The video version of this podcast can be found here: https://youtu.be/MxR8AMtBkDYThis 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.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 November 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.   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 October 2024 can be found here:·      https://www.nice.org.uk/guidance/published?from=2024-11-01&to=2024-11-30&ndt=Guidance&ndt=Quality+standard The links to the guidance covered in this episode can be found here: Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) can be found here:·      https://www.nice.org.uk/guidance/ng245Asthma pathway (BTS, NICE, SIGN) can be found here:·      https://www.nice.org.uk/guidance/ng244Endometriosis: diagnosis and management can be found here:·      https://www.nice.org.uk/guidance/ng73Menopause: identification and management can be found here:·      https://www.nice.org.uk/guidance/ng23TranscriptIf 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 November 2024, focusing on what is relevant in Primary Care only.  In today’s episode we’re covering 3 really important clinical areas. We’ll look at the updates on endometriosis, the all-important menopause, and, of course, the wow factor, the one guideline that we’ve all been waiting for: the new collaborative guideline on asthma! Yes, it’s finally here!  Right, let’s jump into it And, of course, we have to start with the star of the show, the new guideline on the diagnosis, monitoring and management of chronic asthma.  This is a new collaborative guideline developed jointly by NICE, the British Thoracic Society (or BTS), and the Scottish Intercollegiate Guidelines Network (or SIGN).It updates and replaces parts of the BTS/SIGN guideline as well as previous NICE guidance. There’s also an updated asthma pathway, which presents the same recommendations in a different format. This is a major development, so today I’ll just focus on the highlights. But I will dedicate the next episodes to cover this guideline in detail, so stay tuned.When someone presents with a history suggestive of asthma, we need to confirm the diagnosis with objective tests. And from a diagnosis perspective, there are 3 groups of patients:·      Those aged over 16·      Those aged 5 to 16 and ·      Those aged under 5So, to confirm the diagnosis in anyone over the age of 16 with suggestive asthma symptoms we will start by measuring the blood eosinophil count or FeNO level.And we will diagnose asthma if:The Eosinophil count is high, orFeNO level is 50 ppb or more.Then, if these tests are negative and we still suspect asthma, we will do a spirometry with reversibility and diagnose asthma:·      if FEV1 increases by ≥ 12% from baseline and by ≥ 200 ml or, and this is new,if the FEV1 increase is 10% or more of the predicted normal FEV1(that is, not the baseline)If spirometry is unavailable or it is delayed, we will use peak flow (PEF) variability checking readings twice daily over 2 weeks and diagnose asthma if variability ≥ 20%.If all tests are negative and there are still diagnostic doubts, we will refer for a bronchial challenge test.The process is slightly different in children aged 5 to 16, because, as the initial test we will just:measure FeNO levels and diagnose asthma if level ≥ 35 ppb.This is also new because before FeNO testing was not recommended as an initial test in this age group. And please also note that we will not use eosinophil count as an initial test here, although it can play a part at a later stage. But we will come to that a little later.If FeNO is not raised or is unavailable and asthma is still suspected in this group of children:We will check spirometry with reversibility and diagnose asthma if FEV1 increases ≥ 12%. But it does not need to be more than 200mlIf spirometry with reversibility is not raised or is unavailable:We will check peak flow readings twice daily for two weeks and diagnose asthma if variability ≥ 20%.And finally, if asthma is not diagnosed with any of the above tests, we will move to Sensitisation Tests by:·      Doing skin prick testing for house dust mite or measuring total IgE and eosinophil count.And then we will diagnose asthma if:Sensitisation is present on skin prick testing, orTotal IgE is raised and eosinophil count > 0.5 × 10⁹/L.If all tests are negative and there are still diagnostic doubts, we will refer to paediatrics.Diagnosing asthma in the under 5s is more complex and requires clinical judgement, so we will not cover this today.Now that we have looked at the diagnosis, let’s look at what monitoring is recommended. And a significant change is that we are now advised to avoid regular peak flow monitoring unless it's part of a personalised asthma action plan. Instead, we are advised to monitor symptoms and use validated symptom questionnaires for both adults and children. Additionally, for adults, we can also consider monitoring FeNO levels at regular reviews and before or after treatment changes.And finally, let’s touch on a few new treatment recommendations. And the main development is the end of step 1 treatment, where intermittent short-acting bronchodilators were used alone. From now on, the golden rule is clear: no prescribing short-acting beta2 agonists (or SABAs) for asthma at any age without an inhaled corticosteroid (ICS).Let’s look at the management in a little more detail. And from a treatment perspective, there are three groups: ·      Those aged 12 and over·      Those aged 5 to 11 and·      Those aged under 5 For those aged 12 and over, the first step is to offer on-demand AIR therapy. So, what is AIR therapy? It stands for Anti-inflammatory Reliever therapy, where formoterol is used as a reliever in an inhaler that also contains an anti-inflammatory corticosteroid. While many of us are familiar with the MART regimen (that is, Maintenance and Reliever Therapy), AIR therapy is different: it involves using a formoterol/corticosteroid inhaler only in response to symptoms, without regular maintenance dosing. Currently, only specific budesonide/formoterol inhalers are licensed for this, with a low-dose budesonide/formoterol combination recommended as on-demand AIR therapy. So, anyone in this age group who is currently on PRN salbutamol only should now be switched to AIR therapy instead.However, whilst this is really the death of the salbutamol inhaler for anyone aged 12 and over, there is still a role for it in children under 12, for whom a SABA may be prescribed, although always alongside an inhaled corticosteroid.There are a few more changes but, as a taster, we will stop it here today, as we will be covering the full guideline more extensively in future episodes. But, in summary, for me, the highlights are that: ·      New diagnostic criteria for adults include a high eosinophil count and a post bronchodilator increase in FEV1 of the predicted normal FEV1by 10% or more.·      FeNO testing is the main initial test for children aged 5 to 16. ·      Skin prick testing, serum IgE, and eosinophil count now have a role in diagnosing asthma. ·      Peak flow readings are no longer recommended for routine monitoring. ·      And in a notable shift, SABAs have vanished from the management of patients aged 12 and over but remain in use for those under 12.Let’s now move to the updates of endometriosis:And now we are advised to ask if there are any first-degree relatives with a history of endometriosis, as this increases the likelihood of developing it.We should offer an abdominal and an internal vaginal examination as part of the initial assessment, but only an abdominal examination if a vaginal examination is declined, or not suitable.We will offer a transvaginal ultrasound scan even if the examination is normal. If it is declined or not suitable, we will organise a transabdominal pelvic ultrasound instead.But we should not exclude the possibility of endometriosis if the examination and ultrasound scans are normal, so referral may still be necessary for consideration of pelvic MRI scan and laparoscopy.And finally, we will not offer hormonal treatment if they are trying to conceive, because this management does not improve spontaneous pregnancy rates. And now, let’s look at the updated Menopause guideline There are new recommendations on CBT to manage menopausal symptoms and we are advised to consider menopause-specific CBT as a treatment option. There are also new recommendations on managing genitourinary symptoms.If there is no history of breast cancer, we will offer vaginal oestrogen (including to those using systemic HRT), explaining that vaginal oestrogen is absorbed locally and only a minimal amount is absorbed into the bloodstream which is unlikely to have a significant systemic effect. We should also give advice on the use of non-hormonal moisturisers or lubricants, which can be used either alone or in combination with vaginal oestrogens.In resistant or difficult to treat cases, we can consider vaginal prasterone and oral ospemifene.However, if there is a personal history of breast cancer, we will offer non-hormonal moisturisers or lubricants instead. Vaginal oestrogens can still be considered in certain circumstances by a menopause specialist, although this would be an off-label use and the individual safety should be assessed carefully.For example, in oestrogen receptor negative breast cancer, vaginal oestrogen is unlikely to increase the risk, and so it is likely to be safe. On the other hand, in oestrogen receptor positive breast cancer, the risk of vaginal oestrogens is unknown but there is a potential risk. And finally, there are also new recommendations on the effects of HRT on specific health outcomes. There are tables in the guideline that you can use to explain the risks and benefits to patients, so I will only touch briefly on some key aspects. For example, if there is a history of coronary heart disease or stroke, HRT should be discussed with a menopause specialist. This also applies to anyone with a history of breast cancer or at high risk of breast cancer.The Breast cancer risk increases with combined HRT but there is little or no increase in the risk of breast cancer mortality with oestrogen-only HRT.And Stroke risk is unlikely to increase with transdermal combined HRT but it increases with oral combined HRT.And finally, we should not offer HRT for primary or secondary prevention of cardiovascular disease or for the purpose of dementia prevention. 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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