Prescribing Advice for GPs

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NICE Guidance - August 2016

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance for the month of August 2016. This month there are four clinical guidelines that impact upon primary care.

The Heavy menstrual bleeding clinical guideline was updated to include new recommendations for drug treatments for women with large fibroids based on new evidence.

The Autism spectrum disorder in adults clinical guideline was reviewed and while no new recommendations were made, two research recommendations were removed.

The Fertility problems clinical guideline has been reviewed in particular on intrauterine insemination however the new evidence did not justify a change to the recommendation.

The Palliative care for adults: strong opioids for pain relief clinical guideline was reviewed and updated to include links to the Controlled drugs: safe use and management guideline. Two out of date research recommendations were also deleted.

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

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CKS Updates - July 2016

During July 2016 Clinical Knowledge Summaries were updated for the following topics:

There were no major changes other than to the Head injury topic that was updated in line with NICE guidance.

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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Vitamin D advice issued

Public Health England has issued new advice on vitamin D based on the recommendations of the Scientific Advisory Committee on Nutrition.

The advice notes that vitamin D is made in the skin on exposure to UVB in sunlight but since this is difficult to quantify a daily dietary intake of 10 micrograms is being recommended.

It is noted that in spring and summer the majority of the population get enough vitamin D through sunlight on the skin and a healthy, balanced diet. In autumn and winter months it is difficult for people to meet the 10 microgram recommendation from consuming foods naturally containing or fortified with vitamin D so people should consider taking a daily supplement containing 10 micrograms of vitamin D.

The advice also considers people whose skin has little or no exposure to the sun, like those in institutions such as care homes, or who always cover their skin when outside and recommends that they need to take a supplement throughout the year.

Ethnic minority groups with dark skin, from African, Afro-Caribbean and South Asian backgrounds, may not get enough vitamin D from sunlight in the summer and therefore should consider taking a supplement all year round.

Recommendations are also made for children under 5. Children from birth to 1 year old who are breast feed should be given a daily supplement containing 8.5 to 10 micrograms of vitamin D. Formula fed children of this age consuming 500ml or more each day do not require a daily supplement because infant formula is fortified with vitamin D. Children aged 1 to 4 years should be given a daily supplement containing 10 micrograms of vitamin D. It is noted that low-income families can access vitamin D free of charge via Healthy Start schemes.

Action: Clinicians should be aware of this new advice. The advice consistently refers to "dietary sources" of vitamin D including foods naturally containing or fortified with vitamin D and supplements. As such prescribing of vitamin D purely for supplementation following this advice should be resisted.

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NICE Guidance - July 2016

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance for the month of July 2016. This month there are seven clinical guidelines and two technology appraisals that impact upon primary care.

The Type 2 diabetes in adults clinical guideline has been updated to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen.

The Type 1 diabetes in adults clinical guideline has also been updated to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen.

The Non-Hodgkin’s lymphoma clinical guideline covers diagnosing and managing non-Hodgkin's lymphoma in people aged 16 years and over. It aims to improve care for people with non-Hodgkin's lymphoma by promoting the best tests for diagnosis and staging and the most effective treatments for 6 of the subtypes.

The Cardiovascular disease: risk assessment and reduction guideline covers the assessment and care of adults who are at risk of or who have cardiovascular disease. It describes the lifestyle changes people can make and how statins can be used to reduce their risk. It has been updated to clarify the advice on saturated and monounsaturated fat.

The Prophylaxis against infective endocarditis guideline has been updated to make the wording of two of the recommendations more consistent.

The Non-alcoholic fatty liver disease guideline covers how to identify the adults, young people and children with non-alcoholic fatty liver disease (NAFLD) who have advanced liver fibrosis and are most at risk of further complications. It outlines the lifestyle changes and pharmacological treatments that can manage NAFLD and advanced liver fibrosis.

The Oral health for adults in care homes guideline covers oral health, including dental health and daily mouth care, for adults in care homes. The aim is to maintain and improve their oral health and ensure timely access to dental treatment.

The Abiraterone for treating metastatic hormone-relapsed prostate cancer before chemotherapy technology appraisal has been reviewed after a change to the commercial arrangements in July 2016. It has been verified that this change does not impact cost effectiveness and supply is contingent upon the manufacturer providing abiraterone in accordance with the commercial access arrangement as agreed with NHS England.

The Abiraterone for castration-resistant metastatic prostate cancer technology appraisal has been reviewed after a change to the commercial arrangements in July 2016. It has been verified that this change does not impact cost effectiveness and supply is contingent upon the manufacturer providing abiraterone in accordance with the commercial access arrangement as agreed with NHS England.

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

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Shingles immunisation programme for 2016

The Department of Health has written to healthcare colleagues about the shingles immunisation programme from September 2016.

From the 1st September 2016 shingles vaccine should be offered to patients aged 70 or 78 years on the 1st September 2016. In addition, patients who have been eligible in previous years but remain unvaccinated may also be offered the vaccine. This would include anyone aged 71 to 73 or 79 on the 1st September 2016.

Anyone who reaches their 80th birthday is no longer eligible for the vaccine due to the reducing efficacy of the vaccine as age increases.

The letter also notes that by the end of March 2016 just under half of eligible 70 and 78 year olds had been vaccinated against shingles. It is noted that this is a "significant achievement
and one that we can improve on
".

Action: Clinicians should be aware of the age cohorts for the shingles immunisation programme and offer vaccination from September.

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