Primary Care Guidelines

The video version of this podcast can be found here:

·      https://youtu.be/LxlmAeHzjsg

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

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on acute asthma, NG244, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on the treatment of acute asthma in children.

In the last three episodes I covered the initial assessment in adults and children and the treatment in adults and in the next episode, I will cover:

·      Lessons from asthma deaths and near-fatal asthma as well as reviewing the concept of difficult asthma

Just like the NICE guideline on the management of chronic asthma, which was updated in November 2024, the NICE guideline on acute asthma is also a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The link to the new NICE guideline on acute asthma can be found here:

·      https://www.nice.org.uk/guidance/ng244/chapter/Managing-acute-asthma

Based on recommendations on managing acute asthma in the BTS/SIGN British guideline on the management of asthma:

·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/managing-acute-asthma/

Disclaimer:

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

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

Transcript

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

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new NICE guideline on acute asthma, or NG244, focusing on what is relevant in Primary Care only. Just like in chronic asthma, the NICE guideline on acute asthma is a joint effort by NICE, BTS and SIGN. A link to it is in the episode description.

In this episode we will just focus on the treatment of acute asthma in children.

In the last three episodes we have covered the initial assessment in adults and children and the treatment in adults and in the next episode, I will cover lessons from asthma deaths. So, stay tuned for that!

Right, let’s jump into it.

When managing acute asthma in children, it helps to follow a structured approach to ensure effective and timely treatment. And let’s start by looking at the various therapeutic interventions, starting with

Oxygen:

For children with life threatening asthma or oxygen saturation below 94%, we should immediately administer high-flow oxygen using a tight-fitting face mask or nasal cannula to maintain saturations between 94 and 98%.

The next step is Inhaled short-acting β2 agonists:

They are the first-line treatment for acute asthma in children. We need to bear in mind that when children require short-acting β2 agonists more frequently than every four hours, we should discontinue any long-acting β2 agonists.

For mild to moderate asthma, a pMDI with a spacer is the preferred delivery method. We will need to adjust the dose based on severity and response, administering one puff every 30 to 60 seconds, up to a maximum of ten puffs.

Children under three will often require a face mask attached to the spacer for effective drug delivery. The inhaler should be actuated into the spacer one puff at a time, with the child inhaling immediately through tidal breathing for five breaths.

Frequent β2 agonist doses are safe in acute asthma, though children with milder symptoms benefit from lower doses. So, For mild attacks, two to four puffs of salbutamol (100 micrograms via pMDI and spacer) may be sufficient, while more severe attacks might require up to 10 puffs. Bronchodilators should provide symptom relief for 3–4 hours. If symptoms return sooner, a further or larger dose—up to 10 puffs—should be administered, and parents or carers should seek urgent medical advice.

Equally, If the child at home does not improve after 10 puffs of salbutamol via pMDI and spacer, parents or carers should also seek urgent medical advice. While waiting for help, additional bronchodilator doses can be given if symptoms are severe.

Healthcare professionals attending to children with acute asthma in these situations should administer nebulised salbutamol, ideally using an oxygen-driven nebuliser, and transfer the child to the emergency department as soon as possible, particularly in cases of acute severe or life-threatening asthma.

In children aged two years and older, we should monitor the response to β2 agonists through repeat clinical observations and oxygen saturation measurements. Children receiving β2 agonists via a pMDI + spacer are less likely to have tachycardia and hypoxia than when the same drug is given via a nebuliser.

For children under two who show a poor initial response to β2 agonists, despite proper administration technique, we need to consider alternative diagnoses and treatment options.

Children with severe or life-threatening asthma (for example when the SpO2 <92%) should receive frequent doses of nebulised bronchodilators driven by oxygen while waiting for hospital admission. This involves administering 2.5–5 mg of salbutamol in the nebuliser. If the initial β2 agonist dose has a poor response, we should combine subsequent doses with nebulised ipratropium. Continuous nebulisation offers no added benefit over frequent intermittent dosing at the same total hourly dosage.

Schools can hold a generic reliever inhaler, which allows them to treat children having an acute asthma attack while waiting for medical assistance. This practice is both safe and potentially life-saving.

Let’s now look at Ipratropium:

When symptoms do not respond adequately to β2 agonists, we should add ipratropium. This involves using 250 micrograms per dose mixed with the nebulised β2 agonist solution, while we arrange referral to the emergency department.

Then we have Steroid therapy:

We need to introduce oral steroids early in the treatment of acute asthma attacks and Oral prednisolone is the preferred steroid unless the child is unable to tolerate it. Early use of steroids reduces hospital admissions and lowers the risk of relapse. Benefits typically become evident within three to four hours.

In the acute situation, it is often difficult to determine whether a preschool child has asthma or episodic viral wheeze. For preschool children with severe symptoms requiring hospitalisation, we should administer oral steroids, even if we are unsure whether the cause is asthma or episodic viral wheeze.

Therefore, in children with moderate to severe wheeze and no prior asthma diagnosis, oral steroids are still recommended.

However, for children with frequent viral-associated wheeze episodes, we should be cautious with multiple courses of oral steroids.

We should use the following prednisolone doses based on age:

• 10 mg for children under two years
• 20 mg for children aged 2–5 years
• 30–40 mg for children older than five years
• For children already on maintenance steroid tablets, we should give 2 mg/kg of prednisolone, up to a maximum of 60 mg.
• If the child vomits, we should repeat the dose or consider intravenous steroids if oral administration is not feasible.

Treatment courses of up to three days are usually sufficient, but we should tailor the duration based on the child's recovery. Tapering is unnecessary unless the course exceeds 14 days.

Oral and intravenous steroids have similar efficacy, so intravenous hydrocortisone should be reserved for children with severe symptoms who cannot tolerate oral medication. Larger steroid doses generally do not provide additional benefit for the majority of children.

Next we have Inhaled corticosteroids:

And There is currently insufficient evidence to support inhaled corticosteroids as an alternative or add-on treatment to oral steroids in acute asthma, so we should not use inhaled corticosteroids in place of oral steroids during an asthma attack.

However, it is good practice for children already on inhaled corticosteroids to continue their regular maintenance dose during the attack while receiving additional treatment.

Children with chronic asthma who are not on regular preventative treatment will benefit from starting inhaled corticosteroids as part of their long-term management plan.

There is no evidence that increasing the dose of inhaled corticosteroids is effective for acute symptoms, but we should ensure children already on them continue their maintenance dose, adjusting the dose to achieve good asthma control of symptoms.

IN respect of Antibiotics:

We should not routinely prescribe them for children with acute asthma.

Most acute asthma attacks are triggered by viral infections, and there is no clear evidence to support the role of antibiotics in this context.

And finally, In primary care, starting a Leukotriene receptor antagonist such as oral montelukast early during a mild asthma attack may reduce symptoms and the need for follow-up healthcare visits.

We also need to bear in mind that many children who have recurrent wheezing episodes triggered by viruses do not go on to develop atopic asthma. The need for regular preventer treatment depends on the severity and frequency of these episodes. Many may not require inhaled corticosteroids.

In terms of admission to hospital, We should admit to hospital children who present with acute severe asthma that does not resolve after initial treatment and those children presenting with Life-threatening asthma, defined by SpO2 below 92%, along with any of the following features:

• Silent chest
• Poor respiratory effort
• Agitation
• Confusion and
• Cyanosis.

However, We should also consider a lower threshold for hospital admission if:

• The attack occurs late in the afternoon or at night
• The child has had a recent hospital admission or a previous severe attack or
• There are concerns about social circumstances or the family’s ability to manage the condition at home.

Before discharging a child from hospital after an asthma attack, they need to be stable on inhaled bronchodilators, peak expiratory flow or FEV1 should be above 75% of their best or predicted value, and oxygen saturation should be greater than 94%.

The discharge plan should cover the following key points:

• Diagnosis.
• Inhaler technique.
• Preventer treatment.
• Personal Asthma Action Plan (PAAP).
• Exposure to smoke: for example Assessing for environmental tobacco smoke or actual smoking in older children,
• Trigger identification:  trying to Identify the cause of the acute attack and discussing strategies to manage future exposures.
• Follow-up: Arranging a follow-up appointment within two working days.
• And finally, Specialist review: approximately one month after admission.

So that is it, a review of the treatment of acute asthma in children.

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/FkZmvfQVby8

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

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on acute asthma, NG244, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on the initial assessment of acute asthma in children.

In the last two episodes I covered the initial assessment and treatment in adults and in the next two episodes, I will cover:

·      Treatment of acute asthma in children

·      And finally, lessons from asthma deaths and near-fatal asthma as well as reviewing the concept of difficult asthma

Just like the NICE guideline on the management of chronic asthma, which was updated in November 2024, the NICE guideline on acute asthma is also a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The link to the new NICE guideline on acute asthma can be found here:

·      https://www.nice.org.uk/guidance/ng244/chapter/Managing-acute-asthma

Based on recommendations on managing acute asthma in the BTS/SIGN British guideline on the management of asthma:

·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/managing-acute-asthma/

Disclaimer:

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

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

Transcript

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

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new NICE guideline on acute asthma, or NG244, focusing on what is relevant in Primary Care only. Just like in chronic asthma, the NICE guideline on acute asthma is a joint effort by NICE, BTS and SIGN. A link to it is in the episode description.

In this episode I will just focus on the initial assessment of acute asthma in children.

In the last two episodes I covered the initial assessment and treatment in adults and in the next two episodes, I will cover the treatment of acute asthma in children and lessons from asthma deaths. So, stay tuned for those!

Right, let’s jump into it.

Acute asthma in children, particularly in those under five, can be challenging to assess.

In this age group, intermittent wheezing attacks are often triggered by viral infections, and the response to asthma medications can be inconsistent.

Children born prematurely or with low birth weight are at higher risk of recurrent wheezing episodes.

We should also consider other potential diagnoses, which may include:

• Aspiration pneumonitis,
• Pneumonia,
• Bronchiolitis,
• Tracheomalacia,
• Or complications from underlying conditions, such as congenital anomalies or cystic fibrosis.

This guideline is intended for children with acute wheeze related to underlying asthma.

It should be used cautiously in children under two years of age who do not yet have a confirmed asthma diagnosis.

It is not intended for children under one year unless directed by a respiratory paediatrician.

Additionally, this guideline should not be used to treat acute bronchiolitis.

Now let’s look at the different measurements and investigations that apply to children.

And let’s start with the assessment of Oxygen Saturation and Pulse Oximetry.

Accurate pulse oximetry using paediatric probes is essential in all children with acute wheezing. Paediatric pulse oximeters can involve the placement of a small probe on the finger, toe, or ear lobe of an older child but, in neonates and infants, probes may also be placed on other parts of the body such as the palms, feet, arms, and cheeks. 

From a general perspective, Intensive inpatient treatment should be considered if SpO2 <92% in room air persists after initial bronchodilator treatment.

Next is PEF Measurements, which can be useful in Children, but they are only reliable in children who are familiar with the device.

Also, When measuring PEF:

• We should Use the best of three measurements,
• And Express it as a percentage of the personal best, when known, or predicted if not known.
• A PEF <50% of predicted with poor improvement after initial bronchodilator therapy suggests the need for more aggressive hospital management.

Next, Chest X-rays are not routinely indicated in children with acute asthma.

However, we will consider a chest X-ray if we suspect:

• Subcutaneous emphysema,
• Persistent unilateral signs, which may indicate pneumothorax,
• Lobar collapse or consolidation,
• Or in cases of life-threatening asthma which is not responding to treatment.

Now let’s move onto the Clinical Assessment. And for this, we will look at the different categories of acute asthma in children.

And we will start with Moderate Acute Asthma, which is when the child:

• Is Able to talk in sentences,
• Has a SpO2 ≥92%,
• A PEF ≥50% of best or predicted,
• A Heart rate of:
• ≤140/min in children aged 1–5 years,
• ≤125/min in children over 5 years,
• And a Respiratory rate of:
• ≤40/min in children aged 1–5 years,
• ≤30/min in children over 5 years.

The next category is Acute Severe Asthma, which is when the child:

• Is Too breathless to talk or feed,
• Has a SpO2 <92%,
• A PEF between 33 and 50% of best or predicted,
• A Heart rate of:
• >140/min in children aged 1–5 years,
• >125/min in children over 5 years,
• And a Respiratory rate of:
• > 40/min in children aged 1–5 years,
• > 30/min in children over 5 years.

Then we have Life-Threatening Asthma, which is when any one of the following is found in a patient with severe asthma:

• Exhaustion,
• A SpO2 of <92%,
• Hypotension,
• A PEF of  <33% of best or predicted,
• Cyanosis,
• Silent chest,
• Poor respiratory effort, or
• Confusion.

During the assessment, we should document the following:

• Pulse rate, bearing in mind that:
• Tachycardia generally indicates worsening asthma, whereas
• A fall in heart rate in life-threatening asthma is a preterminal event.
• Respiratory rate and degree of breathlessness:
• For example, if the child is too breathless to complete sentences or to feed.
• The Use of accessory muscles:
• Which is Best noted by palpating the neck muscles.
• The Wheezing intensity which may become biphasic or diminish with increased airway obstruction.
• And agitation and conscious leve,l always giving calm reassurance throughout the assessment.

However Clinical signs can correlate poorly with the severity of airways obstruction and some children with acute severe asthma may not appear distressed.

Therefore, in order not to miss these patients, Decisions about admission to hospital should be made after repeated assessment of the response to bronchodilator treatment.

In other words, Frequent reassessment is essential, as clinical signs may not always correlate with the severity of airway obstruction.

So that is it, a review of the initial assessment of acute asthma in children.

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/ua-LV78WIo8

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 March  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 March 2025 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2025-03-01&to=2025-03-26&ndt=Guidance&ndt=Quality+standard

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

The NICE technology appraisal on 12 SQ-HDM SLIT for treating allergic rhinitis and allergic asthma caused by house dust mites [TA1045] can be found here:

·      https://www.nice.org.uk/guidance/ta1045

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 be looking at the NICE updates published in February 2025, focusing specifically on what’s relevant to Primary Care.

We’ve got a short and snappy episode today, as there’s only one clinical area to discuss: the use of house dust mite sublingual immunotherapy for allergic rhinitis. It’s an interesting subject, so let’s dive straight in.

The marketing authorisation for house dust mite sublingual immunotherapy, marketed as Acarizax (12 SQ HDM SLIT), covers both allergic rhinitis and allergic asthma.

But before we move on to the NICE recommendations. What is Acarizax?

Acarizax (12 SQ HDM SLIT) is a sublingual immunotherapy (SLIT) treatment designed to help manage allergic rhinitis caused by house dust mites. It contains extracts from house dust mites and works by gradually desensitising the immune system to these allergens, helping to reduce allergy symptoms over time.

Acarizax is taken as a sublingual tablet that is placed under the tongue once a day. The tablet should be kept under the tongue until it dissolves completely.

By continuously exposing the immune system to small doses of the allergen, Acarizax aims to reduce the severity of allergic reactions to house dust mites over time, offering symptom relief and reducing the need for other allergy medications.

Treatment usually starts a few months before the allergy season to build up tolerance and itt is recommended for long-term use, generally for at least 3 years, to achieve and maintain effectiveness.

Having said all this, NICE only recommends it as an option for treating moderate to severe allergic rhinitis in people aged 12 to 65 years who:

• Have been diagnosed through clinical history and have a positive test for house dust mite sensitisation (either a skin prick test or specific immunoglobulin E), and
• Continue to experience persistent symptoms despite standard treatment.

NICE has not recommended it for allergic asthma.

Now, let’s quickly explore why NICE made these recommendations.

First-line treatment for allergic rhinitis includes oral or intranasal antihistamines. For moderate to severe persistent symptoms, or if initial treatments are ineffective, intranasal corticosteroids are recommended. Combinations of oral antihistamines and intranasal corticosteroids can be used if symptoms persist, and further add-on treatments—such as intranasal anticholinergics, intranasal decongestants, and leukotriene receptor antagonists can be considered depending on the symptoms.

Asthma treatment follows the NICE guidelines as well. The current BTS and SIGN guidelines do not specify when allergy immunotherapy should be used for allergic asthma. It was argued that patients whose asthma is ‘not well controlled by inhaled corticosteroids’ could be eligible for this treatment, and it might be used before biological treatments are recommended in secondary care, but it is not expected to replace them.

NICE reviewed the evidence provided by the company, which suggested potential symptom reduction with this new treatment for both asthma and rhinitis. However, the clinical benefit in practice might be limited, as the sizes of the trials were small and the design did not fully reflect NHS conditions. Therefore we should consider the uncertainty around the long-term effectiveness of this treatment, especially given the need for continuous treatment alongside standard therapies.

The evidence also shows potential quality of life improvements for patients with allergic rhinitis and allergic asthma, although the modelling assumptions introduce uncertainty. Young people aged 12 to 17 years may benefit more, which could reduce their need for symptomatic medications. However, there’s still uncertainty regarding seasonal variations, adolescent effectiveness, and asthma control.

When it comes to long-term use, it offers a plausible benefit for patients with allergic rhinitis and allergic asthma, potentially reducing symptoms and the need for secondary care. However, the cost-effectiveness estimates are uncertain, mainly due to limited long-term trial data and the ongoing need for follow-up care.

In conclusion, because standard treatments sometimes fail to control symptoms of allergic rhinitis, NICE recommends considering acarizax as an option after all appropriate symptom-relieving medications have been tried, and symptoms persist.

However, NICE did not recommend sublingual immunotherapy for house dust mite allergic asthma because it’s not considered cost-effective for this group. That said, the same patients who are eligible for treatment of allergic rhinitis may also have allergic asthma, and having asthma would not prevent them from receiving treatment for their rhinitis.

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/rmkFvK2O0KM

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

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on acute asthma, NG244, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on treatment of acute asthma in adults.

In the last episode I covered the initial assessment in adults and in the next episodes, I will cover:

·      Initial assessment of acute asthma in children

·      Treatment of acute asthma in children

·      And finally, lessons from asthma deaths and near-fatal asthma as well as reviewing the concept of difficult asthma

Just like the NICE guideline on the management of chronic asthma, which was updated in November 2024, the NICE guideline on acute asthma is also a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The link to the new NICE guideline on acute asthma can be found here:

·      https://www.nice.org.uk/guidance/ng244/chapter/Managing-acute-asthma

Based on recommendations on managing acute asthma in the BTS/SIGN British guideline on the management of asthma:

·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/managing-acute-asthma/

Disclaimer:

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

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

Transcript

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

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new NICE guideline on acute asthma, NG244, focusing on what is relevant in Primary Care only. Just like the NICE guideline on the management of chronic asthma, the NICE guideline on acute asthma is also a collaboration between NICE, SIGN and the British Thoracic Society (BTS). It replaces previous guidance, and you can find a link to it in the episode description.

In this episode I will just focus on treatment of acute asthma in adults.

In the last episode we covered the initial assessment in adults and in the next three episodes, I will cover the assessment of children, treatment in children and lessons from asthma deaths. So, stay tuned for those!

Right, let’s jump into it.

When managing acute asthma in adults, our primary goal is to prevent poor outcomes> Many asthma-related deaths are due to clinical staff failing to assess severity with objective measurements, patients or their families underestimating the seriousness of the attack, and the underuse of corticosteroids.

The treatment of acute asthma depends on the severity of the attack, which can range from moderate to life-threatening. For a refresher on how to clinically differentiate between the various severity categories, you can refer to the previous episode on this channel.

But before looking at the specific treatment recommendations for each category, let’s look at some general treatment principles.

Many patients with acute severe asthma are hypoxaemic. We should give oxygen to those who are hypoxaemic. The flow rate needs to be adjusted as necessary to maintain Oxygen saturation between 94 and 98%, while being cautious to avoid overoxygenation, especially if there are concerns about hypercapnia

If pulse oximetry is unavailable, oxygen therapy should still be initiated without delay, and Oxygen saturation monitoring started as soon as possible. We should also monitor and record the patient’s heart rate regularly.

In most acute situations, high-dose inhaled β2 agonists act rapidly to relieve bronchospasm with minimal side effects so high-dose inhaled β2 agonists should be our first-line agents and given as early as possible, ideally nebulised with oxygen rather than air to prevent desaturation,  particularly in cases of acute-severe or life-threatening asthma.

When using oxygen cylinders, it’s important to fit a high-flow regulator and maintain a flow rate of at least 6 L/min to drive the nebuliser effectively. However, if oxygen is unavailable, this shouldn’t prevent us from administering nebulised therapy when clinically indicated.

PEF should also be recorded before and after administering β2 agonists.

For patients with severe asthma who respond poorly to initial β2 agonist therapy, we should repeat β2 agonist doses at 15–30-minute intervals or use continuous nebulisation of salbutamol at 5–10 mg/hour while arranging hospital admission. However, higher bolus doses, such as 10 mg of salbutamol, are unlikely to offer any additional benefit.

Also, all patients experiencing an acute asthma attack should receive adequate doses of oral steroids. Steroids significantly reduce mortality, relapse rates, hospital readmissions, and the need for further β2 agonist therapy. The earlier they are administered, the better the outcome.

Oral steroid tablets are as effective as injected steroids, as long as they can be swallowed and retained. Therefore, we would normally start and continue prednisolone (40–50 mg daily) until recovery, and for a minimum of five days.

While giving systemic corticosteroids, we will not discontinue inhaled corticosteroids.

After recovery, oral steroids can be stopped abruptly without tapering, provided the patient is on inhaled corticosteroids, except in cases of prolonged steroid use for three weeks or more or if maintenance oral steroid therapy is planned.

Nebulised Ipratropium Bromide at a dose 0.5 mg every 4–6 hours can be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who respond poorly to initial β2 agonist therapy.

This is because combining nebulised ipratropium with β2 agonists provides greater bronchodilation, leading to faster recovery and shorter hospital stays.

However, in milder asthma attacks or after stabilisation, anticholinergic treatment is not necessary and offers limited benefit.

Intravenous Aminophylline should only be considered in secondary care because It carries a higher risk of side effects, including arrhythmias and vomiting.

Current evidence does not support the use of oral leukotriene receptor antagonists in acute asthma.

And equally, routine antibiotics are not recommended for acute asthma because most asthma exacerbations triggered by infection are viral rather than bacterial and we should therefore only consider antibiotics when there is clear evidence of bacterial infection, guided by objective clinical measures.

Right, let’s now look at the specific treatment recommendations for each category of severity of the asthma attack.

And let’s start with moderate asthma. Here:

• We can Treat the patient either at home or in the practice and monitor their response.

·      For less severe asthma exacerbations, we can start by administering a β2 bronchodilator using a spacer, delivering one puff at a time with tidal breathing. According to their response, we can give another puff every 60 seconds, up to a maximum of 10 puffs.

·      If the patient doesn’t improve of if the exacerbation is more concerning, we will escalate to a nebuliser—preferably oxygen-driven—with salbutamol at a dose of 5 mg.

• We will also give oral prednisolone 40–50 mg and then either
• Continue or increase the patient’s usual asthma treatment.

If the patient responds well to the first round of treatment – meaning their symptoms improve, respiratory and pulse rate settle, and PEF rises above 50% – they can continue or increase their usual therapy along with daily prednisolone until recovery.

However, we will admit the patient to hospital if:

• They show any life-threatening features.
• They develop Symptoms of acute severe asthma despite initial treatment or if
• They have a previous history of near-fatal asthma.

We should also consider a lower threshold for admission if:

• The attack occurs in the afternoon or evening.
• There are recent nocturnal symptoms or previous hospital admissions.
• The patient has experienced severe asthma attacks in the past.
• They are unable to assess their own condition or
• There are concerns about their social circumstances.

Next is acute severe asthma. For them:

• We will consider hospital admission.
• We will start by administering oxygen to maintain Oxygen saturation between 94–98% and
• We will use a β2 bronchodilator:
• Via an oxygen-driven nebuliser with salbutamol 5 mg or
• If a nebuliser is unavailable, we can use a spacer.
• And we will give prednisolone 40–50 mg or, if available, IV hydrocortisone 100 mg.
• If the patient does not respond to this treatment: we will admit them urgently.

When referring a patient to hospital:

• We will stay with them until the ambulance arrives.
• Provide a written assessment and referral details and
• Continue administering the β2 bronchodilator via an oxygen-driven nebuliser during transport.

For life-threatening asthma:

• We will obviously arrange immediate admission and in the meantime we will
• Give oxygen to maintain Oxygen saturation between 94–98%.
• Administer nebulised therapy:
• Via an oxygen-driven nebuliser with salbutamol 5 mg and ipratropium 0.5 mg.
• If neither the nebuliser nor ipratropium is available, we will use a β2 bronchodilator via spacer.
• And we will give prednisolone 40–50 mg or IV hydrocortisone 100 mg immediately.

As follow up after an acute asthma attack, we will:

• Continue prednisolone until full recovery, for a minimum of 5 days.
• Arrange a GP review within 2 working days.
• Monitor symptoms and PEF regularly.
• Check the patient’s inhaler technique.
• Provide a written asthma action plan, remembering that they have been shown to reduce morbidity and relapse rates.
• We will modify treatment according to guidelines for chronic asthma.
• And finally address any potentially preventable factors and triggers that may have contributed to the asthma attack.

So that is it, a review of the treatment of acute asthma in adults.

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/-fWEa4h6q64

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

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on acute asthma, NG244, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on initial assessment in adults.

In the next four episodes, I will cover:

·      Treatment of acute asthma in adults

·      Initial assessment of acute asthma in children

·      Treatment of acute asthma in children

·      And finally, lessons from asthma deaths and near-fatal asthma as well as reviewing the concept of difficult asthma

Just like the NICE guideline on the management of chronic asthma, which was updated in November 2024, the NICE guideline on acute asthma is also a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

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

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

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

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The link to the new NICE guideline on acute asthma can be found here:

·      https://www.nice.org.uk/guidance/ng244/chapter/Managing-acute-asthma

Based on recommendations on managing acute asthma in the BTS/SIGN British guideline on the management of asthma:

·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/managing-acute-asthma/

Disclaimer:

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

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

Transcript

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

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new NICE guideline on acute asthma, NG244, focusing on what is relevant in Primary Care only. Just like the NICE guideline on the management of chronic asthma, the NICE guideline on acute asthma is also a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

Given how extensive the guidance is, in this episode I will just focus on initial assessment in adults.

In the next four episodes, I will cover the assessment of children, treatment in adults and children and lessons from asthma deaths and the concept of difficult asthma. So, stay tuned for those!

Right, let’s jump into it.

When conducting the initial assessment of a patient with acute asthma, it helps to follow a systematic approach because using a structured recording process helps ensure consistency in order to determine:

• Whether the patient is indeed having an acute attack,
• The severity of the episode,
• And the appropriate treatment required.

So let’s have a look at the different aspects of this Clinical Assessment and let’s start with clinical features.

Examination findings that can indicate severe asthma, are:

• Severe breathlessness, including being too short of breath to complete full sentences,
• Tachypnoea, with a high respiratory rate,
• Tachycardia,
• A silent chest, indicating minimal air entry,
• Cyanosis,
• The use of accessory muscles when breathing,
• Or signs of altered consciousness or collapse.

However, we should note that while these signs are concerning, their absence does not exclude a severe attack.

We should also note that, although pulsus paradoxus is sometimes observed in severe asthma, it is not a reliable indicator of severity and should not be used in clinical decision-making. Pulsus paradoxus is an exaggerated drop in systolic blood pressure during inspiration and, in asthma, it occurs due to increased intrathoracic pressure, but, as we have said, its absence does not rule out a severe attack.

Let’s now look at some measurements, starting with PEF and FEV1 Measurements.

Both are valid indicators to assess the degree of airway obstruction, but PEF is more practical in acute settings.

For clinical accuracy:

• We should express PEF as a percentage of the patient’s previous best value, when known, but
• If the best value is unavailable, we will use the predicted peak flow value as a rough guide.
• Keeping in mind that different peak-flow meters may give slightly different readings, so ideally, we should use the same or a similar device for consistency.

Let’s now look at assessing oxygen levels using Pulse Oximetry

The target of oxygen therapy is to maintain SpO2 between 94 and 98%.

If SpO2 drops below 92%, regardless of whether the patient is on air or oxygen, an arterial blood gas (ABG) measurement will be needed to evaluate for hypoxia and hypercapnia, which can indicate impending respiratory failure. So, in summary,  if the oxygen saturation is below 92%, the patient should be referred to the emergency department.

Looking at other investigations, a chest X-ray is not routinely required for asthma attacks.

However, it may be necessary in cases where we suspect:

• Pneumothorax or consolidation, or in situations when there is
• Life-threatening asthma,
• Failure to respond to treatment,
• Or a need for assisted ventilation.

Now, when assessing a patient with suspected acute asthma, we need to recognize the signs and determine the severity of the attack.

We classify acute asthma into different levels of severity, ranging from mild to life-threatening, based on symptoms and objective measures like peak flow readings. As we said earlier, if we don’t have the patient’s recent best peak flow reading, that is, within the past two years, then we will use the predicted peak flow value as a reference.

Let’s now look at the levels of Severity of Acute Asthma Attacks in Adults

And we will start with moderate acute asthma.

Patients in this category experience increasing symptoms, but their PEF remains between 50 and 75% of their best or predicted value. Importantly, there are no signs of severe asthma.

The next category is acute severe asthma and patients meet the criteria for this category if they exhibit any one of the following signs:

• A PEF between 33 and 50% of their best or predicted value,
• A respiratory rate of 25 breaths per minute or higher,
• A heart rate of 110 beats per minute or more,
• Or an inability to complete full sentences in one breath.

After this we come to the category of life-threatening asthma, which is basically patients who already have severe asthma, who also presents any one of the following features:

• An altered conscious level,
• PEF below 30% of best or predicted,
• Signs of exhaustion,
• Oxygen saturation (SpO2) dropping below 92%,
• The development of an arrhythmia,
• Hypotension,
• Cyanosis,
• A silent chest, indicating minimal air entry,
• Or poor respiratory effort, which can suggest impending respiratory failure.

And finally, the last category is near-fatal asthma, which is the most critical stage.

It’s characterized by raised arterial CO2 levels, indicating respiratory failure, and often requires mechanical ventilation. Given that we do not have direct access to blood gases in Primary care, this category will only be accurately diagnosed in secondary care.

Let’s now look at the Criteria for hospital admission.

And, obviously, any patient showing any feature of a life-threatening or near-fatal asthma attack should be admitted urgently.

However, other factors may also warrant admission to hospital, including patients with severe asthma that does not fully resolve after initial treatment.

Additionally, even if symptoms improve and peak flow increases to over 75% of best or predicted one hour after treatment, hospital admission may still be appropriate if there are ongoing concerns. So, we should also consider admission if there are:

• Persistent symptoms,
• Concerns about medication adherence,
• Psychological issues,
• Other co-morbidities that could complicate the management
• If there is a Physical or learning disability,
• A previous history of near-fatal asthma,
• An attack despite taking an adequate dose of oral corticosteroids prior to arrival,
• A presentation at night, when follow-up may be limited,
• If the patient lives alone or is socially isolated,
• Or if the patient is pregnant.

And just before we finish, let’s just say that, in terms of prevention, the identification of these patients, who are at higher risk of asthma-related death is very important.

Therefore, in primary care we should maintain a register of these patients, ensuring that if they miss a follow-up appointment, they are proactively contacted. This helps prevent deterioration and reduces the risk of fatal outcomes.

And equally, patients with asthma, especially those with severe asthma, should have a written Personal Asthma Action Plan which outlines how to manage their condition day-to-day, when to adjust medication, and when to seek medical help.

Studies have shown that Personal Asthma Action Plans can significantly reduce both hospital admissions and asthma-related deaths.

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

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

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/kk5ADBP1J9M

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through guidance on inflammatory markers, ESR and CRP. For this I have reviewed a number of guidelines and publications, particularly South Tees Hospitals NHS Trust, York and Scarborough Hospitals NHS Trust and Bristol, North Somerset and South Gloucestershire ICB. A full list of the sources consulted can be found below.

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

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 sources consulted can be found here:

·      BJGP article: https://bjgp.org/content/69/684/e462

·      BNSSG guideline: https://remedy.bnssg.icb.nhs.uk/adults/investigations/inflammatory-marker-testing/?utm

·      Clinical audit: https://gps.northcentrallondon.icb.nhs.uk/cdn/serve/service-downloads/1551452026-75436315473b66e9567181d4bb9736a3.pdf?dl=1&utm

·      South Tees Hospitals: https://www.southtees.nhs.uk/services/pathology/tests/c-reactive-protein-crp/?utm and https://www.southtees.nhs.uk/services/pathology/tests/esr/

·      York and Scarborough Hospitals: https://www.yorkhospitals.nhs.uk/seecmsfile/?id=4123

·      Medcentral: https://www.medcentral.com/pain/chronic/erythrocyte-sedimentation-rate-c-reactive-protein-old-useful-biomarkers-pain-treatment?utm

Transcript

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

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the guidance on inflammatory markers, ESR and CRP, focusing on what is relevant in Primary Care only.

For this I have reviewed a number of NHS guidelines and medical publications. A full list of the sources consulted can be found in the episode description.

Right, without further ado, let’s jump into it.

The most commonly used inflammatory markers are Erythrocyte Sedimentation Rate (or ESR) and C-Reactive Protein (or CRP).

ESR and CRP are not only frequently ordered in Primary Care but the rate of testing also appears to be increasing. It is estimated that for every 1000 inflammatory marker tests done there are 236 false positives, which leads to 710 GP appointments, 229 blood test appointments and 24 referrals in the following six months. Furthermore, there are concerns about excessive testing because clinicians often check multiple inflammatory markers simultaneously.

So, this is the reason why it is generally advised to avoid using these tests for screening or as a rule-out for patients with non-specific symptoms.

But let's start with the basics.

Inflammation is a fundamental response to injury, infection, or disease. It involves a complex cascade of immune mediators, which leads to the production of acute-phase reactants, that is, proteins that increase in response to inflammation. This is where ESR and CRP come into play.

Let’s have a look at them individually and in a little bit more detail.

And let’s start with CRP.

What makes CRP clinically useful?

• firstly, CRP is used to assess the progression of inflammation and infection.
• Unlike ESR, CRP test measures the level of just one specific protein.

·      CRP is primarily produced in response to inflammation and can be elevated due to for example, infection, tissue damage, autoimmune diseases, postoperative situations and cancer.

• CRP is produced in the liver by hepatocytes and is triggered by Interleukin-6. However, CRP can also be generated by adipocytes and obesity can sometimes cause low-level elevations in CRP (generally <20 mg/L)in obese people.
• In liver failure, CRP levels may be unexpectedly low.
• CRP rises rapidly following an insult (like infection or inflammation) within 6 hours, peaks at around 48 hours and responds rapidly to treatment, because it has a short half-life of about 18 hours, meaning it falls quickly once inflammation resolves, making CRP a useful marker for both diagnosis and monitoring.

·      Increases in CRP values are non-specific for many disease processes and should not be interpreted without a complete clinical evaluation.

• We should interpret CRP with caution and, for example, it is possible that CRP may be normal in myeloma and in patients with some connective tissue diseases.
• However, because it is a direct marker of inflammation, CRP is generally more sensitive than ESR, particularly in the early stages of the acute phase response.

The fact that CRP rises and falls quickly in response to changes in inflammation makes CRP particularly useful in monitoring acute conditions, such as:

·      Bacterial infections – especially sepsis and pneumonia

·      Postoperative inflammation – distinguishing infection from normal healing and

·      Chronic inflammatory diseases – such as rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) for example.

Now, let's talk about Erythrocyte Sedimentation Rate (or ESR).

Unlike CRP, ESR does not measure a specific protein. Instead, ESR reflects the rate at which red blood cells settle in plasma over one hour and it is measured in millimetres per hour (mm/hr), determined by the amount of clear liquid at the top of the test tube after one hour. During inflammatory states, fibrinogen and other plasma proteins increase which cause red cells to stick together, making them fall more quickly.

So, what are the key characteristics of ESR?

• It is an indirect measure of inflammation.
• ESR rises more slowly than CRP and can take up to 7 days to peak, making it less useful for acute diagnosis and treatment monitoring. Importantly, ESR may be normal, especially in the early stages, in conditions like cancer, connective tissue disease, and infection, so a normal ESR cannot exclude these diagnoses.
• ESR is best for measuring immunoglobulin load which is useful in connective tissue diseases, myeloma, and some haematological malignancies.
• ESR is influenced by multiple factors, including age, sex, anaemia, and hyperlipidaemia, meaning that ESR levels are higher in females and with increasing age.

·      And finally, samples taken during difficult venepuncture may give erroneous results which may not be accurate on short, clotted or haemolysed samples.

So, if ESR is less specific than CRP, why should we ever want to use ESR instead of CRP?

Well, ESR is best used in chronic inflammatory conditions. Examples are:

·      Polymyalgia Rheumatica (or PMR)

·      Temporal Arteritis (or Giant Cell Arteritis, GCA) and

·      Multiple Myeloma and other haematological malignancies

So, let’s recap because this is the interesting part. We know that both ESR and CRP indicate inflammation, but when should we use one over the other?

Well, from a general point of view CRP should be the first line test in most cases. On this basis, we should use CRP when:

• we need rapid information on acute infections or inflammatory conditions.
• We want a result with distinct normal and abnormal reference ranges, without variations for age or gender
• we want to monitor treatment response, since CRP normalises quickly or
• we suspect acute problems like bacterial infections, post-operative infections, or autoimmune flare-ups.

However, we should use ESR when:

• we are dealing with chronic inflammatory conditions, such as PMR or GCA.
• we need a marker of long-term inflammatory burden. Or when
• we are investigating haematological malignancies like myeloma.

Next, let's discuss some common pitfalls and limitations of these tests.

Firstly, in respect of requesting ESR & CRP Together we should point out that

• In most cases, requesting both ESR and CRP together is unnecessary.
• CRP should be the first choice for most inflammatory conditions so this means that CRP alone is enough in the majority of cases.
• However, exceptions could be PMR, GCA, and haematological malignancies, where having both tests may be useful.

Secondly, we should avoid Over-reliance on Inflammatory Markers result. This is because:

• A raised ESR or CRP does not automatically mean infection or autoimmune disease.
• Because many non-pathological factors can increase ESR, including pregnancy, ageing, and obesity. And because
• We should always correlate results with the patient’s history and clinical signs.

And thirdly, we have the pitfall of False Positives & Incidental Findings

• And let’s remember that for every 1,000 inflammatory marker tests done, 236 are estimated to be false positives and that
• This can lead to unnecessary GP consultations, additional tests, and patient anxiety.

Before we conclude, let’s look at the interpretation of results.

So, how should we Interpret ESR and CRP?

Well, when we receive an inflammatory marker result, we should always ask ourselves:

·      Is the elevation significant?

·      Does it correlate with the patient’s symptoms? And

·      Does it change the management plan?

Whilst you could think that this is obviously the trickiest part, in fact, interpretation should be relatively straightforward as long as there is a clear indication against which the test result can be evaluated.

The difficulty lies in the interpretation of an ‘incidental’ abnormality, when no specific disease is suspected. In these cases, we should carry out a systems review, focusing on infection, autoimmune conditions, and malignancy, plus examination of the patient. If a cause is suspected, then we should carry out further specific investigations.

However, if no obvious source can be found the test should be repeated. How soon this should happen will depend on our clinical judgement. Whilst some NHS guidelines indicate that some patients over the age of 50 or 60 with persistently raised inflammatory markers have an increased cancer risk, the presence of a raised inflammatory marker alone is not enough to warrant a cancer pathway referral. This is because ESR and CRP have a low sensitivity rate which is less than 50%.

And that is it, a review of inflammatory markers in 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 episode can be found here:

·      https://youtu.be/YS9hgtsxPi0

The original video on the NICE guideline on AF on this channel that this episode is based on can be found here:

·      https://youtu.be/AGdfwwzcKJs?si=G_TamzKCiQ-LW8WO

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 use AI voices to discuss the NICE guideline on atrial fibrillation, using AI generated clinical cases to illustrate the guidance.

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.

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

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

The video version of this podcast can be found here:

·      https://youtu.be/yHcuYMRLF_4

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 February 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 February 2025 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2025-02-01&to=2025-02-28&ndt=Guidance&ndt=Quality+standard

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

The NICE guidance on early and locally advanced breast cancer: diagnosis and management [NG101] can be found here:

·      https://www.nice.org.uk/guidance/ng101

The NICE guidance on advanced breast cancer: diagnosis and treatment [CG81] can be found here:

·      https://www.nice.org.uk/guidance/cg81

The NICE quality standards Ovarian cancer [QS18] can be found here:

·      https://www.nice.org.uk/guidance/qs18

The NICE guidance on tobacco: preventing uptake, promoting quitting and treating dependence [NG209] can be found here:

·      https://www.nice.org.uk/guidance/ng209

Transcript

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

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in February 2025, focusing on what is relevant in Primary Care only.

In today’s episode, we’ll be covering updates in smoking cessation, breast cancer, and ovarian cancer.

Right, let’s jump into it.

Let’s start with smoking cessation and management for everyone aged 12 and over. The latest evidence review includes new guidance on cytisinicline.

But before moving forward:

What is Cytisinicline?

Cytisinicline (also called cytisine) is a plant-derived substance used as a smoking cessation aid. It is similar in structure to nicotine and acts as a partial agonist of nicotinic receptors. Cytisinicline  or Cytisine has been used in Eastern Europe for decades and now it has gained interest here too.

It has a dual Mechanism of Action, one by reducing nicotine withdrawal symptoms by mildly stimulating the nicotinic receptors and the other by competing with nicotine for the receptors, reducing the pleasurable effects of smoking and decreasing craving.

Compared to varenicline or Champix, Cytisinicline has a shorter half-life (~4.8 hours), meaning it needs more frequent dosing, initially every 2 hours but gradually reducing in frequency until stopped.

Most side effects are mild to moderate and tend to occur early in treatment. These include:

• Gastrointestinal like Nausea, vomiting, dry mouth, and dyspepsia and
• Neurological like Headache, , sleep disturbances, fatigue and irritability

Cytisinicline should not be used:

• During Pregnancy and breastfeeding (as safety is not well established)
• For people aged 66 and over
• In Severe cardiovascular disease, with a caution in patients with arrhythmias, unstable angina, or uncontrolled hypertension) primarily because of a rare but potential side effect of Mild increases in blood pressure and heart rate and
• In Severe psychiatric conditions (such as untreated major depression or schizophrenia, though evidence is still emerging)

We should avoid concurrent use of nicotine replacement therapy products, as cytisinicline already occupies nicotinic receptors and combining with nicotine may increase side effects. Equally, combination with other Smoking Cessation Drugs like Varenicline and Bupropion is not recommended due to overlapping mechanisms.

So NICE has reviewed the evidence for cytisinicline, leading to new and updated stop-smoking interventions. Let’s have a look at them.

A variety of interventions are available, including behavioural support, medicinally licensed products, and nicotine-containing e-cigarettes.

Behavioural support may include individual or group support, as well as very brief advice.

Medicinally licensed products include cytisinicline, varenicline, and bupropion, as well as short- and long-acting nicotine replacement therapy,.

Another option is the use of nicotine-containing e-cigarettes and finally

We have the Allen Carr’s Easyway seminar, which involves elements of CBT and relaxation exercises.

Cytisinicline, varenicline, and bupropion should not be offered to people under 18, during pregnancy, or while breastfeeding. For young people aged 12 and over who are smoking and dependent on tobacco, nicotine replacement therapy should be considered alongside behavioural support.

When combined with behavioural support, all these interventions are more likely to be effective.

However, Interventions less likely to be effective, even when combined with behavioural support, include bupropion, short-acting nicotine replacement therapy used alone, and long-acting nicotine replacement therapy also when used alone.

We will give, cytisinicline, varenicline,  bupropion and NRT or before they stop smoking.

In terms of timing of prescribing, bupropion should be started with a quit date set within the first two weeks of treatment. For cytisinicline, the quit date should be within the first five days of treatment. Nicotine replacement therapy should start the day before the quit date, and varenicline should begin with a quit date set within the first one to two weeks of treatment.

To support smoking cessation in primary care, we will offer to measure patients’ exhaled carbon monoxide levels at each contact. These measurements can serve as motivation to quit smoking and provide feedback on progress.

Some medicines are affected by smoking (or stopping smoking) in terms of their metabolism, efficacy and adverse effects, including medications such as clozapine, olanzapine, theophylline, and warfarin. Therefore, we should monitor these drugs when smoking habits change, adjusting the dosage as needed.

We will advise people that stopping smoking in one go is the best approach. However, for patients who are not ready to quit smoking in one step, we will discuss harm reduction strategies. Cutting down or temporarily abstaining from smoking with or without the use of nicotine replacement therapy can be beneficial. We will reassure patients that medicinally licensed nicotine-containing products are a safe and effective way to reduce tobacco consumption, increasing the likelihood of quitting in the long term and also helping to prevent compensatory smoking. Examples of compensatory smoking is inhaling more deeply or smoking more of each cigarette to compensate for smoking fewer cigarettes.

And let’s also quickly cover the issue of smokeless tobacco, which is any product containing tobacco that is placed in the mouth or nose but not burned. It is typically used in England by people of South Asian family origin.

For people using smokeless tobacco, we will ensure they are aware of the associated health risks, including cardiovascular disease, oropharyngeal cancers, and periodontal disease. A brief intervention should be used to advise them to stop.

In terms of Preventing relapse We will discuss coping strategies and practical ways to avoid returning to smoking at each contact. If needed, we will offer a further course of varenicline, nicotine replacement therapy, or bupropion to prevent relapse. However, as of February 2025, this remains an off-label use of bupropion.

Now, let’s move to the next clinical area, breast cancer, focusing on updated recommendations for identifying, managing, and reducing the risk of lymphoedema. These updates apply to both early and advanced breast cancer.

Patients undergoing breast cancer treatment should be informed about their risk of developing lymphoedema. This includes explaining that there is no consistent evidence linking an increased risk of lymphoedema to air travel, travel to hot countries, manicures, hot tubs, or sports injuries. Similarly, there is no consistent evidence suggesting that medical procedures such as blood tests, injections, intravenous medicines, or blood pressure measurement on the treated side increase the risk of lymphoedema.

Patients should also be informed that physical activity may improve their overall quality of life and that there is no indication that exercise causes or worsens lymphoedema. Importantly, compression therapy should not be offered as a preventive measure but only as active treatment.

If lymphoedema does develop, we will ensure that patients are referred to a specialist lymphoedema service for assessment and discussion of management options.

Once lymphoedema is diagnosed:

• We will address underlying factors, such as nodal disease or cellulitis.
• Compression therapy should be the first-line treatment and
• If compression therapy is not suitable or comfortable, patients may wish to consider kinesiology tape as an alternative.

The third and final area refers to ovarian cancer.

There is an updated quality standards on ovarian cancer which states that adults with a total lifetime risk of five percent or more of developing ovarian cancer should have a discussion about risk-reducing surgery. This five percent risk threshold is calculated based on either a strong family history of ovarian cancer or a specific pathogenic variant.

And let’s look at some definitions:

A strong family history is defined as having one or more close relatives, such as a grandmother, mother, sister, or daughter on the same side of the family with ovarian cancer.

In these cases, referral to genetic services should be considered. These services should then assess their risk of developing ovarian cancer and discuss potential interventions.

Risk-reducing surgery may include bilateral salpingo-oophorectomy, removing both fallopian tubes and ovaries, but another option is a hysterectomy with bilateral salpingo-oophorectomy, which also reduces the risk of endometrial cancer.

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 episode can be found here:

·      https://youtu.be/L1V_9RZSeQU

The original video on the NICE guideline on AF on this channel that this episode is based on can be found here:

·      https://youtu.be/AGdfwwzcKJs?si=G_TamzKCiQ-LW8WO

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 use AI voices to discuss the NICE guideline on atrial fibrillation, using AI generated clinical cases to illustrate the guidance.

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.

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

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

The video version of this podcast can be found here:

·      https://youtu.be/xJwdGqR9Rt0

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 “Gout: diagnosis and management” or NG219, focusing on what is relevant in Primary Care only.

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

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.

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

Primary Care guidelines podcast:

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

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

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

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

• The Practical GP YouTube Channel: 

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

The Full NICE guideline on Gout: diagnosis and management can be found here:

·      https://www.nice.org.uk/guidance/ng219

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

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

Transcript

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

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE guideline on gout, or NG219, focusing on what is relevant in Primary Care only.

Right, without further ado, let’s jump into it.

Looking at the clinical presentation, we will suspect gout if there is either

• the patient has tophi or
• there is rapid onset (often overnight) of severe pain together with redness and swelling, in 1 or both first metatarsophalangeal (MTP) joints, although we will bear in mind that gout can affect other joints.

Other differential diagnoses that we have to consider in people presenting with a painful, red, swollen joint are:

·      Septic arthritis, and let’s remember that septic arthritis is a medical emergency, and in most cases, the patient should be sent to the emergency department immediately. This is because of the risk of rapid joint destruction, systemic spread and because the delay in treatment worsens outcomes.

·      We should also consider other inflammatory arthritis as well as

·      Calcium pyrophosphate crystal deposition. And let’s stop here for a moment. What is Calcium pyrophosphate crystal deposition? It is often referred to as pseudogout because it can cause acute joint inflammation, mimicking the symptoms of gout. However, it is caused by Calcium pyrophosphate crystals rather than uric acid crystals. Diagnosis is confirmed by synovial fluid analysis although it can be suspected if chondrocalcinosis is seen on x-ray.

Now, going back to gout, if instead of presenting with a painful, red, swollen joint, they present with chronic inflammatory joint pain, we should also consider chronic gouty arthritis

In terms of making a diagnosis of gout, as always, we will start with a detailed history and examination.

We will then check urate and confirm the clinical diagnosis is the serum urate level is 360 micromol/litre [6 mg/dl] or more). If the serum urate level is below this threshold during a flare and gout is strongly suspected, we will repeat it at least 2 weeks after the flare has settled. This is because during a gout flare, the serum urate level can be temporarily low due to the inflammatory response and redistribution of urate into the tissues. This means that a single low urate measurement during a flare does not rule out gout.

If the diagnosis remains uncertain or unconfirmed, other tests may be considered, such as joint aspiration and microscopy of synovial fluid or CT imaging or the affected joints, although normally this would be in secondary care.

As treatment of gout flares, we will offer a non-steroidal anti-inflammatory drug, colchicine or a short course of an oral corticosteroid for first-line treatment, taking into account the patient’s individual circumstances. When giving a NSAID or oral steroid, we will consider adding a proton pump inhibitor for gastric protection.

We will also explain that applying ice packs to the affected joint may also help.

If NSAIDs and colchicine are contraindicated, not tolerated or ineffective we can consider an intra-articular or intramuscular corticosteroid injection.

However, at the moment, this is an off-label use of steroids.

We should not offer an interleukin-1 (IL-1) inhibitor in Primary care but we will refer to a rheumatology service instead.

And, What is an Interleukin-1 (IL-1) Inhibitor?

It is a type of biologic drug that blocks the activity of interleukin-1, a key pro-inflammatory cytokine involved in the body's immune response in conditions like gout and rheumatoid arthritis. They are particularly useful in cases where NSAIDs, steroids, or colchicine are not effective or cannot be used due to side effects or contraindications.

After a gout flare, we will arrange follow up to:

• check the serum urate level
• provide information and assess comorbidities
• review medications
• discuss long-term Urate lowering therapy and
• Discuss lifestyle. In this respect, we will explain that there is not enough evidence to show that any specific diet prevents flares or lowers serum urate and we will just advise a healthy, balanced diet. However, we will explain that excess body weight, or excessive alcohol consumption, may exacerbate gout flares and symptoms.

We will also explain that the disease progresses without intervention and that gout is a lifelong condition that benefits from long-term urate-lowering therapy to prevent flares, shrink tophi and prevent long-term joint damage.

Now that we have had a look at the management of an acute flare, let’s look at the long-term management, which involves urate-lowering therapies. Anyone with the diagnosis of gout is likely to benefit, but it is particularly important for those who:

• Have multiple or troublesome flares
• take diuretic therapy
• have developed tophi or
• chronic gouty arthritis and finally anyone with
• CKD stages 3 to 5, that is, anyone with an eGFR less than 60.

However, as explained, we should discuss therapy with everyone with a gout diagnosis, as they are likely to benefit long term.

Normally, we will start urate lowering therapy at least 2 to 4 weeks after a gout flare has settled. However, if flares are more frequent, it can be started during a flare.

In order to prevent gout flares when starting or titrating urate-lowering therapy we can offer colchicine while the target serum urate level is being reached. If colchicine is contraindicated, not tolerated or ineffective, we can use a low-dose NSAID or low-dose oral corticosteroid, and for both a proton pump inhibitor can be given for gastric protection.

How do we prescribe urate lowering therapy?

Well, we will follow a treat-to-target strategy, where we start with a low dose of urate lowering therapy and use monthly serum urate levels to guide dose increases, as tolerated, until the target serum urate level is reached.

We will aim for a target urate below 360 micromol/litre (6 mg/dl) but we will go for a lower target of below 300 micromol/litre (5 mg/dl) if they:

• have tophi or chronic gouty arthritis
• continue to have flares despite having a level below 360 micromol/litre (6 mg/dl).

We will explain that urate lowering therapy is usually continued after the target serum urate level is reached, and is typically a lifelong treatment.

What are the recommended drugs?

We can offer either allopurinol or febuxostat as first-line treatment. If the target urate level is not reached with the first drug or if it is not tolerated, we will consider switching to the second drug.

For patients with major cardiovascular disease, we will go for allopurinol first line. This is because studies suggest that allopurinol may reduce cardiovascular events in those with pre-existing CVD, whereas, conversely, febuxostat has been associated with an increased cardiovascular risk.

Once the target has been reached, we will monitor urate levels annually.

Finally, we will consider referring to rheumatology if:

• the diagnosis is uncertain
• treatment is contraindicated, not tolerated or ineffective
• they have CKD stages 3b to 5, that is, they have an eGFR below 45 or
• they have had an organ transplant.

And that is it, a review of the diagnosis and management of gout in 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.