The National Institute for Health and Care Excellence (NICE) have published new or updated guidance for the month of August 2023. This month there are three clinical guidelines and one diagnostics guidance that impact upon primary care.
The Venous thromboembolic diseases: diagnosis, management and thrombophilia testing guideline has been updated. It covers diagnosing and managing venous thromboembolic diseases in adults. The update contains amended recommendations on the use of Wells score and D-dimer in the diagnostic pathways for pulmonary embolism and deep vein thrombosis, following a review of the evidence for people with COVID-19.
The Suspected cancer: recognition and referral guideline has been updated. It covers identifying children, young people and adults with symptoms that could be caused by cancer. The update relates to newly publish diagnostic guidance.
The Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care diagnostics guidance has been published. It makes recommendations on quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care. This includes a list of patient and symptom characteristics to guide use of the test and subsequent referral.
The Otitis media with effusion in under 12s guideline has been published. It covers identifying and managing otitis media with effusion (OME), also known as 'glue ear', in children younger than 12 years. It aims to improve hearing and quality of life in children with OME.
Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.
The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for August 2023 (PDF).
This issue reminds clinicians of the risk of the risk of disabling and potentially long-lasting or irreversible side effects associated with the use of fluoroquinolone antibiotics. Clinicians are advised to not use these antibiotics in non-severe or self-limiting infections and reserve use in mild and moderate infections unless other antibiotics that are commonly recommended for these infections are considered inappropriate.
Clinicians are also recommended to counsel patients taking methotrexate to take precautions in the sun in order to avoid photosensitivity reactions. This advice is subsequent to a Coroner’s report that identified this reaction as a contributory factor in a patient death. Patients should be advised to use a sun protection product, cover up in the sun and avoid strong UV light such as strong sunlight between 11am and 3pm, sunbeds and tanning equipment.
Also in this issue, a reanalysis of data from a retrospective observational study examining the risk posed to children born to men who took valproate in the 3 months before conception. Errors have been identified in the original analysis. During the reanalysis, no action is needed from patients and it is vitally important that patients do not stop taking valproate unless they are advised to do so by their specialist.
Lastly in this issue is a summary of letters to healthcare professionals in July. These generally related to supply issues and recalls.
Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.
The Scottish Medicines Consortium (SMC) has issued its monthly advice on newly licensed medicines.
Dapagliflozin (Forxiga®) has been accepted for use in the treatment of symptomatic chronic heart failure with left ventricular ejection fraction (LVEF) >40%. It is noted that this drug offers an additional treatment choice in the therapeutic class.
Icosapent ethyl (Vazkepa®) has been accepted for restricted use to reduce the risk of cardiovascular events in adult statin-treated patients at high cardiovascular risk with elevated triglycerides (≥1.7mmol/L) and
- established cardiovascular disease, or
- diabetes, and at least one other cardiovascular risk factor.
The restriction limits use to secondary prevention in patients treated with a stable dose of statins, low-density lipoprotein (LDL) cholesterol levels >1.04mmol/L and ≤2.60mmol/L, raised fasting triglycerides (≥1.7mmol/L) and with established cardiovascular disease as defined within the published advice.
Action: Clinicians should be aware of the recommendations of the SMC. Routine use of rejected and restricted medicines should be avoided.
During July 2023 Clinical Knowledge Summaries were published or updated in the following areas.
The topics have all been reviewed and updated with minor structural and layout changes. The Antiplatelet treatment topic has been restructured to reflect current guidance which does not recommend the routine use of antiplatelets for primary prevention. The Balanitis topic now recommends treating suspected severe bacterial infection with phenoxymethylpenicillin in line with the updated European consensus publication. The Diarrhoea - antibiotic associated topic now includes recommendations on when to consider referral to secondary care. The Polycystic ovary syndrome topic has updated recommendations for metformin.
The NSAIDs - prescribing issues topic has the broadest range of changes including:
- a recommendations that low-dose celecoxib can be cautiously considered in people with risk factors for cardiovascular disease or the elderly
- contraindications to use now include third-trimester of pregnancy and varicella infection
- liver disease has been added as a risk factor for adverse renal effects
- addition of advice to avoid prolonged NSAID use beyond 20 weeks of pregnancy
Action: Clinicians who see patients with any of these conditions may find the new and updated information useful when reviewing current clinical practice.
