considering them here too.

For heart failure with preserved ejection fraction, meaning an ejection fraction of 50% or more, NICE also makes new recommendations. In the past, management was mostly limited to controlling symptoms and comorbidities. Now, on the back of trial evidence, SGLT-2 inhibitors are also recommended here because they reduce hospitalisations for heart failure, even if mortality benefit is less certain.

In practice, this means SGLT-2 inhibitors will be used much more widely — not only in people with reduced EF, but also in those with mildly reduced or preserved EF.

An updated NICE Quality Standard on chronic heart failure has also been published, bringing it into line with these changes.

Next, there is a brand-new NICE guideline on pneumonia, which consolidates and replaces previous guidance, including antimicrobial prescribing guidelines.

The biggest change for us in primary care relates to children: the recommended course of antibiotics for non-severe community-acquired pneumonia without complications or underlying disease has been reduced from 5 days to 3 days. This is because evidence shows that shorter courses are just as effective at resolving symptoms, while reducing the risk of side effects and, most importantly, lowering the risk of antibiotic resistance.

Additionally, although more relevant to secondary care, there are new recommendations on corticosteroids in patients with high-severity community-acquired pneumonia when admitted to hospital. This reflects growing evidence that systemic steroids can improve outcomes in severe cases alongside standard antibiotic and supportive care. However, corticosteroids are not recommended for routine use in mild or moderate pneumonia, so it is something that we will not be doing routinely in Primary Care.

There is also an updated Quality Standard on pneumonia, aligned with the new guideline and reflecting the changes I’ve just mentioned.

Next, we have the updated NICE guideline on suspected acute respiratory infection which covers assessment at first presentation and initial management.

The main change here is that the section on the clinical diagnosis of community-acquired pneumonia in primary care has been removed, because that information is now fully covered by the new pneumonia guideline. In practical terms, pneumonia-specific recommendations move to the pneumonia guideline, while the guideline on respiratory infections continues to provide guidance on the assessment and initial management of these infections more broadly.

This guideline should also be read alongside NICE’s existing antimicrobial prescribing guidelines for acute cough, COPD exacerbations, sinusitis, and sore throat.

The latest update is on the clinical guideline on bipolar disorder, which focuses on recommendations around valproate use, following new safety advice from the MHRA.

The key change is that boys and men taking valproate must now be advised to use effective contraception throughout their treatment and for three months after stopping the drug. This means using condoms in addition to contraception used by a female sexual partner. Additionally, men who are planning a family within the next year should also discuss potential fertility risks and alternative treatment options.

Previously, recommendations were already strict around valproate use in females of childbearing potential. Valproate must not be initiated in anyone under 55 unless two specialists agree there are no other suitable alternatives or that the reproductive risks do not apply. For them, it can only be prescribed if other treatments are unsuitable and the Pregnancy Prevention Programme is in place.

The new update now extends this caution explicitly to male patients, confirming that valproate carries reproductive risks for both sexes.

Finally, there are updates to the NICE technology appraisals on tirzepatide — marketed as Mounjaro — covering both type 2 diabetes and the management of overweight and obesity.

The recommendations themselves remain unchanged. What has changed is that a commercial access agreement has now been added, together with updated pricing. This is intended to reduce the budget impact for the NHS and make implementation of the guidance more sustainable.

As a reminder, let’s remember that for type 2 diabetes, tirzepatide continues to be recommended when triple therapy with metformin and two other oral drugs is ineffective, not tolerated, or contraindicated, and when a GLP-1 receptor agonist would otherwise be considered. For obesity, it remains recommended in adults who meet the BMI and comorbidity thresholds specified in the original appraisal and following a gradual NHS roll out process.

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

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/AC3ncdm77Os

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

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below.

The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will cover 4 clinical groups and the remaining groups were covered in last week’s episode.

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The NICE announcement on Type 2 diabetes management can be found here:

·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced

The NICE draft guideline on Type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450

The visual summary of the NICE draft guideline on type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2

Transcript

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

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the main changes as applied to 7 specific groups of patients. In the previous episode we covered the first 3 groups so today we will cover the rest.

Right, let’s jump into it.

And, as you know, the draft guideline is open for consultation until October, and the final guidance is due in February 2026, so let’s not forget that it is only a draft, and we should not be making clinical decisions based on it yet.

Today’s episode is based on the visual summary created by NICE and the link to it is in the episode description.

The visual summary includes specific guidance for 7 different groups of patients:

1.   The group of patients with no relevant comorbidities, then

2.   Obesity

3.   Frailty

4.   CKD

5.   Heart failure

6.   Atherosclerotic cardiovascular disease and

7.   Early onset type 2 diabetes

And today we will look at the last 4 groups that we did not cover last time.

So let’s start with the CKD group.

For people with CKD, like for many of the other groups. the draft guideline recommends starting treatment with metformin plus an SGLT-2 inhibitor. Because of licensing reasons, we are advised to choose either empagliflozin or dapagliflozin in this group. If metformin is contraindicated or not tolerated, the SGLT-2 inhibitor can be offered on its own.

Treatment will also depend on kidney function, measured by eGFR. As we know, metformin in contraindicated if eGFR is less than 30, and, given that SGLT-2 efficacy decreases with advancing renal impairment, NICE recommends not using empagliflozin or dapagliflozin is eGFR is less than 20.

Therefore, the first line treatment on this basis is as follows:

• If eGFR is above 30 mL/min/1.73 m², in principle we will offer metformin plus dapagliflozin or empagliflozin, although, if metformin is not tolerated the SGLT-2 inhibitor can be given by itself.
• If eGFR is between 20 and 30, we will offer either dapagliflozin or empagliflozin alone.
• And, if eGFR is below 20, we will then go for a DPP-4 inhibitor in preference. If that is contraindicated or not tolerated, we will consider pioglitazone or insulin, given that sulfonylureas should not be given if the eGFR is below 30. This is because sulfonylureas accumulate in renal impairment and increase the hypoglycaemia risk.

If further glycaemic lowering is needed after first line treatment, we can use other options including DPP-4 inhibitors (if not already used), sulfonylureas or insulin depending on renal function and safety profile.

How does this differ from the previous guidance?

Like in other groups, the big change here is the earlier, more proactive use of SGLT-2 inhibitors specifically for renal protection, not just glucose lowering. Previously, SGLT-2 inhibitors were used after metformin for people with established albuminuria or heart failure. Now, the draft guidance recognises the trial evidence showing that, apart from the cardiovascular benefits, SGLT2 inhibitors also reduce progression of CKD, and this benefit occurs even in people with moderately reduced eGFR and independently of albuminuria. The slower progression of CKD is because SGLT2 inhibitors reduce albuminuria, intraglomerular pressure and protect against hyperfiltration.

Another nuance is that the draft now pushes dapagliflozin and empagliflozin explicitly into first-line therapy alongside metformin or alone if necessary, with thresholds set according to kidney function. And it also sets out a clear sequence for treatment as eGFR declines, including when to use DPP-4 inhibitors or move to insulin.

What this means in practice is that:

• We will need to check eGFR early and often, as it will determine the choice of treatment.
• Metformin + SGLT-2 inhibitor is the default down to eGFR 30; SGLT-2 inhibitor alone is preferred between 20 and 30, and below 20, we will switch to a DPP-4 inhibitor, and only after that will we consider pioglitazone or insulin if needed.
• And, practically, the bigger focus on protecting kidney function means that more patients will be started on dapagliflozin or empagliflozin earlier, so we will need to familiarise ourselves with renal thresholds and side effect monitoring.

Now, let’s move to the heart failure group.

For adults with type 2 diabetes and heart failure, NICE also recommends that the initial therapy should be metformin plus an SGLT-2 inhibitor. If metformin is contraindicated or not tolerated, then an SGLT-2 inhibitor alone is advised. If additional therapy is needed to help with weight management, then a GLP-1 receptor agonist (specifically subcutaneous semaglutide) can be considered provided there is no frailty and the patient has a preserved ejection fraction. After that, for further glycaemic lowering, we can add a sulfonylurea or insulin, remembering that pioglitazone is contraindicated in heart failure 

The difference with the old guideline is that the draft makes metformin + SGLT-2 inhibitor the standard, aiming to get heart failure-related benefits earlier. As we know, trial data show that SGLT2 inhibitors reduce hospitalization for heart failure, improve symptoms, slow progression, and improve cardiovascular mortality, independent of glycaemic control. So, using them early helps not just glucose but also cardiac outcomes.

But another big change is that the draft also acknowledges that weight loss (from GLP-1 RAs) can help reduce cardiac workload, reduce fluid overload, and improve quality of life in heart failure. Combining SGLT-2 inhibitors with semaglutide in patients for whom weight is an issue, is intended to deliver a dual benefit: cardiorenal protection and weight reduction. Previously, GLP-1 RAs were less likely to be used early in heart failure, and semaglutide had stricter criteria; now, semaglutide is explicitly considered earlier in heart failure when weight benefit is also a goal. Any limitations? Well, semaglutide will be limited to patients with obesity, preserved EF and no frailty. Frailty and ejection fraction matter because the benefits and risks of semaglutide vary (e.g. risk of dehydration and hypotension,) depending on heart function and overall general state.

What the changes mean in practice is that:

• We will start more patients on both metformin and an SGLT-2 inhibitor upfront. This also means that we will need to discuss SGLT-2 inhibitor side effects like the risk of genital infections, volume depletion, sick-day rules, and renal monitoring from the start.
• Patients will need assessment of heart failure subtype (especially ejection fraction) and frailty to decide who is eligible for early semaglutide.
• Monitoring will need to include not only HbA1c, but also cardiac function, kidney function, and watch for adverse events.
• And finally, when adding semaglutide, the expectation would be that it's for weight benefit, so obesity must be present.

Now, let’s look at the atherosclerotic cardiovascular disease group.

For them, we will offer triple therapy with metformin plus an SGLT-2 inhibitor and the GLP-1 receptor agonist, semaglutide, for additional risk reduction and weight benefit. And it is worth mentioning that we should also consider semaglutide for any other group if at any stage, ASCVD develops after treatment has already been started. If extra glycaemic lowering is needed, we will add a sulfonylurea, pioglitazone, or insulin. As we know, we should not combine a GLP1 receptor agonist and a DPP4 inhibitor, but if a GLP-1 RA isn’t appropriate, we will add a DPP-4 inhibitor instead and before considering the other options of a sulfonylurea, pioglitazone, or insulin.

This is different from the previous version because before GLP-1 RAs were not used for their cardiovascular benefit but their use was rather tied to glycaemic and BMI thresholds. The draft moves to routine early triple therapy with metformin, an SGLT-2 inhibitor, and semaglutide when ASCVD is present or develops, bringing GLP-1 therapy forward in the pathway.

This change is due to trial evidence showing that GLP-1 receptor agonists not only improve weight, blood pressure and post-prandial glycaemia, but they also reduce atherosclerotic cardiovascular events, with semaglutide having one of the strongest evidence for this reduction within the class. Combining semaglutide with metformin and an SGLT-2 inhibitor early is designed to achieve both cardio renal benefits as well as a lower atherothrombotic risk.

What it means in practice is that:

• We will treat ASCVD earlier with SGLT-2 inhibitors and semaglutide and, in principle, we will continue these therapies long term even if HbA1c or weight targets aren’t fully met.

Finally, let’s move to the early-onset type 2 diabetes group. For NICE this group refers to type 2 diabetes diagnosed in people under the age of 40.

First-line treatment here is metformin plus an SGLT-2 inhibitor like everybody else but, on top of that, the draft says that we should consider adding a GLP-1 receptor agonist early. If metformin is contraindicated or not tolerated, we will offer an SGLT-2 inhibitor and still consider adding a GLP-1 RA. If more glycaemic lowering is needed, the add-on choices are, again, a GLP 1 receptor agonist if not already prescribed, a sulfonylurea, pioglitazone, or insulin. If a GLP-1 RA isn’t appropriate we will add a DPP-4 inhibitor instead before considering a sulfonylurea, pioglitazone, or insulin.

This is different from the previous guidance because before early-onset type 2 diabetes did not have its own explicit guidance. NICE is changing this because it has been shown that early-onset type 2 diabetes carries disproportionately higher lifetime risk. In fact, large reviews show that early-onset T2D is linked to higher rates of complications and premature mortality at any given age compared with later-onset disease, due to the additional years exposed to hyperglycaemia, faster β-cell decline, and earlier cardio-renal and microvascular complications. So this is why NICE now favours earlier, multi-mechanism therapy in this group, including GLP-1 receptor agonists for their cardiovascular benefits.

What this means in practice is that we will start combination therapy sooner in the form of metformin + SGLT-2 inhibitor while, proactively considering a GLP-1 RA early, in many cases resulting in early triple therapy.

We will also need to assess tolerance and to monitor side effects as well as reviewing targets explicitly, while being aware that in early-onset T2D, continuing GLP-1 RAs may be appropriate even when targets aren’t met.

So that is it, an review of the draft NICE guideline on type 2 diabetes focusing on the visual summary.

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/M0s2Vvlia70

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

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below.

The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will cover three clinical groups  and the remaining groups will be done in next week’s episode.

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The NICE announcement on Type 2 diabetes management can be found here:

·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced

The NICE draft guideline on Type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450

The visual summary of the NICE draft guideline on type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2

Transcript

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

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the main changes as applied to 7 specific groups of patients.

Right, let’s jump into it.

And, as you know, the draft guideline is open for consultation until October, and the final guidance is due in February 2026, so let’s not forget that it is only a draft, and we should not be making clinical decisions based on it yet.

Today’s episode is based on the visual summary created by NICE and the link to it is in the episode description.

The visual summary includes specific guidance for 7 different group of patients. In today’s episode we will cover three of the groups and we will finish the other groups in next week’s episode.

There are 7 groups:

1.   First, the group of patients with no relevant comorbidities, then

2.   Obesity

3.   Frailty

4.   CKD

5.   Heart failure

6.   Atherosclerotic cardiovascular disease and

7.   Early onset type 2 diabetes

So let’s start with the no relevant comorbidities group.

For adults with type 2 diabetes and no major comorbidities, the draft recommends metformin plus an SGLT-2 inhibitor from the outset. If metformin is contraindicated or not tolerated, then an SGLT-2 inhibitor alone should be offered. If further glycaemic lowering is required, the next step is to add a DPP-4 inhibitor and if this is not effective or tolerated, we can try a sulfonylurea, pioglitazone, or insulin.

This is very different from the previous guidance, which began with metformin monotherapy, and only added other agents if HbA1c targets were not met. SGLT-2 inhibitors and GLP-1 receptor agonists were generally reserved for people with established cardiovascular or renal disease, or later in the treatment pathway. The draft changes our thinking on everything by recommending dual therapy right at diagnosis for all, even in people without comorbidities.

Why is NICE changing the advice?

As we have already explained, evidence shows that SGLT-2 inhibitors consistently reduce heart failure admissions, slow CKD progression, and lower cardiovascular death. Trials have showed these effects in people without established CVD they are now recommended for all, not just for the high-risk subgroups.

What this means in practice is that now:

• The default first-line choice is now metformin + SGLT-2 inhibitor, not metformin alone.
• More people will start dual therapy earlier, meaning that we will need to discuss SGLT-2 inhibitor side effects like the risk of genital infections, volume depletion, sick-day rules, and renal monitoring from the start.
• In those who can’t tolerate metformin, an SGLT-2 inhibitor alone is acceptable. We also need to consider the fact that SGLT2 inhibitors will now be prescribed long term unless there are specific reasons to stop them.
• And, if further glucose control is needed, add-ons agents remain available but they now come after the SGLT-2 inhibitor, not before.

The next group is the obesity group:

For people with type 2 diabetes who also have obesity, the draft recommends also starting with metformin plus an SGLT-2 inhibitor. However, if further treatment is needed to reach glycaemic targets, we will add a GLP-1 receptor agonist if initial therapy started 3 months ago or more. This will usually mean adding subcutaneous semaglutide, provided there are no concerns about frailty and they have preserved ejection fraction (i.e., heart function is acceptable). If metformin is contraindicated or not tolerated, the pathway is to offer an SGLT-2 inhibitor plus semaglutide.

We are again reminded that GLP1 receptor agonists and DPP-4 inhibitors should not be combined. Therefore, if the patient is on a GLP-1 receptor agonist and further glycaemic control is needed, the next add-on therapies are sulfonylurea, pioglitazone, or insulin depending on the case.  However, if a GLP-1 receptor agonist is contraindicated, not tolerated, or not appropriate, we will add a DPP-4 inhibitor first before considering other agents such as a sulfonylurea, pioglitazone, or insulin, as all of these can lead to weight gain.

And let’s remember that previously, people with obesity were more likely to have a stepwise approach: metformin first, then add other agents and then move to GLP-1 RAs only if at last resort and if specific BMI thresholds were crossed.

The draft changes this: it brings semaglutide forward, in obesity and when weight reduction is a priority, also giving more flexibility in continuing GLP-1s if weight or glycaemic goals are lagging—as long as obesity remains a priority.

Why is NICE making this change?

• Primarily because there is strong trial evidence that GLP-1 receptor agonists produce sustained weight loss and
• additionally, evidence has accumulated around reduced major adverse cardiovascular events
• And finally, another justification is that many people with obesity carry a higher lifetime risk of cardiovascular disease so delaying GLP1 receptor agonists may mean a missed opportunity to reduce morbidity and mortality.

What does it mean in practice?

• Well, we will need to identify patients with both diabetes and obesity early, and discuss semaglutide sooner than before.
• Shared decision making must cover not only the benefits (weight loss, better cardiovascular risk, possibly better quality of life) but also the downsides like GI side-effects like nausea, and vomiting, injection route and monitoring requirements.
• We will also need to assess frailty and ejection fraction early and avoid semaglutide if there’s concern frailty might lead to harm (like e.g., unintentional weight loss, reduced reserves) or heart failure with reduced EF, which may be decompensated with GLP1 receptor agonist use.
• And, we will also need to monitor the effect on weight, glycaemia, heart and kidney function, being ready to stop the GLP1 receptor agonist if necessary.

And finally, the last group today, the frailty group.

The draft guidance states that if the person’s level of frailty increases the risk of adverse events from SGLT-2 inhibitors, we will consider metformin alone initially. If metformin is contraindicated or not tolerated, we will consider a DPP-4 inhibitor instead. After metformin, if further glycaemic lowering is needed, we will give a DPP-4 inhibitor (if not already used); and if a DPP-4 inhibitor is contraindicated, not tolerated, or already being taken, we will offer pioglitazone, a sulfonylurea, or insulin, explicitly taking into account hypoglycaemia and falls risk with sulfonylureas and insulin. Alongside this, the draft highlights the need for a medication review, aiming for the smallest effective number of drugs in frailty.

How does this differ from the previous guidance?

Earlier frailty modifiers were less explicit, whereas now, the draft makes frailty a front-door decision point: it deprioritises SGLT-2 inhibitors when volume depletion, hypotension, or acute illness risk is high; it elevates DPP-4 inhibitors as a low-burden alternative; and it puts structured deprescribing on the page. It also flags the hypoglycaemia risk with sulfonylureas and insulin in frail adults, which pushes us to choose agents which are safer in that respect.

NICE is making this change because frailty amplifies medication harms. For example, SGLT-2–related diuresis and BP lowering can precipitate dehydration, orthostatic symptoms, AKI, and falls; GLP-1 RAs can cause GI effects and anorexia that risk weight loss in the frail. By contrast, DPP-4 inhibitors are weight-neutral, have a low hypoglycaemia risk, minimal haemodynamic effects, and simple dosing. The emphasis on medication review reflects evidence that polypharmacy and hypoglycaemia are linked to falls, delirium, and hospitalisation in frail older adults.

What this means in practice is that we will need to:

• Assess frailty up front and let it shape drug choice and dosing.
• If frailty raises safety concerns with SGLT-2 inhibitors, we will start with metformin alone, or use a DPP-4 inhibitor when metformin isn’t suitable.
• We will prioritise low hypoglycaemia risk; being cautious with sulfonylureas and insulin, and use the lowest effective doses with clear sick-day rules.
• We will perform a formal medication review, deprescribing where possible, and aiming for the fewest drugs necessary.
• And we will keep focusing on symptoms, renal function, nutrition, and falls, not just HbA1c.

So that is it, an initial review of the new draft NICE guideline on type 2 diabetes focusing on the visual summary. In the next episode we will cover the remaining groups CKD, heart failure, atherosclerotic cardiovascular disease and early onset type 2 diabetes.

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/xB8BStN4Owg

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

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below.

The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will review the general guidance and we will cover the various groups in future episodes.

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The NICE announcement on Type 2 diabetes management can be found here:

·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced

The NICE draft guideline on Type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450

The visual summary of the NICE draft guideline on type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2

Transcript

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

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the visual summary created by NICE. I will cover the information over several episodes, so stay tuned.

Right, let’s jump into it.

As you may know, the draft NICE guideline on type 2 diabetes is open for public consultation until October, and the final guidance is due in February 2026. It has attracted a lot of attention, but we need to remember that, for now, it is only a draft, which means it could still change. So, we should not be making clinical decisions based on it yet.

Today’s episode is based on the NICE visual summary and the link to it is in the episode description.

The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will review the general guidance and we will cover the various groups in future episodes.

The first page of the draft visual summary sets out the general approach for all.

NICE begins by emphasising that diet and lifestyle are the foundation of management, and these need to be reinforced at every stage of the treatment pathway, pointing out that medicines should come on top of, and not instead of, these lifestyle measures.

When choosing drug therapy, the draft recommends discussing the benefits and risks of every option. That includes looking at each drug’s effectiveness for glycaemic control but also, and this is new compared with the previous guideline, weighing its impact on cardiovascular and renal outcomes.

The guideline also stresses that if a person has more than one comorbidity, for example obesity, cardiovascular disease or chronic kidney disease, we should make a shared decision with the patient about which comorbidity to prioritise in choosing treatment. This means that we move away from a purely HbA1c-driven model towards a model focused on complications and their prevention.

On reviewing medicines, the draft says that before changing therapy, we should first optimise the current regimen, bearing in mind that it may be appropriate to continue some treatment options, like SGLT-2 inhibitors or GLP-1 receptor agonists even if the effect on glycaemic control is not perfect. In fact, the draft advises continuing SGLT-2 inhibitors for their heart and kidney benefits even if they are not achieving glucose or weight targets.

For GLP-1 receptor agonists, the draft changes the stop rules: we will stop if they do not help the person achieve glycaemic or weight goals but only, and this is important, if the person does not have cardiovascular disease or early-onset type 2 diabetes, understood as type 2 diabetes diagnosed under the age of 40. This a huge change.  Previously, stopping criteria were more tightly linked to weight and HbA1c thresholds, for example, if the person had not lost at least 3% of body weight and dropped their HbA1c by 1% within six months. Now, because of the cardiovascular benefit of GLP-1 receptor agonists, it basically means that for people with atherosclerotic cardiovascular disease, it is continued long term, regardless of weight loss or HbA1c change. And a similar, more relaxed attitude also applies to people with early onset type 2 diabetes.

But, why this recommendation?

Well, this comes from trial evidence over the past decade. SGLT-2 inhibitors have consistently reduced hospitalisation for heart failure and slowed CKD progression, even when HbA1c effects were modest. Similarly, GLP-1 receptor agonists have reduced rates of major adverse cardiovascular events. Why these benefits? The pathophysiology is important here: SGLT-2 inhibitors reduce intraglomerular pressure, improve renal haemodynamics, induce diuresis, and reduce preload and afterload on the heart. On the other hand, GLP-1 receptor agonists improve weight, and have an effect on blood pressure and lipids. All these effects are the reason for the beneficial outcomes over and above glucose control

What this means in practice is that:

• The decision to start or continue medicines is now less about HbA1c in isolation, and more about long-term organ protection.
• SGLT-2 inhibitors should be maintained even if glycaemic targets aren’t achieved.
• GLP-1 receptor agonists should be stopped if they don’t achieve targets unless the person has early-onset diabetes or established cardiovascular disease in which case, their longer-term benefits justify continuation.

Finally, NICE advises against combining GLP-1 receptor agonists with DPP-4 inhibitors, as this combination offers no additional benefit.

Why is this? Let’s remember that DPP-4 inhibitors prevent breakdown of endogenous GLP-1, whereas GLP-1 receptor agonists directly activate GLP-1 receptors. Because the GLP-1 agonists already saturate the receptor and they are not affected by DPP-4 degradation, adding a DPP-4 inhibitor offers no additional glycemic or weight benefit. That’s why guidelines recommend using one or the other, but never both.

And before we end, let’s also quickly list the main current recommendations in the draft guideline, making reference to the recommendations that have been either deleted or changed in a major way.

1.   First, the recommendation to start metformin alone as first-line for most people without complications has gone. Now we will start dual Therapy with Metformin + SGLT-2 Inhibitor as Initial Therapy, the reason being the need to maximise the cardiorenal benefits of SGLT2 inhibitors.

2.   Second, the restrictive conditions to start GLP1 receptor agonists have also gone. Now there is Earlier and More Explicit Use of GLP-1 Receptor Agonists, Specifically Semaglutide, in order to maximise the weight and cardiovascular benefits of GLP1 receptor agonists. In particular, semaglutide is the preferred option because it has the most consistent and strong evidence as well as being the most cost-effective.

3.   Third, there is more weight on Stratification by Kidney Function and Frailty. As a result, the draft puts more weight on eGFR thresholds when deciding which medicines to use and it also identifies frailty as a modifier given that frailty increases treatment risks such as dehydration, side effects, hypoglycaemia, etc.

4.   Continuation Criteria and Stop Rules for GLP-1 receptor agonists are now different, meaning that if a person has cardiovascular disease or early onset diabetes, the recommendation is to continue GLP-1 even if glycaemic or weight targets are not fully met.

5.   The advice on how to introduce multiple medicines when initial therapy is combination therapy is also clearer. The draft specifies that medicines should be introduced one at a time. For example, first confirm tolerability of metformin, then of the SGLT-2 inhibitor, then if adding a GLP-1 RA, confirm tolerability of that in turn.

6.   Another change is that the draft is more explicit about reviewing medicines: checking effectiveness, and discontinuing medicines that are not effective unless there is an additional benefit like cardiovascular or renal protection.

7.   Then, insulin guidance has also had a major refresh. The new draft simplifies the advice into a more practical, class-based approach, giving more flexibility as to whether human or analogues insulins are recommended. This is pragmatic response to insulin product withdrawals and shortages. By focusing on broader insulin classes instead of individual types, the guidance is more flexible and easier to apply, even when supply issues arise.

8.   Another significant change is that GLP-1 receptor agonists can now be combined with insulin without the need for specialist approval, making access easier and quicker in primary care.

9.   The ordering and priority of Subsequent Therapy Options has also changed. The draft places DPP-4 inhibitors as the recommended option after Initial treatment. Sulfonylureas, pioglitazone, and insulin remain options but are considered after DPP4 inhibitors.

10. The recommendation against combining a GLP-1 receptor agonist with a DPP-4 inhibitor is repeated and is more strongly worded in the draft. The combinations does not add benefit so it should be avoided and removed if present.

11. The priority of additional therapies is also more dependent on the clinical group that the patient belongs to. This means that the draft makes the escalation pathway group-specific, and more prescriptive, with risks explicitly considered for each clinical category.

And to summarise and close, let’s review again how we think about treatment escalation from a general perspective. The general pathway looks like this:

• We will start most people on metformin plus an SGLT-2 inhibitor right from the beginning.
• For people with atherosclerotic cardiovascular disease, obesity and early onset type 2 diabetes we will consider semaglutide, early in the pathway, not as a late rescue option.
• If HbA1c isn’t controlled with first line treatment and more glucose lowering is needed, the first recommended add-on is a DPP-4 inhibitor, because these are well tolerated, weight neutral, and easy to use, but this only applies as long as the patient is not on a GLP1 receptor agonist.
• If a DPP4 inhibitor not suitable or not effective, then other options like sulfonylureas, pioglitazone, or insulin, can be introduced depending on the person’s needs.
• And finally, frailty will modify how we manage treatment escalation, prioritising safety and symptoms over artificial targets

The main message to remember is that the rationale of the draft guideline is to avoid the old problem of incremental, reactive prescribing, that is, waiting for one drug to fail before adding another, often leaving patients years without treatment that could protect their heart and kidneys.

So that is it, an initial review of the new draft NICE guideline on type 2 diabetes focusing on the visual summary. In the next episode we will cover the recommendations for specific clinical groups.

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/mHyDaVHtb58

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

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

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in August 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. I also give an overview of the draft NICE guideline on type 2 diabetes open for consultation until October 2025 and due for publication in February 2026.

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

Disclaimer:

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

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The Full NICE News bulletin for August 2025 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2025-08-01&to=2025-08-31&ndt=Guidance&ndt=Quality+standard

The updated quality standard Overweight and obesity management [QS212] can be found here:

·      https://www.nice.org.uk/guidance/qs212

The NICE announcement on Type 2 diabetes management can be found here:

·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced

The NICE draft guideline on Type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450

The visual summary of the NICE draft guideline on type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2

Transcript

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

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in August 2025, focusing on what is relevant in Primary Care only.

Today there’s just one updated clinical area to cover, overweight and obesity. But I will also mention that the draft NICE guideline on type 2 diabetes has now been made public, so we will discuss that too.

Right, let’s jump into it.

And I know most of you will be keen to hear about the new diabetes guidance, and understandably so. But before we get to that, I would like to spend the first minute and a half on an area that’s often neglected: overweight and obesity. NICE has just released a new quality standard that replaces three separate guidelines, those on children, adults, and general clinical management, and brings them together into a single standard, reflecting new priorities and evidence.

There are eight quality statements on obesity.

In the first two statements, the focus is on better identification. For adults with long-term conditions, BMI should be recorded at least annually, and if BMI is under 35, waist-to-height ratio should also be measured. This represent a change from previous guidance where BMI alone was the main focus. Also, for children over the age of two, BMI should be recorded opportunistically. putting greater emphasis on early recognition.

Statements three, four, and five are all about improving access to services, including people with learning disabilities. Local authorities and commissioners need to maintain an up-to-date list of services to offer patients, which should reduce barriers and ensure equity of access.

Statements six, seven, and eight deal with clinical management. People prescribed weight management medicines should receive holistic care, covering diet, nutrition, and physical activity. Those who stop medicines or finish behavioural interventions should get long term follow up support, which recognises the importance of relapse prevention. And finally, adults discharged after bariatric surgery should be followed up at least annually within a shared-care model. This is also new because the need for ongoing shared care was not explicit before.

And that is it in respect of overweight and obesity. Now let’s move to the real headline, the draft new NICE guideline on type 2 diabetes. This is the one everyone’s been talking about. The draft is open for public consultation until October, and the final guidance is due in February 2026.

Today I’ll just give you a quick overview. But in a future episode, we’ll look at the proposed changes in slightly more detail, so stay tuned. Just remember, for now it’s only a draft, which means it could still change, and we should not be making clinical decisions based on it yet.

First, the biggest shift: Treatment no longer starts with just metformin. Instead, the new draft guideline recommends combination therapy from day one—metformin plus an SGLT-2 inhibitor for almost all adults with type 2 diabetes. This is a major departure from monotherapy and reflects the fact that type 2 diabetes is not only about sugar control. SGLT-2 inhibitors confer cardiac and renal protection, reducing cardiovascular events and slowing kidney disease progression, benefits that metformin alone can’t offer. NICE has been clear that SGLT2 inhibitors remain underutilised in practice. Why? In many cases, clinicians have stuck with the traditional stepwise model of adding medicines only when HbA1c goes up. Others may be concerned about cost, side effects, or uncertainty over who exactly should benefit. The new guideline cuts through that by saying: everyone with type 2 diabetes will benefit, so we need to make SGLT-2 inhibitors part of the standard starting treatment. The message is that we should be thinking beyond blood glucose from the very beginning, and treating cardiovascular and renal risk right from the start.

Second, we move away from risk-based prescribing. In the past, SGLT-2 inhibitors were reserved only for people with heart failure or at high cardiovascular risk, so their use was much more limited. As we have just said, the new draft guideline takes a completely different approach: now, SGLT-2 inhibitors are recommended for everyone with type 2 diabetes, regardless of their cardiovascular risk profile. The thinking here is simple — we know these drugs consistently reduce hospitalisations for heart failure and slow the progression of kidney disease, and those benefits apply across the board, not just in the highest-risk patients. On top of that, for people who already have established atherosclerotic cardiovascular disease, the guidance goes further by recommending that a GLP-1 receptor agonist, semaglutide, is added as well, creating a triple-therapy regimen right from the start. This combination gives comprehensive coverage: metformin for glucose control, SGLT-2 inhibitors for renal and heart protection, and GLP-1 agonists for both cardiovascular benefit and weight management. It’s simply a move towards using the right drug in the right place earlier, instead of holding them back as late-stage rescue therapies.

Third, let’s talk about GLP-1 receptor agonists a bit more, because this is another big change.

Previously, GLP-1 drugs were considered much later, often for people with obesity or those who hadn’t met glycaemic targets despite multiple therapies, and they were tied to strict BMI criteria. That’s no longer the case.

Now, semaglutide is recommended much earlier:

• It is recommended for people with type 2 diabetes and established atherosclerotic cardiovascular disease, it’s added on top of metformin and an SGLT-2 inhibitor as part of the initial treatment.
• And it is also recommended for people living with obesity or those with early-onset type 2 diabetes who still need extra glycaemic or weight management, so GLP-1 receptor agonists are also considered much sooner in the pathway for them.

And there’s another key change: continuation. In the old guideline, GLP-1 treatment was only continued if the person had lost at least 3% of body weight and dropped their HbA1c by 1% within six months. That rule is gone. Now, if semaglutide is prescribed for cardiovascular protection, it is continued long term, regardless of weight loss or HbA1c change. Only if it’s being used primarily for obesity or metabolic control do continuation decisions depend on whether agreed targets are met. In short, the focus has shifted from short-term numbers to long-term protection.

Fourth, insulin guidance has also had a major refresh.

The old guideline gave long, detailed lists of which insulin types to use in different scenarios. The new draft simplifies this into a more practical, class-based approach. Here’s what’s changed:

• We will start with basal insulin if needed. And what about short-acting and rapid-acting insulins? Well, if HbA1c remains high, then we will add short-acting insulin to basal insulin.

·      However, if someone’s HbA1c is very high, usually 75 mmol/mol or above, then basal plus short-acting insulin can be considered straight away. Rapid-acting insulin analogues are considered if someone’s lifestyle, eating patterns, or risk of hypoglycaemia makes them a better fit than human short-acting insulin. Pre-mixed short-acting analogues are also an option if appropriate. In practice, this means more flexibility while keeping the pathway simple.

• Additionally, the choice of basal insulin, whether human NPH or analogues, should be made through shared decision-making with the patient, taking into account the risk of hypoglycaemia, dosing convenience, and patient preference. If several options are suitable, we will choose the one with the lowest cost.

And this is important because these changes partly reflect a pragmatic response to insulin product withdrawals and shortages. By focusing on broader insulin classes instead of individual types, the guidance is more flexible and easier to apply, even when supply issues arise.

Importantly, GLP-1 receptor agonists can now be combined with insulin without the need for specialist approval, making access easier and quicker in primary care.

And finally, there has also been a change in how we think about escalation overall. Instead of relying on long lists of add-on options, the draft guideline now gives us a much clearer stepwise pathway. The idea is to simplify decision-making and the pathway looks like this:

• We will start most people on metformin plus an SGLT-2 inhibitor right from the beginning.
• If HbA1c isn’t controlled and more glucose lowering is needed, the first recommended add-on is a DPP-4 inhibitor, because these are well tolerated, weight neutral, and easy to use.
• If that’s not suitable or not effective, then other oral options like sulfonylureas or pioglitazone, or insulin, can be introduced depending on the person’s needs.
• For people with atherosclerotic cardiovascular disease, as we said earlier, we will add a GLP-1 receptor agonist, usually semaglutide, early in the pathway, not as a late rescue option.
• And insulin is no longer treated as a last resort — it can be integrated earlier and combined flexibly with GLP-1s when needed.

The rationale here is to avoid the old problem of incremental, reactive prescribing — waiting for one drug to fail before adding another, often leaving patients years without treatment that could protect their heart and kidneys.

So, in short: the new draft guideline is all about earlier combination therapy, universal access to SGLT-2 inhibitors, earlier and more consistent use of GLP-1 receptor agonists, a streamlined approach to insulin, simpler treatment pathways, always with a stronger focus on long-term cardiovascular and renal protection.

In the next episode, I will discuss how the draft guideline is envisaged to be used in specific groups of patients, so make sure not to miss it.

So that is it, a review of the NICE updates relevant to primary care, including an overview of the forthcoming draft guideline on Type 2 diabetes.

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

Thank you for listening and goodbye.