Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

CKS Updates - September 2019

During September 2019 Clinical Knowledge Summaries were published or updated in the following areas.

The End of life care in children is new. The Hypercalcaemia topic has been significantly restructured in line with current evidence with new sections added covering prognosis and specialist assessment. The Leg ulcer - venous topic contains updated recommendations on managing an infected leg ulcer. The Retinal detachment topic has also been updated in line with current evidence and contains new sections on assessment and specialist management. The other topics have undergone reviews and minor restructures.

Action: Clinicians who see patients with any of these conditions may find the new and updated information useful when reviewing current clinical practice.

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NICE Guidance - September 2019

The National Institute for Health and Care Excellence (NICE) have published new or updated guidance for the month of September 2019. This month there are three guidelines that impact upon primary care.

The Attention deficit hyperactivity disorder guideline has been updated. It covers recognising, diagnosing and managing attention deficit hyperactivity disorder (ADHD) in children, young people and adults. It aims to improve recognition and diagnosis, as well as the quality of care and support for people with ADHD. The updated advises that an ECG is not necessary before starting stimulants, atomoxetine or guanfacine if cardiovascular history and examination are normal and the person is not on medicine that poses an increased cardiovascular risk.

The Pneumonia in adults guideline has been updated. It covers diagnosing and managing community- and hospital-acquired pneumonia in adults. The update withdrew some recommendations that have been replaced by antimicrobial prescribing guidance.

The Pneumonia (community-acquired): antimicrobial prescribing guideline has been published. It sets out an antimicrobial prescribing strategy for adults, young people, children and babies aged 72 hours and over with a confirmed diagnosis of community-acquired pneumonia. It aims to optimise antibiotic use and reduce antibiotic resistance.

Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.

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New HRT Risk Data

Last week the Medicines and Healthcare products Regulatory Agency issued an update after new data on breast cancer risk linked with HRT use were published.

This new analysis, published in The Lancet was a prospective, observational study of over 100,000 women. The study extended our understanding as follows:

  • All forms of systemic HRT are associated with a significant excess incidence of breast cancer, irrespective of the type of oestrogen or progestogen or route of delivery
  • Risk of breast cancer increases further with longer duration of HRT use
  • Risk of breast cancer is lower after stopping HRT than it is during current use, but remains increased in ex-HRT users for more than 10 years compared with women who have never used HRT

More reassuringly, the study also found that use of systemic HRT for less than a year is associated with little or no increase in risk and there is also no increase in risk with low doses of oestrogen applied directly via the vagina to treat local symptoms.

New risk tables have been produced to aid communication about risks and benefits. Table 1 summarises risk compared to duration of use while Table 2 summarises risk by HRT type.

The MHRA are advising that this new information is shared with women who use or are considering starting HRT at their next routine appointment. It is also recommended that HRT is used for the shortest time and at the lowest dose to relieve post-menopausal symptoms that are adversely affecting quality of life and that users are advised to be vigilant for signs of breast cancer and attend for breast screening.

Action: Clinicians who prescribe HRT should be aware of this new data and include this new information when discussing the risks and benefits of treatment.

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CKS Updates - August 2019

During August 2019 Clinical Knowledge Summaries were published or updated in the following areas.

The Sepsis topic is new. The Neutropenic sepsis has been updated in line with current evidence and new sections have been added on Specialist assessment and Follow-up. The other topics have undergone reviews and minor restructures.

Action: Clinicians who see patients with any of these conditions may find the new and updated information useful when reviewing current clinical practice.

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NICE Guidance - August 2019

The National Institute for Health and Care Excellence (NICE) have published new or updated guidance for the month of August 2019. This month there are two guidelines and one technology appraisal that impact upon primary care.

The Hypertension in adults: diagnosis and management guideline has been published. It covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively. This guideline updates and replaces NICE guideline CG127. It also updates and replaces the section on blood pressure management in the NICE guideline on type 2 diabetes in adults (NG28).

The Type 2 diabetes in adults: management guideline has been updated. It covers the care and management of type 2 diabetes in adults (aged 18 and over). It focuses on patient education, dietary advice, managing cardiovascular risk, managing blood glucose levels, and identifying and managing long-term complications. The update removed the recommendations on blood pressure management which were updated and replaced by recommendations in the NICE guideline on hypertension in adults mentioned above.

The Dapagliflozin with insulin for treating type 1 diabetes technology appraisal has been published. Dapagliflozin with insulin is recommended as an option for treating type 1 diabetes in adults with a body mass index (BMI) of at least 27 kg/m2, when insulin alone does not provide adequate glycaemic control despite optimal insulin therapy, only if:

  • they are on insulin doses of more than 0.5 units/kg of body weight/day and
  • they have completed a structured education programme that is evidence based, quality assured, delivered by trained educators and includes information about diabetic ketoacidosis, such as:
    • how to recognise its risk factors, signs and symptoms
    • how and when to monitor blood ketone levels
    • what actions to take for elevated blood ketones
  • treatment is started and supervised by a consultant physician specialising in endocrinology and diabetes.

It is also recommended that haemoglobin A1c (HbA1c) levels are assessed after 6 months and regularly after this. Stop dapagliflozin if there has not been a sustained improvement in glycaemic control (that is, a fall in HbA1c level of at least 0.3%).

Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.

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