Primary Care Guidelines

The video version of this episode can be found here:

·      https://youtu.be/OnnjnhsXu4A

The 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 CHA₂DS₂-VASc & ORBIT in AF.

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

Information

CHA₂DS₂-VASc

NICE suggest to use the CHA₂DS₂-VASc stroke risk score to assess stroke risk in people with any of the following:

• symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
• atrial flutter
• a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm

CHA₂DS₂-VASc score for stroke risk in atrial fibrillation

Feature

Score

Congestive Heart Failure

1

Hypertension

1

Age >75 years

2

Age between 65 and 74 years

1

Stroke/TIA/TE

2

Vascular disease (previous MI, peripheral arterial disease or aortic plaque)

1

Diabetes mellitus

1

Female

1

NICE recommends

• do not offer stroke prevention therapy to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA₂DS₂-VASc score of 0 for men or 1 for women)
• anticoagulation based on CHA₂DS₂-VASc score
• anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist
• consider anticoagulation for men with a CHA₂DS₂-VASc score of 1.
• offer anticoagulation to people with a CHA₂DS₂-VASc score of 2 or above.

ORBIT

NICE have suggested that the ORBIT bleeding risk score should be used in assessing the risk of bleeding when a patient commences, or is under review, regarding anticoagulation therapy in atrial fibrillation.

NICE state that "because evidence shows that it has a higher accuracy in predicting absolute bleeding risk than other bleeding risk tools. The ORBIT bleeding risk scoring system developed a five-factor numerical bleeding risk score from the five strongest predictors termed ORBIT:

Risk Factor For Bleeding

Points Attributed

(older (75 years or older)

1 point

reduced haemoglobin (<13 mg/dL in men and <12 mg/dL in women), haematocrit (<40% in men and <36% in women) or history of anaemia

2 points

bleeding history

2 points

insufficient kidney function (eGFR < 60 mg/dL/1.73 m2)

1 point

treatment with an antiplatelet agent

1 point

• Interpretation:

ORBIT Score

Risk group

Bleeds per 100 patient-years

0-2

Low

2.4

3

Medium

4.7

4-7

High

8.1

The ORBIT risk score can provide a simple, easily remembered tool to support clinical decision making

The video version of this podcast can be found here:

·      https://youtu.be/xPm1G9aiSv8

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 “Renal and ureteric stones: assessment and management” or NG118, focusing on what is 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.

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 Renal and ureteric stones: assessment and management can be found here:

·      https://www.nice.org.uk/guidance/ng118

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 renal stones, or NG118, focusing on what is relevant in Primary Care only.

Right, let’s jump into it.

And before we get started on the NICE guideline itself, let’s have a quick overview of the clinical presentation.

Patients with renal stones often present with:

1. Severe, colicky flank pain that can radiate to the groin and genitals.
2. Nausea and vomiting – which are common due to the intensity of the pain
3. Lower urinary tract symptoms – like urgency, frequency, or dysuria and
4. Haematuria – which can be visible or invisible. And if we suspect renal stones we would normally check urinalysis to test not only for invisible haematuria but also for possible signs of infection like leucocytes and nitrites.

So, when is immediate referral to the emergency department necessary? We should do just that if the patient has:

• Fever or signs of sepsis like tachycardia, hypotension, or being systemically unwell.
• Renal impairment or anuria which would suggest obstruction, which is a urological emergency and
• Uncontrolled pain or vomiting as these patients will need urgent care.

On the other hand, we will consider non-urgent referral and investigations if we suspect renal stones because of milder but persistent symptoms or a previous history of recurrent stones.

But now, let’s tackle a question: Why does renal colic cause such severe, colicky pain that radiates to the groin and genitals?

There are three reasons:

1. First, when a stone obstructs the ureter, it causes sudden distension and spasmodic contractions of the ureteric smooth muscle, which leads to that classic, severe, colicky pain.
2. The pain can be a visceral pain from uretericl distension, which is poorly localized and felt deep in the flank and abdomen or it could be a somatic pain, when the stone irritates the bladder or urethra, leading to sharp, localised pain in the groin or perineum. And finally
3. The referred pain is due to the fact that the ureter shares sensory innervation with the T10–L2 spinal segments, which also supply the flank, lower abdomen, groin, and genitals.

And here is one final Clinical Clue: if the pain starts in the flank, moves to the lower abdomen, and then radiates to the groin or genitals, it’s a strong indicator of a stone migrating through the ureter.

Now that we have reviewed the clinical presentation, let’s start the review of the NICE guideline itself.

In terms of diagnostic imaging, limited evidence shows that MRI, ultrasound and plain abdominal X-rays were not as good as non-contrast CT for detecting renal and ureteric stones. CT is more expensive than ultrasound or a plain abdominal X-ray but the extra cost is likely to be outweighed by avoiding additional investigations when a first test misses the diagnosis. So, a low-dose non-contrast CT should be offered urgently, that it within 24 hours of presentation, to adults with suspected renal colic. However, for pregnant women and children, in order to minimise radiation, an urgent ultrasound scan should be offered instead. If there is still uncertainty about the diagnosis after ultrasound, for children and young people, a low-dose non-contrast CT can still be considered.

Why do we need the imaging urgently, that is, within 24h? Well, NICE says that the reason is  because there are occasions where renal colic can cause renal function to decline quickly, so an early diagnosis is really important here.

For pain management, we will offer a non-steroidal anti-inflammatory drug (NSAID) by any route as first-line treatment. This is because evidence shows that these drugs are the most effective compared with opioids, antispasmodics and paracetamol. Most studies used intravenous or intramuscular NSAIDs whereas oral or rectal NSAIDs are more common in the UK. However, due to insufficient evidence supporting any specific route, NICE did not recommend a particular method of administration.

If NSAIDs are not enough or they are contraindicated, the next step would be paracetamol. Most of the evidence is based on intravenous paracetamol, commonly used in secondary care. However, even though NICE specifically recommends the intravenous route, in primary care, we would normally use the oral route.

We can consider opioids if both NSAIDs and intravenous paracetamol are contraindicated or are not giving sufficient pain relief but there are concerns about misuse and dependency.

NICE advises against antispasmodics, as they offer no benefit over NSAIDs. Additionally, in studies, they were administered intravenously, which increases the risk of adverse events and needs intensive monitoring.

In terms of combination treatments, people with recurrent stones may already self-manage with both oral paracetamol and NSAIDs.  There is some evidence showing benefit of a combination of NSAIDs and oral paracetamol without an increase in adverse events. However, there was no strong evidence for any of the combination treatments so they are not routinely recommended over the step-wise approach.

In terms of metabolic testing, for adults we will measure serum calcium and, if it can be obtained, we will arrange stone analysis. However, children should be referred to a paediatric nephrologist or urologist for this assessment.

In terms of preventing recurrence, we will give the following advice:

• adults should drink 2.5 to 3 litres of water per day, and children and young people (depending on their age) 1 to 2 litres
• they should add fresh lemon juice to drinking water. This is because lemon juice is rich in citrate, which can help prevent stone formation by binding to calcium and reducing calcium oxalate crystallization. It also alkalinizes the urine, making the environment less favourable for the formation of certain types of kidney stones, such as uric acid and cystine stones. And finally, by making water more palatable, it also encourages a higher fluid intake.
• We should also advise avoiding carbonated drinks. This is because many carbonated drinks, especially colas, contain phosphoric acid, which can lower urinary pH and promote the formation of calcium phosphate and uric acid stones. In addition, sugary sodas, can increase urinary calcium excretion and decrease citrate levels, both of which also contribute to stone formation.
•  We will also recommend reducing salt intake. This is because excess sodium increases calcium excretion in urine which promotes calcium oxalate and calcium phosphate stone formation. Furthermore, a high salt intake can cause dehydration and a more concentrated urine, which can increase the risk further.
• And finally, we will not restrict dietary calcium, but recommend maintaining a normal calcium intake. And you could ask yourself, why maintain a normal calcium intake instead of restricting it? Well, contrary to what might seem logical, reducing calcium intake does not prevent renal stones and can actually increase the risk. The reason is that calcium from food binds with oxalate in the gut, preventing oxalate absorption into the bloodstream, reducing the risk of calcium oxalate stones, the most common type of kidney stone. Additionally, inadequate calcium intake can lead to bone demineralisation and an increased risk of osteoporosis.

The actual management of renal stones corresponds to secondary care and the treatments include both medical and surgical approaches, including shockwave lithotripsy. Examples of medical treatment include the use of alpha-blockers, potassium citrate and thiazides.

And that is it, a review of the initial assessment and management of renal stones 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/r0h6m-Hxoa0

The original video that this episode is based on can be found here:

·      https://youtu.be/VFiwyS1c3yk?si=Y-iz5dqx1KUKDXF8

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 issue of raised alkaline phosphatase levels. There are 3 parts and this is part 3.

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

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

·      My Summary: https://1drv.ms/b/s!AiVFJ_Uoigq0mC4pm_bYELFa9wEx?e=07p2dJ

The video version of this podcast can be found here:

·      https://youtu.be/Mx9iVonx61Q

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 Primary Hyperparathyroidism, focusing on what is relevant to Primary Care only. Make sure to stay for the entirety of the episode because, at the end, I will also explain the pathophysiology of secondary and tertiary hyperparathyroidism.

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 guideline Hyperparathyroidism (primary): diagnosis, assessment and initial management or [NG132] can be found here:

·      https://www.nice.org.uk/guidance/ng132

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 Primary Hyperparathyroidism, or NG132, focusing on what is relevant to Primary Care only. Make sure to stay for the entirety of the episode because, at the end, I will also touch on secondary and tertiary hyperparathyroidism.

Right, let’s jump into it.

What features could indicate primary hyperparathyroidism?

Well, experience suggests that hypercalcaemia in primary hyperparathyroidism is commonly associated with symptoms such as thirst, frequent or excessive urination, and constipation, and with conditions such as osteoporosis, fragility fractures and renal stones. So, these are the prime clues to look for.

However, sometimes there are also chronic non-specific symptoms, including fatigue, anxiety and depression, confusion, irritability and digestive problems.

And, of course, primary hyperparathyroidism can also be asymptomatic showing simply as hypercalcaemia. Hypercalcaemia is defined as a corrected calcium of 2.6 mmol/litre or more. 

What diagnostic testing should we do in primary care?

The main initial test is the albumin-adjusted serum calcium, which, from now on and for simplicity, I will refer to as just corrected calcium. We should not rely on ionised calcium. This is because calcium that is bound to albumin is not active and does not have clinical effects, so adjusting for albumin is a better measurement. Furthermore, ionised calcium is not subject to the same stringency of laboratory testing and the sample has to be handled very quickly, making it unreliable.

And when should we check corrected calcium?

We will definitely check it if we suspect primary hyperparathyroidism because of, as we have just said:

·      symptoms of hypercalcaemia, primarily thirst, frequent or excessive urination, or constipation but also those with chronic non-specific symptoms.

• Or if there are conditions like osteoporosis
• a previous fragility fracture or
• a renal stone

Then we should repeat the corrected calcium if the level is either:

• high, that is, 2.6 mmol/litre or above or
• if it is 2.5 mmol/litre or above and features of primary hyperparathyroidism are present.

And you may ask yourselves? Should we be checking parathyroid hormone or PTH with this second blood test?

Well, NICE says, not yet. This is because calcium levels can vary with changes in blood pH or albumin, and the cost of the test is low, so it should be checked at least twice before moving on to more expensive tests like PTH.

So, then, we will check PTH if the corrected calcium level continues to be either:

• high, that is, 2.6 mmol/litre or above on at least 2 separate occasions or
• if it is 2.5 mmol/litre or above on at least 2 separate occasions and primary hyperparathyroidism is suspected.

But you may be thinking: a corrected calcium of 2.5 is in the normal range. Should we be even thinking of primary hyperparathyroidism in these cases? Well, NICE explains that although most people with primary hyperparathyroidism have hypercalcaemia, there is a smaller number of people that develop 'normocalcaemic primary hyperparathyroidism' which often goes unrecognised, so this is the reason for this lower calcium threshold.

When measuring PTH, we will check the corrected calcium again at the same time. To check PTH we can use a random sample at any time of day because, although there is a marginal diurnal difference, it is not enough to need adjusting for. Once checked, we should not routinely repeat the PTH in primary care

Once we have the results, we will conclude that primary hyperparathyroidism is unlikely if:

• the PTH is below the midpoint of the reference range and
• the corrected calcium is below 2.6 mmol/litre.

However, we will refer to a specialist if the PTH is either:

• below the midpoint of the reference range but with a concurrent corrected calcium level of 2.6 mmol/litre or above or
• if PTH is above the midpoint of the reference range and primary hyperparathyroidism is suspected. Considering that we should not be checking PTH unless we suspect hyperparathyroidism, this means that we may have refer patients even if their PTH level is within the normal range, as long as it is above the midpoint of the reference range. 

Do we need to worry about low PTH levels? Well, NICE says that we should look for alternative diagnoses, including malignancy, if the PTH is below the lower limit of normal.

Why is this? A low PTH or hypoparathyroidism, can have several causes including autoimmune diseases, genetic disorders and low magnesium but also malignancy. Certain cancers, particularly those that metastasise to the bones, can disrupt the normal function of the parathyroid glands. Additionally, some cancers can produce substances that mimic PTH, causing hypercalcemia of malignancy, which can suppress the normal parathyroid function.

Now, moving on, although NICE recommends the following tests in secondary care, some of them can be done in Primary Care, so we can use our clinical judgement in this respect. These tests are:

·      Vitamin D. This is because vitamin D deficiency can lead to a rise in PTH level and exacerbate bone disease. Therefore, assessing and correcting vitamin D in important. However, NICE also considers that waiting for vitamin D to be checked, and corrected, if necessary, could delay the diagnosis of primary hyperparathyroidism. So, although we could indeed check it, we should not delay referral because of it.

·      The other tests that we can consider are less common in Primary Care. They are tests to check urine calcium excretion, for example with a 24-hour urinary calcium excretion. They are used to exclude familial hypocalciuric hypercalcaemia so perhaps they are really best left for secondary care.

Now, secondary care will decide which cases of primary hyperparathyroidism need referral for surgery and which follow up is needed after it depending on whether the surgery is deemed to have been successful or not.

However, we need to be aware that patients who haven’t had successful surgery should be monitored by checking:

·      corrected calcium and renal function at least once a year

·      a renal ultrasound scan at diagnosis and if a renal stone is suspected and

·      a DXA scan at diagnosis and then every 2 to 3 years until the hyperparathyroidism has been corrected.

Whilst a bisphosphonate can be considered for those with an increased fracture risk, it should not be used just to treat the hypercalcaemia of primary hyperparathyroidism.

And of course, primary hyperparathyroidism in pregnancy should be managed in secondary care being aware that these patients are at increased risk of hypertensive disease in pregnancy.

Now, as promised, I am going to tell you a little about secondary and tertiary hyperparathyroidism.

But before, let’s go through some definitions:

Primary hyperparathyroidism is when the parathyroid glands produce excessive amounts of parathyroid hormone without any external trigger, that is, it is an intrinsic problem within the parathyroid glands and the most common cause is a benign tumour or adenoma.

Secondary hyperparathyroidism is when the parathyroid glands overproduce PTH as a compensatory response to low calcium and it is the body's attempt to normalise the levels. Possible causes are chronic kidney disease and vitamin D deficiency.

And, finally, tertiary hyperparathyroidism is when hyperplastic parathyroid glands overproduce PTH autonomously, that is, not responding to normal regulatory feedback. This is generally seen after prolonged secondary hyperparathyroidism in patients with CKD.

And let’s quickly look at the pathophysiology of tertiary hyperparathyroidism:

In CKD, the kidneys lose their ability to excrete phosphate, leading to hyperphosphatemia.

In CKD, the kidneys also produce less active vitamin D, resulting in decreased calcium absorption and hypocalcemia.

Both hypocalcemia and hyperphosphatemia stimulate the parathyroid glands to produce more PTH to maintain calcium levels. This is the secondary hyperparathyroidism stage.

However, over time, the continuous stimulation of the parathyroid glands leads to glandular hyperplasia and, as it progresses, the parathyroid glands become less responsive to normal feedback mechanisms.

So, in some patients, particularly in those after prolonged and severe secondary hyperparathyroidism, the parathyroid glands can become autonomous, meaning that they secrete PTH independently of blood calcium levels. At this stage, even when the initial cause of secondary hyperparathyroidism is corrected (for example, after a kidney transplant), the overactive parathyroid glands continue to produce excessive PTH which will lead to hypercalcemia. This is when we talk about tertiary hyperparathyroidism.

So that is it, a quick review of the different types of hyperparathyroidism.

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/Lwcio-XOxbs

The original video that this episode is based on can be found here:

·      https://youtu.be/VFiwyS1c3yk?si=Y-iz5dqx1KUKDXF8

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 issue of raised alkaline phosphatase levels. There are 3 parts and this is part 2.

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

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

·      My Summary: https://1drv.ms/b/s!AiVFJ_Uoigq0mC4pm_bYELFa9wEx?e=07p2dJ

The video version of this podcast can be found here:

·      https://youtu.be/tgzpDd-LUR8

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 January 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 January 2025 can be found here:

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

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

The NICE guideline on Overweight and obesity management [NG246] can be found here:

·      https://www.nice.org.uk/guidance/ng246

Transcript

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

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

In today’s episode, there is only one area relevant to us, which is a brand-new guideline on overweight and obesity management, or NG246. This guideline consolidates and updates previous NICE recommendations on this topic. Today I will cover general principles of care, including BMI and waist-to-height ratio and pharmacological treatments.

Right, let’s jump into it.

As general principles of care, NICE emphasises a person-centred approach, advocating for non-judgmental communication and tailoring advice to individual circumstances, such as age, gender, cultural background, and socioeconomic status.

In terms of prevention, we should provide information and practical advice on diet and exercise, particularly focusing on people at high risk because of family history or co-morbidities. We will encourage self-monitoring of weight and waist measurements but also being conscious of the risks for those who have or might develop an eating disorder.

When advising about lifestyle, we will advise to avoid extreme physical activity or dietary behaviours that are difficult to sustain long term. 

We should explain that even small, gradual improvements to physical activity and dietary intake are likely to be helpful.

For discussions about children, we need to think about the impact of measuring their weight as well as their vulnerability to eating disorders, and for many children we should focus on weight maintenance and growing into a healthier weight, rather than weight loss. Additionally, for them we should use age- and sex-specific growth charts, to visually show their weight and BMI centile. 

Furthermore, for children and young people, the main responsibility for behavioural changes should fall upon their families and carers, taking into account the maturity of the child and their preferences. We should also encourage them to get enough sleep, explaining that lack of sleep may increase the risk of excess weight gain.

In primary care, we should routinely assess BMI but also waist circumference to assess central adiposity, which is linked to increased morbidity.

We can classify the degree of overweight or obesity in adults using BMI or waist-to-height ratio.

In terms of BMI:

• overweight: is a BMI of 25 to 29.9 kg/m2
• obesity class 1: is a BMI of 30 to 34.9 kg/m2
• obesity class 2: is a BMI of 35 to 39.9 kg/m2
• and obesity class 3: is a BMI of 40 kg/m2 or more.
• 
  
• 
  

People with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African–Caribbean background are prone to central adiposity and their cardiometabolic risk occurs at lower BMIs, so all these thresholds should be lower BMI. And so:

• overweight for them would be a BMI of 23 kg/m2 to 27.4 kg/m2
• and obesity would be a BMI of 27.5 kg/m2 or above. For obesity classes 2 and 3 we will also reduce the thresholds by 2.5 kg/m2. 

BMI is not a perfect measurement so we will interpret BMI with caution in people aged 65 and over and those with high muscle mass.

In children, we will use BMI centiles and standard variations. I will not go through the thresholds in detail today but I will just mention that anything higher than the 91st centile is high.

We should also encourage the calculation of waist-to-height ratio. For this, they should measure their waist circumference and height in the same units and divide the waist measurement by the height measurement.

The waist-to-height ratio thresholds can be:

• healthy when the ratio is between 0.4 to 0.49.
• increased when the ratio is between 0.5 to 0.59 and
• high when the ratio is 0.6 or more, indicating further increased health risks.
• 
  
• 
  

Therefore, when talking to a person about their waist-to-height ratio, we should explain that they should try and keep their waist to less than half their height that is, under 0.5.

The waist-to-height ratio classification can be used for adults and children of both sexes and all ethnicities, including those with high muscle mass.

The health risks associated with higher levels of central adiposity include type 2 diabetes, hypertension and cardiovascular disease. 

And now let’s have a look at the drug treatment.

NICE has provided detailed guidance on medicines for weight management in adults and children.

Here are the main key facts:

1. Medicines approved include Orlistat, Tirzepatide, Semaglutide, and Liraglutide.
2. For overweight and obesity, semaglutide, and liraglutide should be prescribed by secondary care only.
3. Orlistat is taken as an oral capsule up to three times a day and it can be prescribed in Primary Care for those with a BMI of 30 kg/m2 or more or a BMI of 28 kg/m2 or more and associated risk factors. It should be stopped after 12 weeks if at least 5% of the initial body weight has not been lost.
4. Tirzepatide is given as weekly subcutaneous injections and it is also approved to use in Primary Care for those with a BMI of at least 35 kg/m² with at least one weight-related comorbidity. For people with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African–Caribbean background, the BMI threshold is reduced by 2.5 kg/m² to 32.5. However, tirzepatide is subject to a gradual NHS rollout process, so there may be local variations in its availability on the NHS. If less than 5% of the initial weight has been lost after 6 months on the highest tolerated dose, we will need to decide whether to continue treatment, taking into account its benefits and risks.
5. These drugs are not recommended during pregnancy and generally not recommended for those under 12. For children 12 and above, specialist services must be involved.

Bariatric surgery is an option for people with severe obesity. NICE recommends referral for adults if:

1. The BMI is 40 kg/m² or more or
2. The BMI is between 35 and 39.9 kg/m² with significant health conditions that could improve with weight loss, such as type 2 diabetes or obstructive sleep apnoea.
3. For expedited assessments, people with a BMI of 35 or more and recent-onset (that is, diagnosed within the past 10 years) type 2 diabetes and
4. We will bear in mind that ethnic-specific adjustments will lower BMI thresholds by 2.5 kg/m² for groups at higher risk of cardiometabolic complications.

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/myqMGzw4SUQ

The original video that this episode is based on can be found here:

·      https://youtu.be/VFiwyS1c3yk?si=Y-iz5dqx1KUKDXF8

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 issue of raised alkaline phosphatase levels. There are 3 parts and this is part 1.

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

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

·      My Summary: https://1drv.ms/b/s!AiVFJ_Uoigq0mC4pm_bYELFa9wEx?e=07p2dJ

The video version of this podcast can be found here:

·      https://youtu.be/b9WhusF36qQ

The previous episode on diagnosis, and classification of CKD can be found here:

·      https://youtu.be/iJKpE3H_Lbk

The previous episode on investigations, monitoring, referral recommendation and BP management in CKD can be found here:

·      https://youtu.be/6WtRlgjCt34

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 guideline on CKD, NG203, by the National Institute for Health and Care Excellence (NICE), last updated in November 2021, focusing on what is relevant to Primary Care only.

Given how extensive the guidance is, in this episode I will just focus on other CKD management in Primary Care, including the management of renal anaemia and CKD mineral bone disease.

If you haven’t already, I recommend checking out the two previous episodes on diagnosis, classification, monitoring, referral recommendation and BP management in CKD

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 guideline chronic kidney disease: assessment and management [NG203] can be found here:

·      https://www.nice.org.uk/guidance/ng203

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

The 4-variable Kidney Failure Risk Equation can be found here:

·      https://www.nice.org.uk/guidance/ng203/chapter/recommendations#variable-kidney-failure-risk-equation

A Kidney Failure Risk Equation calculator can be found here:

·     https://ukidney.com/calculators/kidney-failure-risk-equation-kfre

The NICE technology appraisal guidance on SGLT2 inhibitors for adults with CKD, can be found here:

• Empagliflozin (TA942, 2023): https://www.nice.org.uk/guidance/ta942/chapter/1-Recommendations
• Dapagliflozin (TA775, 2022): https://www.nice.org.uk/guidance/ta775/chapter/1-Recommendations

The recommendations on hyperkalaemia treatment in adults with categories G3b to G5 chronic kidney disease can be found here:

·      Zirconium: https://www.nice.org.uk/guidance/ta599

·      Patiromer: https://www.nice.org.uk/guidance/ta623

The link to the hypertension video can be found here:

·      https://youtu.be/wjIbwy9SdAQ?si=dsPA_Wc6uvxhNANd

The links to the videos on cardiovascular disease risk reduction and lipid modification can be found here:

·      Part 1: https://youtu.be/jIhlkmOcsiI?si=4BGzj8Bwz9KqPMKJ

·      Part 2: https://youtu.be/QyN3toBGCNU?si=9kTWk5HVTHrHVeCv

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 doing a review of the NICE guideline on CKD, or NG203, focusing what is relevant to Primary Care only.

Given how extensive the guidance is, in this episode I will just focus on other CKD management in Primary Care, including the management of renal anaemia and CKD mineral bone disease.

If you haven’t already, I recommend checking out the two previous episodes on diagnosis, classification, monitoring, referral recommendation and BP management in CKD

Right, let’s jump into it.

And let’s remember that, for this review, I have excluded recommendations related to children and young people with CKD. While their management is often similar to that of adults, most children with CKD are managed by secondary care, which is why I am focusing on adults only.

SGLT2 inhibitors have been proven to help CKD in both people with and without diabetes. There is NICE guidance on dapagliflozin and empagliflozin but their use is outside the scope of this episode. Links to this guidance are in the episode description.

The advice on statins in CKD is also covered in a different NICE guideline. The link is also in the episode description. But in summary, in CKD we will give Atorvastatin 20 mg for both primary and secondary prevention. Then, if the lipid target is not met and the eGFR is 30 or more, we will increase the dose. However, if eGFR < 30, we will discuss and agree the use of higher doses with a renal specialist

We will offer antiplatelet medicines only for the secondary prevention of cardiovascular disease, being aware of the increased risk of bleeding in CKD. 

And why is this? The real cause for the association between CKD and bleeding is not well known but research studies have shown that CKD has been associated with a 1.5-fold increased risk of bleeding, which has been attributed to platelet dysfunction and activation of the fibrinolytic system.

However, although some patients are prone to bleeding, other patients also develop excessive clot formation. Little is known about the reasons why some patients develop bleeding problems, while others have excessive clotting.

So, in summary, for the secondary prevention of CVD, we definitely need to give aspirin, but being aware of the risks. 

We know that renal anaemia can be common. Do we need to fully investigate everyone with CKD for this? 

NICE says that we should investigate and treat anaemia in CKD if:

·      their Hb is 110 g/litre or less or

·      they develop symptoms like tiredness, shortness of breath, etc 

Then:

·      If eGFR is above 60, we will fully investigate other causes because it is unlikely to be due to CKD.

·      If eGFR is between 30 and 60 ml/min/1.73 m2, we will investigate other causes but we will use clinical judgement to decide how extensive this investigation should be, because the anaemia may be caused by CKD.

·      And, if eGFR is below 30 ml/min/1.73 m2, we will think about other causes but we will note that anaemia is often caused by CKD in these circumstances. 

Why is this? Let’s have a look at the causes. Anaemia of CKD is generally a normocytic normochromic, hypoproliferative anaemia. Although the widely accepted aetiology is a decreased renal production of erythropoietin, the hormone responsible for stimulating red cell production, anaemia of CKD is of multifactorial origin. Other mechanisms include uraemia, folate and vitamin B12 deficiency, iron deficiency, a shortened lifespan of red blood cells and bleeding due to dysfunctional platelets. And very significantly, CKD patients are at higher risk of iron deficiency, so we must always consider iron supplementation as part of their treatment.

Consequently, as we have just said, the management of anaemia in CKD involves iron therapy, erythropoietin stimulating agents and blood transfusions. Let’s begin with iron therapy.

In primary care, we should check for iron deficiency at least every 3 months and we will diagnose iron deficiency if:

·      The Percentage of hypochromic red blood cells (%HRC) is more than 6%, or

·      The reticulocyte haemoglobin content is less than 29 pg, or

·      Transferrin saturation (TSAT) is less than 20% and ferritin is less than 100 µg/L.

However, these last two tests alone are not ideal for assessing iron status in CKD. They should only be used when other diagnostic tests are unavailable or when the patient has conditions like thalassaemia or thalassaemia trait.

When treating with iron, NICE says that ferritin levels should not exceed 800 µg/L and to prevent this, we will review the iron dose when ferritin reaches 500 µg/L.

So, what this means is that we are going to keep giving iron to our patients even when their ferritin is well above the normal range. Why? This is because, in addition to true iron deficiency, CKD patients also have a functional iron deficiency, which is a type of cell iron blockade. This results in reduced iron release from body stores which is then unable to meet the requirement for erythropoiesis. By having a higher-than-normal ferritin level we would expect iron to be released for erythropoiesis more easily.

Erythropoietin -Stimulating Agents and Blood Transfusions will be guided by secondary care and I will not cover it here except to say that we should avoid transfusions in patients who are candidates for a kidney transplant. This is multiple transfusions increase the risk of developing HLA antibodies, which can reduce long-term graft survival.

Other aspects of CKD management include:

·      Hyperphosphataemia and

·      Renal acidosis

Which will normally be managed in secondary care, so the use of phosphate binders or bicarbonate will not be covered here.

However, NICE does talk about the effect of CKD on bone metabolism and osteoporosis. What is CKD mineral bone disease? It is the disturbed mineral metabolism caused by uraemic toxins and secondary hyperparathyroidism which disturbs bone mineralisation and makes it difficult for calcium and phosphate to enter the bones. This can result higher serum calcium and phosphate as well as in bone loss. The prevalence of osteoporosis in the population with CKD certainly exceeds the prevalence in the general population.

As already mentioned, when bone resorption exceeds bone formation, calcium and phosphate are released and contribute to hyperphosphatemia and hypercalcemia. This is an important stimulus to what is called heterotopic calcifications, especially in blood vessels, which can lead to cardiovascular events and mortality.

Consequently, vascular calcification and osteoporosis are the most common complications related to CKD mineral bone disease.

And because vitamin D deficiency plays an important role in this, vitamin D supplements are important in treating both osteoporosis and vascular calcifications at the same time. Although NICE says that vitamin D should not be prescribed routinely, proven vitamin D deficiency should be treated with colecalciferol or ergocalciferol.

Then, if vitamin D deficiency is corrected but symptoms of CKD–mineral and bone disorders persist, this may indicate a need for treatment with alfacalcidol or calcitriol.

And let’s take a moment here too to understand why. For this, let’s give a quick overview of vit D metabolism in the human body. The proximal tubular cells in the kidney converts Vit D, into the active form calcitriol also known as 1,25-dihydroxycholecalciferol. As kidney disease worsens, there is a reduction in the renal 1α-hydroxylase activity for converting Vit D into the active form calcitriol.

So why do we bother with colecalciferol or ergocalciferol? Well, whilst you would think that giving calcitriol straightaway would be the solution, we also know that treatment with colecalciferol or ergocalciferol has been shown to increase calcitriol levels in both stage 3 and 4 CKD. So, this is the reason why cholecalciferol and ergocalciferol are the first line approach and treatment with alfacalcidol or calcitriol remain second line.

So that is it, a review of other CKD management in Primary Care, including the management of renal anaemia and CKD mineral bone disease.

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/3KFod0_RiAI

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 technology appraisal on Tirzepatide for managing overweight and obesity or TA1026, published in December 2024, focusing on what is relevant to Primary Care only. In particular, I also make reference to NHS implementation information and 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 YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

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

The technology appraisal on Tirzepatide for managing overweight and obesity [TA1026] can be found here:

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

The section on implementation of the technology appraisal on Tirzepatide for managing overweight and obesity [TA1026] can be found here:

·      https://www.nice.org.uk/guidance/ta1026/chapter/4-Implementation

The link to the NICE News- December 2024 discussing TA1026 can be accessed here:

·      https://youtu.be/Od1QDebGbBQ?si=EsJhm3IavpWu8ZC_

The video version of this podcast can be found here:

·      https://youtu.be/6WtRlgjCt34

The previous episode on diagnosis, and classification of CKD can be found here:

·      https://youtu.be/iJKpE3H_Lbk

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 guideline on CKD, NG203, by the National Institute for Health and Care Excellence (NICE), last updated in November 2021, focusing on what is relevant to Primary Care only.

Given how extensive the guidance is, in this episode I will just focus on investigations, monitoring, referral recommendation and BP management in CKD

I recommend checking out the previous episode on diagnosis, and classification of CKD. In the next episode, I will cover referral the rest CKD management in Primary care, including renal anaemia and mineral bone disease in CKD.

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 guideline chronic kidney disease: assessment and management [NG203] can be found here:

·      https://www.nice.org.uk/guidance/ng203

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

The table showing the minimum number of monitoring checks per year is:

·      https://www.nice.org.uk/guidance/ng203/chapter/Recommendations#frequency-of-monitoring

The 4-variable Kidney Failure Risk Equation can be found here:

·      https://www.nice.org.uk/guidance/ng203/chapter/recommendations#variable-kidney-failure-risk-equation

A Kidney Failure Risk Equation calculator can be found here:

·     https://ukidney.com/calculators/kidney-failure-risk-equation-kfre

The NICE technology appraisal guidance on SGLT2 inhibitors for adults with CKD, can be found here:

• Empagliflozin (TA942, 2023): https://www.nice.org.uk/guidance/ta942/chapter/1-Recommendations
• Dapagliflozin (TA775, 2022): https://www.nice.org.uk/guidance/ta775/chapter/1-Recommendations

The recommendations on hyperkalaemia treatment in adults with categories G3b to G5 chronic kidney disease can be found here:

·      Zirconium: https://www.nice.org.uk/guidance/ta599

·      Patiromer: https://www.nice.org.uk/guidance/ta623

The link to the hypertension video can be found here:

·      https://youtu.be/wjIbwy9SdAQ?si=dsPA_Wc6uvxhNANd

The links to the videos on cardiovascular disease risk reduction and lipid modification can be found here:

·      Part 1: https://youtu.be/jIhlkmOcsiI?si=4BGzj8Bwz9KqPMKJ

·      Part 2: https://youtu.be/QyN3toBGCNU?si=9kTWk5HVTHrHVeCv

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 doing a review of the NICE guideline on CKD, or NG203, focusing what is relevant to Primary Care only.

Given how extensive the guidance is, in this episode I will just focus on investigations, monitoring, referral recommendation and BP management in CKD

If you haven’t already, I recommend checking out the previous episode on diagnosis, and classification of CKD.

In the next episode, I will cover referral the rest CKD management in Primary care, including renal anaemia and mineral bone disease in CKD, so stay tuned for that.

Right, let’s jump into it.

And let’s remember that, for this review, I have excluded recommendations related to children and young people with CKD. While their management is often similar to that of adults, most children with CKD are managed by secondary care, which is why I am focusing on adults only.

We will offer a renal ultrasound scan in CKD if there is:

·      visible or persistent invisible haematuria

·      suspicion of urinary tract obstruction

·      a family history of polycystic kidney disease and are older than 20

·      a GFR of less than 30

·      if there is a need for a renal biopsy and

·      accelerated progression of CKD.

We will define accelerated progression of CKD as:

·      a sustained decrease in eGFR of 25% or more and a change in GFR category within 12 months or

·      a sustained decrease in eGFR of 15 per year. 

·      These people are at high risk of progression to end stage renal disease

If we are worried and we want to identify the rate of progression of CKD:

·      We will obtain a minimum of 3 eGFRs over no fewer than 90 days.

·      And, if we see a low GFR for the first time, we will repeat the GFR within 2 weeks to exclude acute deterioration e.g. acute kidney injury or secondary to starting treatment with an ACE inhibitor or ARB. 

Although CKD is not progressive in many people, we should monitor CKD regularly and the frequency will depend on the stage. It will be once a year when the risk is low, for example categories G1, G2 and up to 4 times a year or more when the risk is very high, for example category G5. For G3a, G3b and G4 the frequency of monitoring will depend on the ACR level. There is a table showing the frequency of monitoring depending of the CKD classification, which you can find in the episode description.

Monitoring should be tailored according to:

·      the underlying cause

·      the rate of decline in eGFR or increase in ACR

·      other risk factors, including heart failure, diabetes and hypertension

·      changes to their treatment (such as ACE inhibitors, ARBs, NSAIDs and diuretics) and

·      intercurrent illness (for example acute kidney injury)

Risk factors for CKD progression are:

·      cardiovascular disease 

·      proteinuria

·      previous episode of acute kidney injury

·      hypertension 

·      diabetes 

·      smoking

·      African, African-Caribbean or Asian family origin

·      untreated urinary outflow tract obstruction and

·      chronic use of NSAIDs 

And let’s remember that in CKD the chronic use of NSAIDs may be associated with progression and acute use is associated with a reversible decrease in GFR, so we should exercise caution when prescribing them.

When it comes to patient education, we will give lifestyle and dietary advice including guidance on potassium, phosphate, calorie, and salt intake. However, we will not offer low-protein diets. 

We should give patients information about their 5-year risk of needing renal replacement therapy. For this, there is a 4-variable Kidney Failure Risk Equation. You’ll find a link to the calculator in the episode description.

We will refer for specialist assessment if they have:

·      a 5-year risk of needing renal replacement therapy greater than 5%

·      an ACR of 70 or more, unless caused by diabetes and already treated 

·      an ACR of more than 30 with haematuria

·      poorly controlled hypertension despite 4 antihypertensive medicines

·      known or suspected rare or genetic causes of CKD

·      suspected renal artery stenosis and

·      accelerated progression of CKD. Accelerated progression of CKD is defined as a sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months or a sustained decrease in eGFR of 15 or more per year

Additionally, we will refer people with CKD and renal outflow obstruction to urological services

Let’s look at the management of various aspects in CKD.

In respect of blood pressure control in CKD, if ACR is under 70, we will aim for a clinic BP below 140/90 mmHg

However, if ACR is 70 or more, we will go for a lower clinic BP below 130/80.

If someone has hypertension and CKD with an ACR of 30 or less, we will simply follow the NICE guideline on hypertension. The link to the corresponding episode on this channel is in the episode description.

However, for those with hypertension and CKD with an ACR over 30, we will offer an ACE inhibitor or an ARB in the first instance, and we will titrate it to the highest licensed tolerated dose. If they also have diabetes, we will lower this threshold to an ACR of 3 mg/mmol or more. 

And, as we know, the combination of ACEIs and ARBs are not recommended.

We will measure potassium and eGFR before starting an ACEI or ARB and between 1 and 2 weeks after starting treatment and after each dose increase. More frequent monitoring may be needed if they are already taking medicines known to promote hyperkalaemia.

We will not routinely offer an ACEI or ARB if their pre-treatment potassium is greater than 5.0 mmol/litre. In these cases, we will:

·      assess and treat any factors that promote hyperkalaemia and we will

·      check the potassium again

We will stop ARBs and ACEIs if the potassium level increases to 6.0 mmol/litre or more and other medicines known to promote hyperkalaemia have been discontinued. 

There is a separate guidance on the management of hyperkalaemia – and a link to it is in the episode description.

Because their mode of action, ARBs and ACEIs can reduce the eGFR and increase the creatinine levels. However, after starting or increasing the dose, we will not modify the dose if either:

·      the eGFR drop is less than 25% or

·      the serum creatinine increase is less than 30%. 

·      In these cases, we will repeat the test 1 to 2 weeks  later and we will not change anything if the decrease in eGFR remains less than 25% or the increase in creatinine remains less than 30%. 

Why this advice? Let’s remember a little bit of anatomy. The glomerulus receives its blood supply from an afferent arteriole and, unlike most capillary beds, the glomerular capillaries exit into efferent arterioles rather than venules. Let’s also remind ourselves that ACEI prevent the conversion of angiotensin I to angiotensin II, and ARBs block the effect of angiotensin II. This results in relative vasodilation, which preferentially reduces postglomerular resistance. Consequently, this will lower intraglomerular pressure which will reduce the glomerular filtration rate and cause a subsequent rise in creatinine.

So, as stated before, an increase in creatinine of up to 30% and a decrease of eGFR of up to 25% are acceptable and, in the absence of renovascular disease, creatinine levels will frequently return to baseline or below if blood pressure is lowered, despite the continued use of an ACEI or ARB.

However, if the eGFR decrease is 25% or more, or the increase in creatinine is 30% or more:

·      We will investigate other causes, such as volume depletion or concurrent medication (for example, NSAIDs) 

·      And if no other cause is found, we will stop the ACEI or ARB or reduce the dose to a previously tolerated lower dose, adding an alternative antihypertensive medication if needed. 

So that is it, a review of monitoring, referral recommendation and BP management in CKD.

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.