The video version of this podcast can be found here: ·     https://youtu.be/Od1QDebGbBQThis 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 December 2024 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 December 2024 can be found here:·     https://www.nice.org.uk/guidance/published?from=2024-12-01&to=2024-12-31&ndt=Guidance&ndt=Quality+standard The links to the guidance covered in this episode can be found here: Tirzepatide for managing overweight and obesity: ·      https://www.nice.org.uk/guidance/ta1026 Urinary tract infection (recurrent): antimicrobial prescribing: ·      https://www.nice.org.uk/guidance/ng112 Meningitis (bacterial) and meningococcal disease: ·      https://www.nice.org.uk/guidance/qs19 TranscriptIf 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 December 2024, focusing on what is relevant in Primary Care only.  In today’s episode, we’re covering two important clinical topics:Tirzepatide for managing overweight and obesity, andAntimicrobial prescribing for recurrent UTIs.But before we jump into the details, let’s take a moment to highlight a game-changing development: the new NICE technology appraisal on Tirzepatide.For many GPs, the surge in patient requests for Ozempic (or semaglutide) to manage obesity has been a challenging situation, especially as NICE does not recommend its use in primary care for this purpose. Could Tirzepatide mark the end of the GP Ozempic nightmare?Right, let’s find out!In the technology appraisal assessing Tirzepatide for overweight and obesity NICE has recommended it as an option for adults, alongside diet and exercise only if they have:an initial BMI of at least 35 kg/m2 reduced to 32.5 for people from Asian, Chinese, Middle Eastern, and Black African or African-Caribbean ethnic backgrounds. andat least 1 weight-related comorbidity. Examples would be, for example, hypertension, dyslipidaemia, obstructive sleep apnoea, cardiovascular disease, prediabetes, and type 2 diabetes.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 the benefits and risks of treatment.The availability of obesity treatments in primary care has been limited, with semaglutide for obesity currently recommended for use in secondary care only. However, this is an exciting development: NICE has now approved the use of tirzepatide in primary care too. Furthermore, indirect comparisons suggest that tirzepatide may be more effective than semaglutide in managing obesity.While the manufacturer initially proposed a BMI threshold of 30 kg/m² with at least one weight-related comorbidity, NICE has a stricter criterion. For NICE the acceptable threshold for NHS resource use is a BMI of at least 35 kg/m² and at least one weight-related comorbidity.Let’s talk a bit more about tirzepatide.Tirzepatide, marketed as Mounjaro, is available as pre-filled pen devices for subcutaneous injection, with doses ranging from 2.5 mg to 15 mg.It is a once-weekly injection indicated for:Type 2 Diabetes andWeight ManagementWhat type of drug is Tirzepatide? Well, it is a dual GIP and GLP-1 receptor agonist.GIP stands for glucose-dependent insulinotropic polypeptide. By activating the GIP receptor, tirzepatide enhances glucose-dependent insulin secretion from pancreatic beta cells, which improves glycaemic control. And it also modulates lipid metabolism.GLP-1 stands for glucagon-like peptide-1. By activating the GLP-1 receptors, tirzepatide also enhances insulin secretion, but it also inhibits glucagon release, and slows gastric emptying, leading to a more gradual absorption of glucose and reduced postprandial glucose spikes.Both GIP and GLP-1 pathways work synergistically to influence the central nervous system, suppressing appetite and promoting satiety, leading to weight loss. This combined mechanism offers unique benefits for managing both glycaemic control and obesity.Is tirzepatide better than semaglutide?Tirzepatide is considered potentially better than semaglutide in certain contexts.For example, the dual pathway of tirzepatide allows multiple metabolic pathways, leading to superior outcomes. Clinical trials have demonstrated that tirzepatide leads to greater weight loss compared to semaglutide. Some studies reported reductions of up to 20% of body weight with tirzepatide versus around 15% with semaglutide.Tirzepatide has also shown superior glycaemic control, achieving greater reductions in HbA1c levels compared to semaglutide in head-to-head studies.In addition, GIP receptor activation by tirzepatide may have additional benefits on lipid metabolism, such as reducing triglycerides and improving HDL cholesterol. These benefits are less pronounced with semaglutide.So, bearing this in mind, would we ever choose semaglutide over tirzepatide? Well, although both drugs share common side effects like nausea and vomiting, tolerability varies and some patients may be intolerant to one drug but not the other, so this may have an effect on the choice of treatment too.Uncommon side effects of tirzepatide include gallbladder disorders and acute pancreatitis. We will discontinue it if there is persistent, severe abdominal pain and, if pancreatitis is confirmed, we will not restart treatment.In summary, this is indeed a game changer. With Tirzepatide now approved by NICE for use in primary care, we may finally have another clear, accessible option to treat the pressing issue of obesity and overweight in General Practice.Let’s now briefly touch on the updates on the prevention and management of recurrent UTIs. The changes include new referral recommendations, advice on oestrogen use, new advice on methenamine Hippurate, and choice of medication. Now, let’s have a look at a summary of the main points:We will refer to secondary care anyone with:·      recurrent UTI of unknown cause·      recurrent UTI and suspected cancer·      recurrent upper UTI·      recurrent lower UTI in anyone with a male genitourinary system·      pregnant people·      children and young people and·      anyone who has had gender reassignment surgery that involved structural alteration of the urethra. We will consider vaginal oestrogen if:·      the person is experiencing perimenopause or menopause, or they have already experienced menopause, and·      behavioural or personal hygiene measures alone are not effective·      At the moment, this is an off-label use of vaginal oestrogen products.We will also check the NICE guideline on the menopause, which includes advice on the use of vaginal oestrogen if there is a history of breast cancer.We will review treatment with vaginal oestrogen within 12 months, or earlier if appropriate. But we will not offer systemic HRT specifically to reduce the risk of recurrent UTI. We will consider methenamine hippurate as an alternative to daily antibiotic prophylaxis for recurrent UTI in anyone with a female urinary system, if:they are not pregnant andany current UTI has been adequately treated andthe recurrent UTI has not improved with behavioural and personal hygiene measures, vaginal oestrogen or single-dose antibiotic prophylaxis if appropriate.When discussing prophylaxis with methenamine hippurate we will explain that:over-the-counter sachets that make urine more alkaline (such as sachets used to relieve UTI symptoms that contain potassium citrate or sodium citrate) should not be used while taking methenamine hippurate because these can make it less effective and thatmedical help should be sought for acute UTI symptoms. We will review treatment with methenamine hippurate within 6 months, and then every 12 months, or earlier if appropriate. But, what is Methenamine Hippurate?Methenamine hippurate is a prodrug of methenamine, which means it is inactive in its original form but becomes active after metabolism in the body.How does Methenamine Hippurate Work?Methenamine is stable in neutral or alkaline conditions, but in acidic urine it is hydrolyzed into formaldehyde and ammonia. Formaldehyde is toxic to bacteria and has therefore antibacterial properties. So, for Methenamine Hippurate to be effective, it is necessary to maintain an acidic urine. This may be achieved naturally, through dietary measures (for example, cranberry juice or vitamin C) or with urinary acidifiers.Unlike antibiotics, methenamine hippurate does not target specific bacteria but acts broadly against a wide range, therefore reducing the risk of developing antibiotic resistance.Methenamine hippurate is used as a prophylactic agent rather than as a treatment for acute UTIs. It is especially helpful in recurrent uncomplicated UTIs for those who may want to avoid regular antibiotics.And finally, let’s now look at the choice of prophylactic options. We can choose between:Antiseptic prophylaxis andAntibiotic prophylaxisFor antiseptic prophylaxis:Methenamine hippurate is recommended for adults.And it may be considered for children over the age of 6, but only with specialist advice.For antibiotic prophylaxis:As a first-line option, we will use trimethoprim or nitrofurantoin.As a second-line option, we will use amoxicillin or cefalexin.The choice of antibiotic should take into account recent culture results and adhere to local antimicrobial policies.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.

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