Primary Care Guidelines

The video version of this podcast can be found here: ·      https://youtu.be/IzuigE4BNVMThis 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 October 2025 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 October 2025 can be found here: ·      https://www.nice.org.uk/guidance/published?from=2025-10-01&to=2025-10-31&ndt=Guidance&ndt=Quality+standard The updated Quality standard on head injury [QS74] can be found here:·      https://www.nice.org.uk/guidance/qs74TranscriptIf 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’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in October 2025, focusing on what is relevant in Primary Care only.And this time there hasn’t been an awful lot that is relevant to Primary care, only an update to the quality standard on head injury.  Right, let’s jump into it.The updated quality standard on head injury covers the assessment, management and rehabilitation after a head injury. While much of it applies to secondary care, there are important areas where we play an important role in general practice This updated quality standard focuses on the NICE guideline on head injury and rehabilitation for chronic neurological disorders. For GPs, the main message is on recognition and referral. When a patient presents after a head injury, the standard reinforces the importance of same-day assessment and appropriate referral for imaging. The thresholds for CT scans are unchanged, but we should ensure rapid referral if the criteria are met. But what exactly are these referral criteria? Let’s have a look at them.The criteria can be divided between emergency referrals and urgent referrals, depending on whether imaging should be done within 1 hour or within 8 hours.Let’s look at the emergency referral criteria first. They may appear fairly obvious but it is still worthwhile going through them:For those aged 16 and over, we need to do a CT head scan within 1 hour if any of the following risk factors are present: a Glasgow Coma Scale (GCS) score of 12 or less on initial assessmenta GCS score of less than 15 at 2 hours after injurya suspected skull fractureA post-traumatic seizurea focal neurological deficit more than one episode of vomiting andany worrying signs of a basal skull fracture such as haemotympanum, “panda” eyes, cerebrospinal fluid leakage from the ear or nose and bruising over the mastoid process, also known as Battle’s signFor children under 16, in addition to what has already been mentioned, we also need to do a CT scan of the head within 1 hour if any of the following apply:a suspicion of non-accidental injuryGCS < 14 or < 15 for babies on initial assessmentGCS < 15 at 2 h a tense fontanelle andfor babies under 1 year also a head swelling or laceration > 5 cmAdditionally, a CT should be done within 1 hour if children have more than one of the following risk factors:witnessed loss of consciousness >5 minutesabnormal drowsiness3 or more episodes of vomitingdangerous mechanism of injuryamnesia >5 minutes andany bleeding disorderNow, let’s look at the urgent referral criteria, that is, when a CT head scan should be done within 8 hours:For adults we will do a CT head scan within 8 hours of the head injury, or within one hour if they present more than 8 hours after the injury, if they have had loss of consciousness or amnesia and they also have any of the following factors:age 65 or overany bleeding or clotting disorder (including anticoagulants) and a dangerous mechanism of injury, for example, a pedestrian/cyclist being hit by car, a fall from >1 m or >5 stairs, or more than 30 minutes’ retrograde amnesia before the injury Additionally, even if there is no other indication, we should consider a CT head scan within 8 hours of injury (or within 1 hour if presenting >8 hours after injury) for anyone on anticoagulant treatment. This includes warfarin, DOACs, heparin, and antiplatelet treatment excluding aspirin monotherapyIn practice this means that if a patient comes with head trauma, we will need to identify if any of these thresholds are met and refer them appropriately via A&E for imaging. Our role is not to decide whether a CT is indicated or not, but to pick up risk factors, and expedite referral.Now, going back to the quality statements, the rest of them simply emphasise the role of rehabilitation. In this respect in Primary Care, we should ensure that referral to community neuro-rehabilitation or therapy services happens in a timely fashion and that rehabilitation plans, and shared care arrangements are in place. In summary: the update doesn’t change the imaging thresholds but for us, it emphasises follow-up, rehabilitation, and long-term management after a head injury.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.

The video version of this podcast can be found here: ·      https://youtu.be/30qLbVnKHW8My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I give a brief overview of the mechanism of action of sacubitril valsartan for heart failure.The NICE guidance on Chronic Heart Failure is covered in these episodes:Part 1- Diagnosis: https://youtu.be/hjKE4JAQM6c Part 2 – Drug management: https://youtu.be/UGD7-osSlv0 Part 3 – Additional management: https://youtu.be/i0L-Nv4bJzs 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 NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here: ·      https://www.nice.org.uk/guidance/ng106 Additional information on ARNIs can be found here: ·      https://www.ncbi.nlm.nih.gov/books/NBK507904/#:~:text=Mechanism%20of%20Action,-The%20pathophysiology%20of&text=Valsartan%20is%20an%20angiotensin%20receptor,neprilysin%20will%20accumulate%20angiotensin%20II TranscriptHello and welcome! I’m Fernando, a GP in the UK. What are Angiotensin receptor–neprilysin inhibitors? They are a relatively new class of medications used specifically in the management of heart failure with reduced ejection fraction. At present, the only available one is sacubitril/valsartan. If you are interested in learning how Sacubitril/valsartan works, here is some background information.The first thing to understand is that the pathophysiology of heart failure involves an abnormal activation of the renin-angiotensin-aldosterone system (RAAS). This leads to vasoconstriction, hypertension, increased aldosterone levels, increased sympathetic tone, and eventually, cardiac remodelling, all of which worsen the disease over time. ACEIs or ARBs play a major role in reducing HF morbidity and mortality by blocking this abnormal activationAt the same time that the renin-angiotensin-aldosterone system is activated, the natriuretic peptide system is also activated, hence the elevated BNP and NT-pro BNP seen in heart failure. This compensatory mechanism leads to vasodilation, natriuresis, and diuresis. As a result, the natriuretic peptide system decreases blood pressure, lowers the sympathetic tone, and reduces aldosterone levels. The natriuretic peptide system functions antagonistically to the renin-angiotensin-aldosterone system and has favourable impact on heart failure. Natriuretic peptides are broken down by an enzyme called neprilysin. Sacubitril/valsartan is a combination product. Sacubitril is a pro-drug that, upon activation, acts as a neprilysin inhibitor. So, it works by blocking the action of neprilysin, thus preventing the breakdown of natriuretic peptides, which leads to a prolonged duration of the favourable effects of these peptides.However, because neprilysin also breaks down angiotensin II, inhibiting neprilysin will accumulate angiotensin II. For this reason, a neprilysin inhibitor cannot be used alone; it must always be combined with an ARB to block the effect of the excess angiotensin II. This is why Valsartan is used.Another important substance broken down by neprilysin is bradykinin; neprilysin inhibition will also cause a build-up of bradykinin. Therefore, sacubitril cannot be used with an ACEI due to an increased risk of angioedema if both these drugs are combines or given in a short timeframe. And this is why when switching between ACEI and sacubitril/valsartan, the patient must undergo a 36-hour washout period to lower the risk of angioedema.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. 

The video version of this podcast can be found here: ·      https://youtu.be/i0L-Nv4bJzsThis 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 the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the additional management of heart failure. In previous episodes we covered the initial assessment and diagnosis and the drug management of the different subtypes of heart failure.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 NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here: ·      https://www.nice.org.uk/guidance/ng106 Additional information on ARNIs can be found here: ·      https://www.ncbi.nlm.nih.gov/books/NBK507904/#:~:text=Mechanism%20of%20Action,-The%20pathophysiology%20of&text=Valsartan%20is%20an%20angiotensin%20receptor,neprilysin%20will%20accumulate%20angiotensin%20II 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’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure, which was last updated in September 2025.Today’s episode focuses on the additional management of heart failure. If you haven’t already, I recommend that you check the previous episodes where we covered heart failure diagnosis and the drug management of the different subtypes of heart failure.Right, let’s jump into it.And as we have just said, today we’re going to focus on the additional management of heart failure. Now let’s start by looking at how to initiate and monitor medication use.When tailoring treatment, we should use the person’s medical history, frailty status, and prognosis to decide which specific medicine combinations to use and how to introduce them.In primary care, we should seek the advice from a heart failure specialist before starting someone on an angiotensin receptor–neprilysin inhibitor, that is, sacubitril/ valsartan.Before prescribing an ACE inhibitor, ARB, angiotensin receptor-neprilysin inhibitor (ARNI), or mineralocorticoid receptor antagonist, we will measure renal function and electrolytes.Once these drugs have been started, we should measure renal function and electrolytes:one to two weeks after starting treatment,one to two weeks after each dose increment,every three to six months once the maximum tolerated dose has been established,and at any time renal function may be compromised.If the serum creatinine increases by more than 50%, or potassium rises above 5.5 millimoles per litre, we will follow local guidelines.We will measure blood pressure, or ask the person to measure it themselves, before and after each dose increment. For people with symptoms of postural hypotension, we will measure blood pressure according to the NICE hypertension guideline, which essentially recommends ideally checking the initial blood pressure in the supine position, and then again after standing for at least 1 minute, in order to check for a drop in systolic blood pressure of 20 mmHg or more. Although checking the BP in a seated position can also be acceptable, we need to remember that measuring blood pressures from sitting to standing may miss some cases of postural hypotension, especially in older or frail people, and that measuring from lying to standing is more accurate for detecting a significant postural drop.When prescribing beta-blockers, we should not withhold treatment solely because of age, or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease, or COPD.We will assess heart rhythm, heart rate, and conduction abnormalities using a 12-lead ECG before deciding whether to prescribe a beta-blocker.We will not offer a beta-blocker to people with second-degree or third-degree heart block who do not have a pacemaker, or to those with bradycardia, that is, a heart rate below 50 beats per minute.We will assess heart rate and clinical status after each betablocker dose increment, and for people with symptoms and bradycardia, we will consider repeating a 12-lead ECG after each dose increment.For digoxin, we will not routinely monitor serum digoxin concentrations. But we should be aware that a digoxin level measured within 8 to 12 hours of the last dose may help confirm toxicity or non-adherence, but we must interpret results in the clinical context, since toxicity may occur even when the concentration is within the therapeutic range.Now, let us move on to clinical review.We will monitor all people with heart failure and provide:·      a clinical general assessment including cardiac rhythm·      a medication review checking for any necessary changes or side effects, ·      An assessment of renal function, and ·      Measurement of iron status and haemoglobin.This is just the very minimum, Additionally, we should provide more detailed monitoring for people with significant comorbidities, co-prescribed medications, or recent deterioration. The frequency of monitoring will depend on the clinical situation and the stability of the patient’s condition.If the clinical condition or medication has changed, we should monitor the patient more frequently — from days to every two weeks. For stable people with proven heart failure, we will monitor at least every six months.For people under 75 years old with heart failure with reduced ejection fraction and normal renal function — that is, an eGFR greater than 60— we can consider measuring NT-proBNP levels to monitor and optimise treatment.Now let’s look at other treatments and advice relevant to all types of heart failure.We will use diuretics to relieve congestive symptoms and fluid retention, and we will titrate the dose up or down as needed, always using the lowest effective dose.Amiodarone, should be started under specialist supervision and we will review the need to continue it every six months, and at each review, we will check liver and thyroid function tests and assess for side effects.For people with heart failure and atrial fibrillation, we will follow the NICE recommendations on anticoagulation for stroke prevention. For people in sinus rhythm, we will consider anticoagulation if there is a history of thromboembolism, left ventricular aneurysm, or intracardiac thrombus.We should offer annual influenza vaccination and a one-time pneumococcal vaccination to all people with heart failure.For people of childbearing potential, we should discuss contraception and pregnancy. If pregnancy is being contemplated or occurs, we will seek specialist advice from both cardiology and obstetrics.We will not routinely advise people with heart failure to restrict sodium or fluid intake. However, we should ask about salt and fluid consumption and provide advice when necessary, for example, by restricting fluids for dilutional hyponatraemia or by reducing intake for those with high salt or fluid consumption. Additionally, we will advise people to avoid salt substitutes that contain potassium in order to minimise the risk of hyperkalaemia.In terms of air travel, we can advise that it will be possible for most people, depending on their clinical condition at the time. Regarding driving, we will simply follow DVLA guidelines.We should offer people wit

The video version of this podcast can be found here: ·      https://youtu.be/UGD7-osSlv0This 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 the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the drug management of the different subtypes of heart failure. The guidance on the remaining aspects of heart failure management will be covered in other episodes. In the previous episode we covered the initial assessment and diagnosis.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 NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here: ·      https://www.nice.org.uk/guidance/ng106 Additional information on ARNIs can be found here: ·      https://www.ncbi.nlm.nih.gov/books/NBK507904/#:~:text=Mechanism%20of%20Action,-The%20pathophysiology%20of&text=Valsartan%20is%20an%20angiotensin%20receptor,neprilysin%20will%20accumulate%20angiotensin%20II 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’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure in adults, which was last updated in September 2025.Today’s episode focuses on the drug management of the different subtypes of heart failure. If you haven’t already, I recommend that you check the previous episode on heart failure diagnosis.The guidance on the remaining aspects of heart failure management will be covered in the next episode, so stay tuned.Right, let’s jump into it.And as we have just said, today we’re going to focus on the specific drug treatment for heart failure.Also, as we said in the previous episode, echocardiograms assess both systolic and diastolic function of the left ventricle. Categorising cardiac function is crucial because the treatment of heart failure will be different depending on the ejection fraction. We classify heart failure as follows:Heart failure with reduced ejection fraction, when the ejection fraction is 40% or below.Heart failure with mildly reduced ejection fraction, when it is between 41 and 49%.And Heart failure with preserved ejection fraction, when it is 50% or higher.So let’s have look at the treatment of each of these subtypes For people with heart failure with reduced ejection fraction, we will offer a combination of four medicines:·      an ACE inhibitor, ·      a beta-blocker, ·      a mineralocorticoid receptor antagonist, and ·      an SGLT-2 inhibitor.For people who are on the maximum tolerated dose of each of these four medicines but continue to have symptoms of heart failure, we should consider switching the ACE inhibitor to an angiotensin receptor–neprilysin inhibitor. What are Angiotensin receptor–neprilysin inhibitors? They are a relatively new class of medications used specifically in the management of heart failure with reduced ejection fraction. At present, the only available one is sacubitril/valsartan, which combines two mechanisms of action:Sacubitril, which inhibits neprilysin — an enzyme that breaks down beneficial natriuretic peptides. By blocking neprilysin, sacubitril helps with vasodilation, sodium excretion, and reduced cardiac remodelling.And then we have Valsartan, an angiotensin II receptor blocker (ARB), which helps counteract the harmful effects of the renin–angiotensin–aldosterone system by reducing vasoconstriction, sodium retention, and aldosterone secretion.Together, the combination of sacubitril and valsartan improves cardiac function, reduces hospitalisations, and lowers mortality in patients with heart failure with reduced ejection fraction.OK, let’s go back to the general management of heart failure with reduced ejection fraction. And we need to note that if certain medicines are not tolerated, there are alternative treatment combinations that we should consider.For example, for people who have had angioedema after taking an ACE inhibitor, we will still offer a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor, and we should also consider an angiotensin receptor blocker, or ARB instead of the ACEI. This is because the risk of angioedema is lower with ARBs than with ACE inhibitors, although it is not zero so we should use caution and monitor the patient accordingly. An important safety add-on is that we should not use sacubitril/valsartan in anyone with a history of angioedema, as this is listed as a contraindication.People with heart failure with reduced ejection fraction who have symptoms of intolerance to ACE inhibitors, other than angioedema, should have a beta-blocker, an MRA, an SGLT2 inhibitor and sacubitril/valsartan. The initiation of sacubitril valsartan should be guided by a heart failure specialistAdditionally, in people with heart failure with reduced ejection fraction, we should assess iron status and check for anaemia using:·      transferrin saturation (TSAT), ·      serum ferritin, and ·      haemoglobin.For people with heart failure with reduced ejection fraction and haemoglobin less than 150 grams per litre, and iron deficiency, that is, a TSAT less than 20% or serum ferritin less than 100, we should offer intravenous iron therapy. This is because trial evidence shows that IV iron improves symptoms and quality of life and reduces HF hospitalizations in several settings, especially in patients with symptomatic heart failure with reduced ejection fraction. If iron deficiency anaemia is identified, we should not assume it is related to the person’s heart failure, and we should consider investigating for alternative causes.There are other drugs that can be initiated in a specialist setting. I will not cover them in detail, but specialist treatments options include ivabradine, hydralazine in combination with a nitrate, and digoxin.Additionally, in heart failure with reduced ejection fraction we should avoid verapamil, diltiazem, and short-acting dihydropyridine calcium-channel blockers. The “why” boils down to hemodynamics and outcomes:Verapamil & diltiazem are negative inotropes and slow AV conduction. In heart failure with reduced ejection fraction that can worsen cardiac function and precipitate decompensation.Then Short-acting dihydropyridines (like immediate-release nifedipine) cause rapid vasodilation and reflex tachycardia and hypotension, which has been linked to increased mortality, so it is considered unsafe in HFFor people with heart failure with mildly reduced ejection fraction, we should also consider treatment with the same four drugs as the reduced ejection fraction subtype, that is, an ACE inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor.For those who have symptoms of intolerance to ACE inhibitors, we should consider an ARB, a beta-blocker, an MRA, and an SGLT2 inhibitor. But we need to note that an angiotensin receptor–neprilysin inhibitor, that is, sacubitril/valsartan, is not recommended in heart failure with mildly reduced ejection fraction. It is recommended only in heart failure with reduced ejection fraction.SGLT2 inhibitors specifically recommended by NICE for heart failure with mildly reduced ejection fraction, are empagliflozin and dapagliflozin, for which we have specific NICE recommenda

The video version of this podcast can be found here: ·      https://youtu.be/hjKE4JAQM6cThis 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 the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the initial assessment and diagnosis.The guidance on the remaining aspects of heart failure management will be covered in future episodes.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 NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here:·      https://www.nice.org.uk/guidance/ng106 Additional information on ARNIs can be found here: ·      https://www.ncbi.nlm.nih.gov/books/NBK507904/#:~:text=Mechanism%20of%20Action,-The%20pathophysiology%20of&text=Valsartan%20is%20an%20angiotensin%20receptor,neprilysin%20will%20accumulate%20angiotensin%20II 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’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure in adults, which was last updated in September 2025.Today’s episode focuses on the initial assessment and diagnosis.The guidance on the remaining aspects of heart failure management will be covered over forthcoming episodes so stay tuned.Right, let’s jump into it.And as we have just said, today we’re going to focus on how we diagnose heart failure.We will obviously begin by taking a thorough history, performing a clinical examination, and arranging appropriate tests to confirm the diagnosis.And we should start by measuring N-terminal pro-B-type natriuretic peptide, or NT-proBNP, in anyone with suspected heart failure. Because very high levels of NT-proBNP carry a poor prognosis, we will refer people with suspected heart failure and an NT-proBNP level above 2,000 nanograms per litre — or 236 picomoles per litre — urgently, for specialist assessment and an echocardiogram within two weeks.We should refer people with suspected heart failure and lower NT-proBNP levels, between 400 and 2,000 nanograms per litre — that’s 47 to 236 picomoles per litre — for specialist assessment and an echocardiogram but this time to be seen within six weeks.We need to be aware that an NT-proBNP level below 400 nanograms per litre, or 47 picomoles per litre, in an untreated person makes a diagnosis of heart failure less likely. We also need to remember that the level of serum natriuretic peptide does not differentiate between heart failure with preserved, mildly reduced, or reduced ejection fraction.When NT-proBNP levels are below 400 nanograms per litre, we should consider alternative causes for the symptoms. If there’s still concern that the symptoms might be related to heart failure, we should discuss the case with a heart failure specialist.We also need to be aware that there are factors that can affect the NT-proBNP level. Examples of factors that can reduce the level are:·      Obesity·      African or African–Caribbean ethnic background, or ·      Treatment with certain medications. These include:o  Diuretics, o  Beta-blockerso  Mineralocorticoid receptor antagonistso  ACE inhibitors, ARBs ando  Angiotensin receptor-neprilysin inhibitors. And let’s just quickly say that Angiotensin receptor–neprilysin inhibitors, or ARNIs, are a relatively new class of medications used in the management of heart failure with reduced ejection fraction. At present, the only available one is sacubitril/valsartan which combines two mechanisms of action:§ Sacubitril, which inhibits neprilysin — an enzyme that breaks down beneficial natriuretic peptides. By blocking neprilysin, sacubitril helps with vasodilation, sodium excretion, and reduced cardiac remodelling.§ And then we have Valsartan, an angiotensin II receptor blocker (ARB), which helps counteract the harmful effects of the renin–angiotensin–aldosterone system by reducing vasoconstriction, sodium retention, and aldosterone secretion. Together, this combination of sacubitril and valsartan improves outcomes in patients with heart failure with reduced ejection fraction.Ok, going back to the factors that can affect NT-proBNP levels, we should remember that high levels can have causes other than heart failure — for example, pulmonary, renal, liver, or systemic disease, sepsis, COPD, diabetes, or liver cirrhosis.As we can see, the main tools to diagnose heart failure are the NT-proBNP blood test followed by a transthoracic echocardiogram. The purpose for performing transthoracic echocardiography is to exclude important valve disease, detect intracardiac shunts and assess both systolic and diastolic function of the left ventricle. Categorising cardiac function is important because the treatment of heart failure will be different depending on the ejection fraction. We classify heart failure as follows:Heart failure with reduced ejection fraction, when the ejection fraction is 40% or below.Heart failure with mildly reduced ejection fraction, when it is between 41 and 49%.And Heart failure with preserved ejection fraction, when it is 50% or higher.We will look at the specific drug treatment of each of these subtypes of heart failure in the next episode.And going back to the diagnosis, although transthoracic echocardiography is our first-line imaging option, if image quality is poor, alternative imaging methods such as radionuclide angiography, cardiac MRI, or transoesophageal echocardiography should be considered.Also, although NT-proBNP and echocardiography are the cornerstone of the diagnosis of heart failure, we should also consider further investigations to assess possible aggravating factors or alternative diagnoses. These include:·      An ECG·      A chest X-ray·      Blood tests including renal, liver and thyroid function tests, a lipid profile, HbA1c, and a full blood count ·      And we will also do Urinalysis, and ·      Peak flow or spirometry.We do this because we should always try to exclude other disorders that may present in a similar manner. Once a diagnosis of heart failure has been made, we will assess its severity, causes, precipitating factors, type of cardiac dysfunction, and any correctable causes, and, in particular, for people with heart failure caused by valve disease, we will refer them for specialist assessment and advice.We should also review patients with a historical diagnosis of heart failure, and manage them according to the NICE guideline only if the diagnosis has been confirmed with an echocardiogram. If heart failure is still suspected but no underlying cardiac abnormality has been identified on imaging, we will refer to a heart failure specialist.So that is it, a review of the initial assessment and diagnosis of heart failure.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. 

The video version of this podcast can be found here: ·      https://youtu.be/qZPisPCp4eQThis 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 September 2025 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 September 2025 can be found here: ·      https://www.nice.org.uk/guidance/published?from=2025-09-01&to=2025-09-30&ndt=Guidance&ndt=Quality+standardThe updated Clinical guideline CG57 on Atopic eczema in under 12s: diagnosis and management can be found here: ·      https://www.nice.org.uk/guidance/cg57 The updated NICE guideline on Chronic heart failure in adults: diagnosis and management NG106 can be found here:·      https://www.nice.org.uk/guidance/ng106 The updated Quality standard on Chronic heart failure in adults QS9 can be found here:·      https://www.nice.org.uk/guidance/qs9 The new NICE guideline on Pneumonia: diagnosis and management NG250 can be found here:·      https://www.nice.org.uk/guidance/ng250 The updated Quality standard on Pneumonia: diagnosis and management QS110 can be found here:·      https://www.nice.org.uk/guidance/qs110The updated NICE guideline on Suspected acute respiratory infection in over 16s: assessment at first presentation and initial management NG237 can be found here:·      https://www.nice.org.uk/guidance/ng237 The updated Clinical guideline on Bipolar disorder: assessment and management CG185 can be found here:·      https://www.nice.org.uk/guidance/cg185 The updated technology appraisal guidance on Tirzepatide for treating type 2 diabetes TA924 can be found here:·      https://www.nice.org.uk/guidance/ta924 The updated Technology appraisal guidance on Tirzepatide for managing overweight and obesity TA1026 can be found here:·      https://www.nice.org.uk/guidance/ta1026 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’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in September 2025, focusing on what is relevant in Primary Care only.In recent months, there hasn’t been much in the way of updates that directly affect us in General Practice. But September is very different — there’s a lot we need to pay attention to. These updates cover eczema, respiratory infections, pneumonia, bipolar disorder, tirzepatide, and, importantly, a new updated guideline on chronic heart failure.Right, let’s jump into it.The updated NICE guideline on atopic eczema in children under 12 has revised the section on complementary therapies, washing, and clothing. The new wording makes it clear that children with atopic eczema may bathe or shower once daily. Bathing can help remove crusts and skin debris and improve comfort, but it should always be followed by emollient application to prevent the skin from drying out.The update also clarifies that water softeners and silk garments do not improve eczema severity and therefore should not be recommended.So, in summary: daily bathing is acceptable and can be beneficial if followed by emollient use, and water softeners or silk clothing should not be recommended because they provide no proven benefit.The next section is on Chronic Heart failure. The updated NICE guideline has introduced substantial changes, particularly to how we treat and monitor different categories of heart failure. This is such an important area that I’ll only cover the highlights today, as I will cover it in more detail in a future episode.The main focus of the update was the drug management of the three subtypes of heart failure, that is, heart failure with reduced ejection fraction, mildly reduced ejection fraction, and preserved ejection fraction.For heart failure with reduced ejection fraction, that is, an ejection fraction 40% or less, the recommendations now reflect strong evidence for SGLT-2 inhibitors, which consistently reduce hospitalisations for heart failure and improve survival regardless of diabetes status. These drugs are now embedded alongside established treatments such as ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists.For heart failure with mildly reduced ejection fraction — that is, an ejection fraction between 41% and 49% — NICE issues new recommendations for the first time. This group used to be a bit of a grey area. The update highlights evidence that people with mildly reduced EF may benefit from SGLT-2 inhibitors in much the same way as those with reduced EF, and the guidance now advises considering them here too.For heart failure with preserved ejection fraction, meaning an ejection fraction of 50% or more, NICE also makes new recommendations. In the past, management was mostly limited to controlling symptoms and comorbidities. Now, on the back of trial evidence, SGLT-2 inhibitors are also recommended here because they reduce hospitalisations for heart failure, even if mortality benefit is less certain.In practice, this means SGLT-2 inhibitors will be used much more widely — not only in people with reduced EF, but also in those with mildly reduced or preserved EF.An updated NICE Quality Standard on chronic heart failure has also been published, bringing it into line with these changes.Next, there is a brand-new NICE guideline on pneumonia, which consolidates and replaces previous guidance, including antimicrobial prescribing guidelines.The biggest change for us in primary care relates to children: the recommended course of antibiotics for non-severe community-acquired pneumonia without complications or underlying disease has been reduced from 5 days to 3 days. This is because evidence shows that shorter courses are just as effective at resolving symptoms, while reducing the risk of side effects and, most importantly, lowering the risk of antibiotic resistance.Additionally, although more relevant to secondary care, there are new recommendations on corticosteroids in patients with high-severity community-acquired pneumonia when admitted to hospital. This reflects growing evidence that systemic steroids can improve outcomes in severe cases alongside standard antibiotic and supportive care. However, corticosteroids are not recommended for routine use in mild or moderate pneumonia, so it is something that we will not be doing routinely in Primary Care.There is also an updated Quality Standard on pneumonia, aligned with the new guideline and reflecting the changes I’ve just mentioned.Next, we have the updated NICE guideline on suspected acute respiratory infection which covers assessment at first presentation and initial management.The main change here is that the section on the clinical diagnosis of community-acquired pneumonia in primary care has been removed, because that information is now fully covered by the new pneumonia guideline. In practical terms, pneumonia-specific recommendations move to the pneumonia guideline, while the guideline on respiratory infections continues to provide guidance on the assessment and initial management of these infections more broadly.This guideline should also be read alongside NICE’s existing antimicrobial prescribing guidelines for acute cough, COPD exacerbations, sinus

The video version of this podcast can be found here: ·      https://youtu.be/AC3ncdm77OsThis 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 the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below.The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will cover 4 clinical groups and the remaining groups were covered in last week’s episode.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 NICE announcement on Type 2 diabetes management can be found here: ·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced The NICE draft guideline on Type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450 The visual summary of the NICE draft guideline on type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2 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’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the main changes as applied to 7 specific groups of patients. In the previous episode we covered the first 3 groups so today we will cover the rest.Right, let’s jump into it.And, as you know, the draft guideline is open for consultation until October, and the final guidance is due in February 2026, so let’s not forget that it is only a draft, and we should not be making clinical decisions based on it yet.Today’s episode is based on the visual summary created by NICE and the link to it is in the episode description. The visual summary includes specific guidance for 7 different groups of patients:1.   The group of patients with no relevant comorbidities, then2.   Obesity3.   Frailty4.   CKD5.   Heart failure6.   Atherosclerotic cardiovascular disease and 7.   Early onset type 2 diabetesAnd today we will look at the last 4 groups that we did not cover last time.So let’s start with the CKD group.For people with CKD, like for many of the other groups. the draft guideline recommends starting treatment with metformin plus an SGLT-2 inhibitor. Because of licensing reasons, we are advised to choose either empagliflozin or dapagliflozin in this group. If metformin is contraindicated or not tolerated, the SGLT-2 inhibitor can be offered on its own. Treatment will also depend on kidney function, measured by eGFR. As we know, metformin in contraindicated if eGFR is less than 30, and, given that SGLT-2 efficacy decreases with advancing renal impairment, NICE recommends not using empagliflozin or dapagliflozin is eGFR is less than 20. Therefore, the first line treatment on this basis is as follows:If eGFR is above 30 mL/min/1.73 m², in principle we will offer metformin plus dapagliflozin or empagliflozin, although, if metformin is not tolerated the SGLT-2 inhibitor can be given by itself.If eGFR is between 20 and 30, we will offer either dapagliflozin or empagliflozin alone.And, if eGFR is below 20, we will then go for a DPP-4 inhibitor in preference. If that is contraindicated or not tolerated, we will consider pioglitazone or insulin, given that sulfonylureas should not be given if the eGFR is below 30. This is because sulfonylureas accumulate in renal impairment and increase the hypoglycaemia risk.If further glycaemic lowering is needed after first line treatment, we can use other options including DPP-4 inhibitors (if not already used), sulfonylureas or insulin depending on renal function and safety profile.How does this differ from the previous guidance?Like in other groups, the big change here is the earlier, more proactive use of SGLT-2 inhibitors specifically for renal protection, not just glucose lowering. Previously, SGLT-2 inhibitors were used after metformin for people with established albuminuria or heart failure. Now, the draft guidance recognises the trial evidence showing that, apart from the cardiovascular benefits, SGLT2 inhibitors also reduce progression of CKD, and this benefit occurs even in people with moderately reduced eGFR and independently of albuminuria. The slower progression of CKD is because SGLT2 inhibitors reduce albuminuria, intraglomerular pressure and protect against hyperfiltration.Another nuance is that the draft now pushes dapagliflozin and empagliflozin explicitly into first-line therapy alongside metformin or alone if necessary, with thresholds set according to kidney function. And it also sets out a clear sequence for treatment as eGFR declines, including when to use DPP-4 inhibitors or move to insulin.What this means in practice is that:We will need to check eGFR early and often, as it will determine the choice of treatment.Metformin + SGLT-2 inhibitor is the default down to eGFR 30; SGLT-2 inhibitor alone is preferred between 20 and 30, and below 20, we will switch to a DPP-4 inhibitor, and only after that will we consider pioglitazone or insulin if needed.And, practically, the bigger focus on protecting kidney function means that more patients will be started on dapagliflozin or empagliflozin earlier, so we will need to familiarise ourselves with renal thresholds and side effect monitoring.Now, let’s move to the heart failure group.For adults with type 2 diabetes and heart failure, NICE also recommends that the initial therapy should be metformin plus an SGLT-2 inhibitor. If metformin is contraindicated or not tolerated, then an SGLT-2 inhibitor alone is advised. If additional therapy is needed to help with weight management, then a GLP-1 receptor agonist (specifically subcutaneous semaglutide) can be considered provided there is no frailty and the patient has a preserved ejection fraction. After that, for further glycaemic lowering, we can add a sulfonylurea or insulin, remembering that pioglitazone is contraindicated in heart failure The difference with the old guideline is that the draft makes metformin + SGLT-2 inhibitor the standard, aiming to get heart failure-related benefits earlier. As we know, trial data show that SGLT2 inhibitors reduce hospitalization for heart failure, improve symptoms, slow progression, and improve cardiovascular mortality, independent of glycaemic control. So, using them early helps not just glucose but also cardiac outcomes.But another big change is that the draft also acknowledges that weight loss (from GLP-1 RAs) can help reduce cardiac workload, reduce fluid overload, and improve quality of life in heart failure. Combining SGLT-2 inhibitors with semaglutide in patients for whom weight is an issue, is intended to deliver a dual benefit: cardiorenal protection and weight reduction. Previously, GLP-1 RAs were less likely to be used early in heart failure, and semaglutide had stricter criteria; now, semaglutide is explicitly considered earlier in heart failure when weight benefit is also a goal. Any limitations? Well, semaglutide will be limited to patients with obesity, preserved EF and no frailty. Frailty and ejection fraction matter because the benefits and risks of semaglutide

The video version of this podcast can be found here: ·      https://youtu.be/M0s2Vvlia70This 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 the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below.The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will cover three clinical groups  and the remaining groups will be done in next week’s episode.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=ecJGF5QCuMLQ6hrkThe NICE announcement on Type 2 diabetes management can be found here: ·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced The NICE draft guideline on Type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450 The visual summary of the NICE draft guideline on type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2 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’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the main changes as applied to 7 specific groups of patients. Right, let’s jump into it.And, as you know, the draft guideline is open for consultation until October, and the final guidance is due in February 2026, so let’s not forget that it is only a draft, and we should not be making clinical decisions based on it yet.Today’s episode is based on the visual summary created by NICE and the link to it is in the episode description. The visual summary includes specific guidance for 7 different group of patients. In today’s episode we will cover three of the groups and we will finish the other groups in next week’s episode.There are 7 groups:1.   First, the group of patients with no relevant comorbidities, then2.   Obesity3.   Frailty4.   CKD5.   Heart failure6.   Atherosclerotic cardiovascular disease and 7.   Early onset type 2 diabetesSo let’s start with the no relevant comorbidities group.For adults with type 2 diabetes and no major comorbidities, the draft recommends metformin plus an SGLT-2 inhibitor from the outset. If metformin is contraindicated or not tolerated, then an SGLT-2 inhibitor alone should be offered. If further glycaemic lowering is required, the next step is to add a DPP-4 inhibitor and if this is not effective or tolerated, we can try a sulfonylurea, pioglitazone, or insulin.This is very different from the previous guidance, which began with metformin monotherapy, and only added other agents if HbA1c targets were not met. SGLT-2 inhibitors and GLP-1 receptor agonists were generally reserved for people with established cardiovascular or renal disease, or later in the treatment pathway. The draft changes our thinking on everything by recommending dual therapy right at diagnosis for all, even in people without comorbidities. Why is NICE changing the advice?As we have already explained, evidence shows that SGLT-2 inhibitors consistently reduce heart failure admissions, slow CKD progression, and lower cardiovascular death. Trials have showed these effects in people without established CVD they are now recommended for all, not just for the high-risk subgroups.What this means in practice is that now:The default first-line choice is now metformin + SGLT-2 inhibitor, not metformin alone.More people will start dual therapy earlier, meaning that we will need to discuss SGLT-2 inhibitor side effects like the risk of genital infections, volume depletion, sick-day rules, and renal monitoring from the start.In those who can’t tolerate metformin, an SGLT-2 inhibitor alone is acceptable. We also need to consider the fact that SGLT2 inhibitors will now be prescribed long term unless there are specific reasons to stop them.And, if further glucose control is needed, add-ons agents remain available but they now come after the SGLT-2 inhibitor, not before.The next group is the obesity group:For people with type 2 diabetes who also have obesity, the draft recommends also starting with metformin plus an SGLT-2 inhibitor. However, if further treatment is needed to reach glycaemic targets, we will add a GLP-1 receptor agonist if initial therapy started 3 months ago or more. This will usually mean adding subcutaneous semaglutide, provided there are no concerns about frailty and they have preserved ejection fraction (i.e., heart function is acceptable). If metformin is contraindicated or not tolerated, the pathway is to offer an SGLT-2 inhibitor plus semaglutide. We are again reminded that GLP1 receptor agonists and DPP-4 inhibitors should not be combined. Therefore, if the patient is on a GLP-1 receptor agonist and further glycaemic control is needed, the next add-on therapies are sulfonylurea, pioglitazone, or insulin depending on the case.  However, if a GLP-1 receptor agonist is contraindicated, not tolerated, or not appropriate, we will add a DPP-4 inhibitor first before considering other agents such as a sulfonylurea, pioglitazone, or insulin, as all of these can lead to weight gain.And let’s remember that previously, people with obesity were more likely to have a stepwise approach: metformin first, then add other agents and then move to GLP-1 RAs only if at last resort and if specific BMI thresholds were crossed.The draft changes this: it brings semaglutide forward, in obesity and when weight reduction is a priority, also giving more flexibility in continuing GLP-1s if weight or glycaemic goals are lagging—as long as obesity remains a priority.Why is NICE making this change?Primarily because there is strong trial evidence that GLP-1 receptor agonists produce sustained weight loss andadditionally, evidence has accumulated around reduced major adverse cardiovascular events And finally, another justification is that many people with obesity carry a higher lifetime risk of cardiovascular disease so delaying GLP1 receptor agonists may mean a missed opportunity to reduce morbidity and mortality.What does it mean in practice?Well, we will need to identify patients with both diabetes and obesity early, and discuss semaglutide sooner than before.Shared decision making must cover not only the benefits (weight loss, better cardiovascular risk, possibly better quality of life) but also the downsides like GI side-effects like nausea, and vomiting, injection route and monitoring requirements.We will also need to assess frailty and ejection fraction early and avoid semaglutide if there’s concern frailty might lead to harm (like e.g., unintentional weight loss, reduced reserves) or heart failure with reduced EF, which may be decompensated with GLP1 receptor agonist use.And, we will also need to monitor the effect on weight, glycaemia, heart and kidney function, being ready to stop the GLP1 receptor agonist if necessary.And finally, the last group today, the frailty group.The draft guidance states that if the person’s level of frailty increases the risk of adverse events from SGLT-2 inhibitors, we will consider metformin alone initially. If metformin is

The video version of this podcast can be found here: ·      https://youtu.be/xB8BStN4OwgThis 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 the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below.The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will review the general guidance and we will cover the various groups in future episodes.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 NICE announcement on Type 2 diabetes management can be found here: ·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced The NICE draft guideline on Type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450 The visual summary of the NICE draft guideline on type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2 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’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the visual summary created by NICE. I will cover the information over several episodes, so stay tuned.Right, let’s jump into it.As you may know, the draft NICE guideline on type 2 diabetes is open for public consultation until October, and the final guidance is due in February 2026. It has attracted a lot of attention, but we need to remember that, for now, it is only a draft, which means it could still change. So, we should not be making clinical decisions based on it yet.Today’s episode is based on the NICE visual summary and the link to it is in the episode description.The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will review the general guidance and we will cover the various groups in future episodes.The first page of the draft visual summary sets out the general approach for all.NICE begins by emphasising that diet and lifestyle are the foundation of management, and these need to be reinforced at every stage of the treatment pathway, pointing out that medicines should come on top of, and not instead of, these lifestyle measures.When choosing drug therapy, the draft recommends discussing the benefits and risks of every option. That includes looking at each drug’s effectiveness for glycaemic control but also, and this is new compared with the previous guideline, weighing its impact on cardiovascular and renal outcomes.The guideline also stresses that if a person has more than one comorbidity, for example obesity, cardiovascular disease or chronic kidney disease, we should make a shared decision with the patient about which comorbidity to prioritise in choosing treatment. This means that we move away from a purely HbA1c-driven model towards a model focused on complications and their prevention.On reviewing medicines, the draft says that before changing therapy, we should first optimise the current regimen, bearing in mind that it may be appropriate to continue some treatment options, like SGLT-2 inhibitors or GLP-1 receptor agonists even if the effect on glycaemic control is not perfect. In fact, the draft advises continuing SGLT-2 inhibitors for their heart and kidney benefits even if they are not achieving glucose or weight targets.For GLP-1 receptor agonists, the draft changes the stop rules: we will stop if they do not help the person achieve glycaemic or weight goals but only, and this is important, if the person does not have cardiovascular disease or early-onset type 2 diabetes, understood as type 2 diabetes diagnosed under the age of 40. This a huge change.  Previously, stopping criteria were more tightly linked to weight and HbA1c thresholds, for example, if the person had not lost at least 3% of body weight and dropped their HbA1c by 1% within six months. Now, because of the cardiovascular benefit of GLP-1 receptor agonists, it basically means that for people with atherosclerotic cardiovascular disease, it is continued long term, regardless of weight loss or HbA1c change. And a similar, more relaxed attitude also applies to people with early onset type 2 diabetes.But, why this recommendation?Well, this comes from trial evidence over the past decade. SGLT-2 inhibitors have consistently reduced hospitalisation for heart failure and slowed CKD progression, even when HbA1c effects were modest. Similarly, GLP-1 receptor agonists have reduced rates of major adverse cardiovascular events. Why these benefits? The pathophysiology is important here: SGLT-2 inhibitors reduce intraglomerular pressure, improve renal haemodynamics, induce diuresis, and reduce preload and afterload on the heart. On the other hand, GLP-1 receptor agonists improve weight, and have an effect on blood pressure and lipids. All these effects are the reason for the beneficial outcomes over and above glucose controlWhat this means in practice is that:The decision to start or continue medicines is now less about HbA1c in isolation, and more about long-term organ protection.SGLT-2 inhibitors should be maintained even if glycaemic targets aren’t achieved.GLP-1 receptor agonists should be stopped if they don’t achieve targets unless the person has early-onset diabetes or established cardiovascular disease in which case, their longer-term benefits justify continuation.Finally, NICE advises against combining GLP-1 receptor agonists with DPP-4 inhibitors, as this combination offers no additional benefit.Why is this? Let’s remember that DPP-4 inhibitors prevent breakdown of endogenous GLP-1, whereas GLP-1 receptor agonists directly activate GLP-1 receptors. Because the GLP-1 agonists already saturate the receptor and they are not affected by DPP-4 degradation, adding a DPP-4 inhibitor offers no additional glycemic or weight benefit. That’s why guidelines recommend using one or the other, but never both.And before we end, let’s also quickly list the main current recommendations in the draft guideline, making reference to the recommendations that have been either deleted or changed in a major way.1.   First, the recommendation to start metformin alone as first-line for most people without complications has gone. Now we will start dual Therapy with Metformin + SGLT-2 Inhibitor as Initial Therapy, the reason being the need to maximise the cardiorenal benefits of SGLT2 inhibitors.2.   Second, the restrictive conditions to start GLP1 receptor agonists have also gone. Now there is Earlier and More Explicit Use of GLP-1 Receptor Agonists, Specifically Semaglutide, in order to maximise the weight and cardiovascular benefits of GLP1 receptor agonists. In particular, semaglutide is the preferred option because it has the most consistent and strong evidence as well as being the most cost-effective.3.   Third, there is more weight on Stratification by Kidney Function and Frailty. As a result, the draft puts more weight on eGFR thresholds when deciding which medicines to use and it also identifie

The video version of this podcast can be found here: ·      https://youtu.be/mHyDaVHtb58This 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 August 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. I also give an overview of the draft NICE guideline on type 2 diabetes open for consultation until October 2025 and due for publication in February 2026. 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 August 2025 can be found here: ·      https://www.nice.org.uk/guidance/published?from=2025-08-01&to=2025-08-31&ndt=Guidance&ndt=Quality+standardThe updated quality standard Overweight and obesity management [QS212] can be found here: ·      https://www.nice.org.uk/guidance/qs212 The NICE announcement on Type 2 diabetes management can be found here: ·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced The NICE draft guideline on Type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450 The visual summary of the NICE draft guideline on type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2TranscriptIf 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’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in August 2025, focusing on what is relevant in Primary Care only.Today there’s just one updated clinical area to cover, overweight and obesity. But I will also mention that the draft NICE guideline on type 2 diabetes has now been made public, so we will discuss that too. Right, let’s jump into it.And I know most of you will be keen to hear about the new diabetes guidance, and understandably so. But before we get to that, I would like to spend the first minute and a half on an area that’s often neglected: overweight and obesity. NICE has just released a new quality standard that replaces three separate guidelines, those on children, adults, and general clinical management, and brings them together into a single standard, reflecting new priorities and evidence.There are eight quality statements on obesity.In the first two statements, the focus is on better identification. For adults with long-term conditions, BMI should be recorded at least annually, and if BMI is under 35, waist-to-height ratio should also be measured. This represent a change from previous guidance where BMI alone was the main focus. Also, for children over the age of two, BMI should be recorded opportunistically. putting greater emphasis on early recognition.Statements three, four, and five are all about improving access to services, including people with learning disabilities. Local authorities and commissioners need to maintain an up-to-date list of services to offer patients, which should reduce barriers and ensure equity of access.Statements six, seven, and eight deal with clinical management. People prescribed weight management medicines should receive holistic care, covering diet, nutrition, and physical activity. Those who stop medicines or finish behavioural interventions should get long term follow up support, which recognises the importance of relapse prevention. And finally, adults discharged after bariatric surgery should be followed up at least annually within a shared-care model. This is also new because the need for ongoing shared care was not explicit before.And that is it in respect of overweight and obesity. Now let’s move to the real headline, the draft new NICE guideline on type 2 diabetes. This is the one everyone’s been talking about. The draft is open for public consultation until October, and the final guidance is due in February 2026.Today I’ll just give you a quick overview. But in a future episode, we’ll look at the proposed changes in slightly more detail, so stay tuned. Just remember, for now it’s only a draft, which means it could still change, and we should not be making clinical decisions based on it yet.First, the biggest shift: Treatment no longer starts with just metformin. Instead, the new draft guideline recommends combination therapy from day one—metformin plus an SGLT-2 inhibitor for almost all adults with type 2 diabetes. This is a major departure from monotherapy and reflects the fact that type 2 diabetes is not only about sugar control. SGLT-2 inhibitors confer cardiac and renal protection, reducing cardiovascular events and slowing kidney disease progression, benefits that metformin alone can’t offer. NICE has been clear that SGLT2 inhibitors remain underutilised in practice. Why? In many cases, clinicians have stuck with the traditional stepwise model of adding medicines only when HbA1c goes up. Others may be concerned about cost, side effects, or uncertainty over who exactly should benefit. The new guideline cuts through that by saying: everyone with type 2 diabetes will benefit, so we need to make SGLT-2 inhibitors part of the standard starting treatment. The message is that we should be thinking beyond blood glucose from the very beginning, and treating cardiovascular and renal risk right from the start.Second, we move away from risk-based prescribing. In the past, SGLT-2 inhibitors were reserved only for people with heart failure or at high cardiovascular risk, so their use was much more limited. As we have just said, the new draft guideline takes a completely different approach: now, SGLT-2 inhibitors are recommended for everyone with type 2 diabetes, regardless of their cardiovascular risk profile. The thinking here is simple — we know these drugs consistently reduce hospitalisations for heart failure and slow the progression of kidney disease, and those benefits apply across the board, not just in the highest-risk patients. On top of that, for people who already have established atherosclerotic cardiovascular disease, the guidance goes further by recommending that a GLP-1 receptor agonist, semaglutide, is added as well, creating a triple-therapy regimen right from the start. This combination gives comprehensive coverage: metformin for glucose control, SGLT-2 inhibitors for renal and heart protection, and GLP-1 agonists for both cardiovascular benefit and weight management. It’s simply a move towards using the right drug in the right place earlier, instead of holding them back as late-stage rescue therapies.Third, let’s talk about GLP-1 receptor agonists a bit more, because this is another big change. Previously, GLP-1 drugs were considered much later, often for people with obesity or those who hadn’t met glycaemic targets despite multiple therapies, and they were tied to strict BMI criteria. That’s no longer the case.Now, semaglutide is recommended much earlier:It is recommended for people with type 2 diabetes and established atherosclerotic cardiovascular disease, it’s added on top of metformin and an SGLT-2 inhibitor as part of the initial treatment.And it is also recommended for people living with obesity or those with early-onset type 2 diabetes who still need extra glycaemic or weight management, so GLP-1 receptor agonists are also considered much sooner in the pathway for them.A

The video version of this podcast can be found here: ·      https://youtu.be/z7eZ1MLItGwThe previous episode on first line treatment of T2DM can be found here: ·      https://youtu.be/32Lf5UlyTOAThis 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 them.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 the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The links to the NICE guideline can be found below. In today’s episode, we are focusing on treatment options if further interventions are needed after first line treatment. If you haven’t already, I recommend that you check the previous episode on the first line drug management of type 2 diabetes. 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=ecJGF5QCuMLQ6hrkThe NICE guideline on Type 2 diabetes in adults: management [NG28] can be found here:·      https://www.nice.org.uk/guidance/ng28 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’m Fernando, a GP in the UK. In this episode, we’ll go through the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The link to it is in the episode description. In today’s episode, we are focusing on glucose lowering treatment options if further interventions are needed after first line treatment.  If you haven’t already, I recommend that you check the previous episode on the first line drug management of type 2 diabetes. Right, let’s jump into it.So we are going to look at treatment options if further intervention is needed—basically, what to do after first-line treatment.But first, let’s talk about reviewing drug treatments and when we will need to add an SGLT2 inhibitor at any point after starting first-line therapy.For adults with type 2 diabetes, no matter where they are in their treatment journey, if they have or develop chronic heart failure, established atherosclerotic cardiovascular disease, or become high risk for cardiovascular disease, if they are not already on it, we should offer an SGLT2 inhibitor that has proven cardiovascular benefits. This can be added on to their current treatment or used to replace an existing medication.And let’s remember that this is because there is strong evidence in large randomised controlled trials, that has shown that SGLT2 inhibitors not only improve blood glucose control but also reduce the risk of hospitalisation for heart failure, and in some cases lower cardiovascular mortality. These benefits are seen even in patients without diabetes, which highlights their role in protecting the cardiovascular system as well as the kidneys.Right, now, before we look into how to intensify treatment, let’s quickly cover what NICE says about monitoring and targets.Regarding diabetes monitoring, NICE recommends measuring HbA1c every 3 to 6 months until it’s stable on unchanging treatment. After that, once HbA1c is fully stable, measuring every 6 months is usually enough.When it comes to HbA1c targets, we should discuss and agree on an individual goal with each patient. The aim is to help them reach and maintain that target—unless trying to do so causes problems like hypoglycaemia or lowers their quality of life.Generally speaking, for those managing their diabetes with lifestyle changes or a single drug that doesn’t cause hypoglycaemia, the target is around 48 mmol/mol, or 6.5%. For patients on medications that do carry a risk of hypoglycaemia, the target is a bit higher, around 53 mmol/mol, or 7.0%.If an adult’s HbA1c isn’t controlled by a single drug and rises to 58 mmol/mol, or 7.5%, or above, then we need to review and reinforce their current treatment and after that, we usually move to intensify drug treatment by adding a second medication.Now let’s look at treatment options when further intervention is needed.For adults with type 2 diabetes, if monotherapy isn’t enough to keep HbA1c below their individual target, we can consider adding one of the following: ·      a DPP-4 inhibitor, ·      pioglitazone, ·      a sulfonylurea, ·      or an SGLT2 inhibitor.If dual therapy—usually metformin plus another oral drug—still isn’t controlling HbA1c below the agreed threshold, then we have two main options. We can either:·      move to triple therapy by adding a DPP-4 inhibitor, pioglitazone, a sulfonylurea, or an SGLT2 inhibitor, ·      or we can consider starting insulin.In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, and dual therapy with two oral drugs still isn’t keeping HbA1c below the agreed threshold, then insulin should be considered. This essentially means that triple therapy is only recommended by NICE when one of those three drugs is metformin, not otherwiseIf triple therapy with metformin and two other oral drugs isn’t effective, isn’t tolerated, or is contraindicated, we may consider switching one of those drugs for a GLP-1 mimetic—but according to NICE, this is only for adults who:Have a BMI of 35 or higher (with adjustments for people from Black, Asian, and other minority ethnic groups by reducing the BMI by 2.5 to 32.5) and who also have specific psychological or medical problems linked to obesity, orHave a BMI under 35 but for whom insulin would have significant occupational impacts, or where weight loss would help other serious obesity-related health issues.GLP-1 mimetic therapy should only be continued if the patient shows a clear benefit, that is, a drop in HbA1c of at least 11 mmol/mol (or 1%) and a weight loss of at least 3% of their starting body weight within six months.Also, we need to be aware that combining a GLP-1 mimetic with insulin should only be done under specialist care and advice.So, as we’ve just seen, NICE recommends using GLP-1 mimetics mainly for people with type 2 diabetes who have a higher BMI or specific obesity-related problems. They also set clear criteria for continuing treatment, based on how well the patient responds metabolically and whether they lose enough weight.Now, we should also point out that other guidelines, like those from the ADA and EASD, take a fairly different approach. They suggest considering GLP-1 receptor agonists earlier in the treatment journey—especially for patients who already have cardiovascular disease or are at high risk of developing it, no matter their BMI. These guidelines focus more on the cardiovascular benefits of GLP-1 therapies, in addition to blood sugar control.So, while NICE tends to emphasize weight and BMI, the ADA and EASD put more weight on cardiovascular risk when they recommend GLP-1 receptor agonists.This is because research has shown that GLP-1 receptor agonists can reduce the risk of major cardiovascular events in people with type 2 diabetes who either have established cardiovascular disease or are at high risk.For example, the LEADER trial looked at liraglutide, and the SUSTAIN-6 trial studied semaglutide. Both showed significant reductions in cardiovascular events compared to placebo. Next, let’s move on to insulin-based treatments for adults with type 2 diabetes.When starting insulin therapy, we are likely to continue offering metformin—provided there are no contraindications or intolerance. At the same time, we should review whether other blood glucose-lowering medications are still needed.For insulin options, we have several choices. The first line o

The video version of this podcast can be found here:·      https://youtu.be/32Lf5UlyTOAThis 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 them.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 the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The links to the NICE guideline can be found below. In today’s episode, we are focusing on the first line drug management. In the next episode, we will cover treatment options if further interventions are needed.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/id1608821148There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrkThe NICE guideline on Type 2 diabetes in adults: management [NG28] can be found here:·      https://www.nice.org.uk/guidance/ng28 Transcript If 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’m Fernando, a GP in the UK. In this episode, we’ll go through the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The link to it is in the episode description. In today’s episode, we are focusing on the first line glucose-lowering drugs. In the next episode, we will cover treatment options if further interventions are needed.Right, let’s jump into it.And before we look at regular glucose-lowering drugs, we first need to check whether rescue therapy is required, remembering that it can be necessary at any stage of treatment.If the patient has symptoms of hyperglycaemia, we’ll consider starting insulin or a sulfonylurea, then review the treatment once blood glucose control is achieved. In symptomatic patients, the priority is to bring glucose levels down quickly to prevent complications and improve wellbeing. Because insulin and sulfonylureas lower blood glucose faster than most other diabetes medications, we’ll use these first, and once control is restored, switch to more suitable long-term treatment.After that, we’ll move on to first-line regular drug treatment. The usual starting point is standard-release metformin. After starting a low dose, we will increase the dose gradually over several weeks to reduce the risk of gastrointestinal side effects, and if those occur, we can switch to a trial of modified-release metformin.Metformin is recommended first because it’s been shown in large clinical trials to lower blood glucose with a low risk of hypoglycaemia, and it doesn’t promote weight gain. The UK Prospective Diabetes Study — or UKPDS — found that in people with type 2 diabetes who were overweight, metformin not only improved blood glucose control, but also reduced the risk of diabetes-related complications. Importantly, it also lowered their cardiovascular risk and overall mortality. These benefits, together with its long track record of safety, make metformin the preferred first-line treatment for most patients.At the same time that we start metformin, we’ll assess the patient’s cardiovascular status and risk. The goal is to determine whether they have chronic heart failure, established atherosclerotic cardiovascular disease, or are at high risk of developing it.We need to remember that established atherosclerotic cardiovascular disease includes conditions such as coronary heart disease, acute coronary syndrome, previous myocardial infarction, stable angina, ischaemic stroke or TIA, and peripheral arterial disease.We also need to be aware that a high cardiovascular risk means a QRISK score above 10% in anyone aged 40 or over, or, for those under 40, having any one of these factors: hypertension, dyslipidaemia, smoking, obesity, or a family history in a first-degree relative of premature cardiovascular disease.If the patient has chronic heart failure, established atherosclerotic cardiovascular disease, or is at high risk of developing cardiovascular disease, we’ll offer an SGLT2 inhibitor in addition to metformin — and we’ll do this regardless of their HbA1c level.This approach is supported by strong evidence. Large randomised controlled trials, have shown that SGLT2 inhibitors not only improve blood glucose control but also reduce the risk of hospitalisation for heart failure, and in some cases lower cardiovascular mortality. These benefits are seen even in patients without diabetes, which highlights their role in protecting the cardiovascular system as well as the kidneys.Now, when starting dual therapy with metformin and an SGLT2 inhibitor as first-line treatment, we’ll introduce the drugs sequentially. We will start with metformin first, then check tolerability, and then add the SGLT2 inhibitor as soon as metformin is confirmed to be well tolerated.If metformin is contraindicated or not tolerated, our approach will also depend on the patient’s cardiovascular history and risk.If they have chronic heart failure, established atherosclerotic cardiovascular disease, or are at high risk of developing it, we’ll offer an SGLT2 inhibitor as monotherapy. We do this because of the SGLT2 inhibitors cardiovascular benefits.If the patient is not in any of these higher-risk groups, we can consider any other glucose-lowering treatments. Options include:a DPP-4 inhibitorpioglitazonea sulfonylureaor an SGLT2 inhibitor.In order to make the right choice of drug, it may be a good idea here to give a comparative overview based on their effect on weight, hypoglycaemia risk etc.And let’s start with weight. Although metformin was once thought to cause weight loss, NICE now describes it as weight neutral. DPP-4 inhibitors, or gliptins, are also generally weight neutral, meaning they usually don’t cause significant weight gain or loss. In contrast, SGLT2 inhibitors—also called flozins—tend to promote weight loss, which can be especially helpful for patients who are overweight or need to lower their cardiovascular risk. On the other hand, both Pioglitazone and Sulfonylureas are linked with weight gain, something to watch out for, particularly in patients where added weight could worsen insulin resistance or raise cardiovascular risk.In terms of hypoglycaemia risk. Metformin, DPP-4 inhibitors, Pioglitazone, and SGLT2 inhibitors all carry a low risk of hypoglycaemia. However, Sulfonylureas stand out here with a much higher risk, especially in older adults or those with irregular meal patterns.All these oral medications are contraindicated in diabetic ketoacidosis but SGLT2 inhibitors, in particular, carry a significant risk of ketoacidosis, including the unusual euglycemic form, so patients on these drugs need careful monitoring. Pioglitazone is also contraindicated in patients with current or past heart failure, as well as those with a history of bladder cancer or unexplained haematuria.Renal function is another key factor. Most of these drugs need dose adjustments or close monitoring when kidney function is reduced. Metformin, for example, requires dose reduction or may need to be avoided depending on the patient’s eGFR. Most clinicians will reduce the dose of metformin to half if the eGFR is between 30 and 45 and metformin is stopped completely if eGFR falls below 30. Pioglitazone generally doesn’t require dose changes for kidney impairment, but it should still be used with caution.Finally, liver impairment can affect how we prescribe these medications. Many require caution or should be avoided depending on the severity of liver disease. I won’t cover every detail here, but we should always consult the BNF before prescri

The video version of this podcast can be found here: ·      https://youtu.be/t8U8-isTieMThis 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 them.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 recommendations on the diagnosis and monitoring of type 2 diabetes, which includes guidance by NICE. The links to the NICE guideline is in the episode description. 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 NICE guideline on Type 2 diabetes in adults: management [NG28] can be found here:·      https://www.nice.org.uk/guidance/ng28TranscriptIf 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’m Fernando, a GP in the UK. In today’s episode, we’ll go through recommendations on the diagnosis and monitoring of type 2 diabetes using HbA1c, focusing on what is relevant in primary care only. This information includes guidance by NICE contained in the NICE guideline on Type 2 diabetes. The link to it is in the episode description. Right, let’s jump into it.Let’s start with the diabetic diagnostic thresholds. They could be:An HbA1c of 48 mmol/mol or 6.5% or more orA Fasting plasma glucose level of 7.0 mmol/L or more orA Random plasma glucose of 11.1 mmol/L or more in the presence of symptoms or signs of diabetes.Why have these thresholds been chosen?These thresholds are based on the evidence of glucose levels at which the risk of diabetes-related complications—particularly retinopathy—increases significantly.They have been agreed in order to strike a balance between diagnostic accuracy and early intervention, helping to catch diabetes at a point where treatment can prevent progression and complications.And let’s also remember that if the person has symptoms of diabetes, a single abnormal HbA1c or fasting plasma glucose level can be used, although repeat testing is always advisable to confirm the diagnosis.However, If the person is asymptomatic, we should not diagnose diabetes on the basis of a single abnormal HbA1c or plasma glucose result. Instead, we should arrange repeat testing, preferably with the same test, to confirm the diagnosis. If the repeat test result is normal, we will monitor the person for the development of diabetes, and the frequency of such monitoring will depend on our clinical judgement.This guidance to not diagnose diabetes in an asymptomatic person based on a single abnormal result is based on principles of biological variability, and the importance of avoiding misdiagnosis.This is because Glucose levels and HbA1c can fluctuate due to a variety of reasons and a single abnormal result may not reflect the person's usual glycaemic status. Repeating the test helps rule out false positives due to possible transient factors or a lab artefact or error.Can we use HbA1c and plasma glucose interchangeably to diagnose type 2 diabetes?Well, in general, yes, but there are times when HbA1c should not be used to diagnose diabetes. This is the case for:Children and young people under the age of 18. Pregnant women or women within 2 months postpartum. People with symptoms of diabetes for less than 2 months. People at high diabetes risk who are acutely ill.People taking medication that may cause hyperglycaemia (for example, long-term corticosteroids). People with acute pancreatic damage, including pancreatic surgery.And People with end-stage renal disease (ESRD).Additionally, HbA1c should be interpreted with caution in people with abnormal red blood cell turnover or abnormal haemoglobin type, like: Abnormal haemoglobin, such as haemoglobinopathy, including sickle cell trait. Severe anaemia (of any cause). Altered red cell lifespan (for example, in post-splenectomy). And a recent blood transfusion.Why do we need caution in these situations? Well, HbA1c reflects the percentage of haemoglobin that has glucose attached to it—essentially giving us an average of blood glucose over the past 2 to 3 months, which is the typical lifespan of a red blood cell. However, anything that alters red blood cell turnover or haemoglobin structure can affect the accuracy of this measurement. For example:In conditions like haemoglobinopathies (e.g. sickle cell trait or thalassaemia), the structure of haemoglobin is different, which can interfere with how HbA1c is measured or how glycation occurs.In severe anaemia or increased red cell turnover, red blood cells are cleared from the circulation more quickly, so there’s less time for glucose to attach—leading to falsely low HbA1c.Conversely, if red cells live longer than normal (such as after splenectomy), HbA1c may be falsely high because glucose has more time to accumulate.And finally, after a recent blood transfusion, the donor’s red blood cells—often with a different glycaemic history—can distort the result.So, in these cases, HbA1c may not accurately reflect the patient’s glycaemic control, and alternative measures like fasting glucose or an oral glucose tolerance test may be more reliable.What about diabetic monitoring?NICE recommends that we should measure HbA1c levels in adults with type 2 diabetes:Every 3 to 6 months until HbA1c is stable on unchanging therapy orEvery 6 months once the HbA1c and diabetic therapy are stable. If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, we will need to estimate trends in blood glucose control using one of the following:quality-controlled plasma glucose profilestotal glycated haemoglobin estimation (if there are abnormal haemoglobins) orfructosamine. What do these alternative forms of monitoring involve?Well:Quality-controlled plasma glucose profiles involve measuring fasting and postprandial glucose at regular intervals, giving a day-to-day picture of control, although they don’t reflect long-term trends as well as HbA1c.Total glycated haemoglobin measures all forms of glycated haemoglobin (not just HbA1c), and may be more accurate when variant haemoglobins interfere with standard HbA1c assays.And finally, fructosamine reflects glycation of serum proteins (mainly albumin) rather than haemoglobin, giving an average of blood glucose over the past 2–3 weeks. As we have said, it's useful in cases where red blood cell lifespan is abnormal, but also in pregnancy, or when rapid changes in glucose control are occurring.Each of these methods has limitations, but they can give a more reliable picture than HbA1c when red cell-related interference is present.What about HbA1c targets?NICE advises that we should discuss and agree an individual HbA1c target with patients, encouraging them to reach and maintain it, unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target impair their quality of life. However, from a general perspective, for those managed either by lifestyle and diet alone, or combined with a single drug not associated with hypoglycaemia, we should aim for an HbA1c target of 48 mmol/mol (6.5%). For those on a drug associated with hypoglycaemia, we will aim for an HbA1c target of 53 mmol/mol (7.0%). In adults, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:we will review and reinforce their current treatment andthen proceed to intensify drug treatment, generally by adding a second drug.These thresholds are heavily influenced by the results of clinical trials such as th

The video version of this podcast can be found here: ·      https://youtu.be/j5z0Qv35dWEThis 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 July 2025 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 July 2025 can be found here: ·      https://www.nice.org.uk/guidance/published?from=2025-07-01&to=2025-07-31&ndt=Guidance&ndt=Quality+standardThe updated quality standard Cardiovascular risk assessment and lipid modification [QS100]  can be found here: ·      https://www.nice.org.uk/guidance/qs100 The new technology appraisal Dapagliflozin for treating chronic kidney disease [TA1075] can be found here: ·      https://www.nice.org.uk/guidance/ta1075 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’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in July 2025, focusing on what is relevant in Primary Care only.Today we just have two clinical areas to discuss, the updated quality standard on cardiovascular risk assessment and a new technology appraisal on Dapagliflozin for CKD.Right, let’s jump into it.There are only 5 updated quality standard on cardiovascular risk assessment and lipid modification, so let’s have a look at them:  Quality statement 1 refers to the identification of adults who are likely to be at high CV risk.What does the new statement say?It says that General practices should systematically search their patient records to identify people who are likely to be at high risk of CVD. Using routinely collected data, practices can estimate someone's 10-year risk of CVD ideally using the QRISK3 tool.What’s different from the old guideline?Previously, the guidance said that If a person between 25–84 was flagged as having an increased CVD risk, we would offer them a formal QRISK3 assessment.Now, the focus is to use a proactive, structured search of patient records to find those likely to be at risk. So instead of waiting for risk to be flagged, we now go looking for it.However, we have to be cautious and use clinical judgment, especially in groups which may have missing or incomplete data in their records, which can lead to their risk being underestimated. Let’s now look at Quality Statement 2, which covers Diet and lifestyle advice for primary prevention. What does the new guideline say?Someone with a CVD risk of 10% or more, should be given lifestyle advice and this should happen within 3 months of their risk score being recorded.What’s different from the older guidelines?The previous (now obsolete) standards said that:People should be assessed for secondary causes before being offered statins and thatThey should get lifestyle advice before being offered statins.So, this update simplifies and strengthens this advice. Everyone with a ≥10% CVD risk should get lifestyle advice within 3 months. It's no longer just a “before statins” step. It’s a core part of primary prevention.Let’s move on to Quality Statement 3, on Lipid-lowering treatment for primary prevention.What does the new guideline say?People with a 10-year CVD risk of 10% or more should be prescribed a high-intensity statin unless it's not suitable for them. If they can’t tolerate statins or have a medical reason not to take them, then an alternative lipid-lowering treatment should be offered.The recommended statin here is atorvastatin 20 mg, which is proven to be effective.What’s different?Under the obsolete standards we were first advised to try lifestyle changes, and only if those changes were ineffective or unsuitable, would a discussion about statin therapy take place Now, the emphasis is on timely treatment. If a person has a 10-year CVD risk of 10% or more, and they choose to start treatment, they should be prescribed a high-intensity statin straightaway, usually atorvastatin 20 mg. There is no longer a requirement to try lifestyle changes first. While lifestyle advice remains important, it’s not a prerequisite to offering statins. This change reflects stronger evidence that earlier intervention with statins in high-risk people can significantly reduce the risk of CVD events.But let’s remember other key considerations:For those close to the 10% threshold, we will need to use our clinical judgement.For Trans people we need to be aware that QRISK3 needs the biological sex, which may not reflect an individual’s gender identity, so adjustment may be necessary.And for people aged 85 and over: Atorvastatin 20 mg may still be appropriate, but we should consider factors like frailty, comorbidities, polypharmacy, etc.Quality statement 4 refers to Assessing response to lipid-lowering treatment. This one focuses on how we monitor people after starting or changing lipid-lowering treatment, such as statins.The obsolete guidance recommended that adults on a high-intensity statin should have a repeat lipid profile and liver transaminase levels measured after 2 to 3 months.What’s changed?The new quality statement broadens this. It now applies to all adults starting or changing any lipid-lowering treatment, not just those on high-intensity statins.This change recognises that monitoring response and safety is important for everyone, not just high-intensity statin users.And let’s remember that Fasting is not required for a full lipid profile, which should includeTotal cholesterolHDL cholesterol andTriglyceridesAnd that, from these, non-HDL and LDL cholesterol are calculatedLet’s now look at the final quality statement, Quality statement 5 which focuses on Secondary prevention of cardiovascular disease The previous (now obsolete) guidance said that people newly diagnosed with CVD should be offered atorvastatin 80 mg and that, if someone developed side effects, they should be offered a lower dose or a different statin.What’s changed?The new guidance shifts the focus from prescribing a specific drug or dose to achieving a specific cholesterol target. It says that people with CVD should have either:An LDL cholesterol which is 2 or below (≤ 2.0 mmol/L), Or a non-HDL cholesterol which is 2.6 or below (≤ 2.6 mmol/L)This is a move toward outcome-focused care, rather than just prescribing a medication and assuming it's effective.So, instead of asking:"Did we prescribe atorvastatin 80 mg?" We now ask: "Has this person’s cholesterol actually reached a level that protects them?"Besides, using non-HDL cholesterol as an alternative to LDL is helpful when LDL hasn't been specifically measured or calculated. Let’s remember that, for example,  LDL may not be calculated in people with very high triglycerides.Let’s now take a few minutes to go through the updated NICE guidance on dapagliflozin for chronic kidney disease. This updated recommendation replaces earlier guidance and reflects both new evidence and a broader treatment scope for patients with CKD.So, what’s changed?Under the previous guidance dapagliflozin was only recommended for people with CKD, with or without type 2 diabetes, but only if their eGFR was between 25 and 75.This meant that certain patients were excluded — for example:Those with mild CKD and an eGFR above 75Those with an eGFR betw

The video version of this podcast can be found here: ·      https://youtu.be/sUlAwcaUrB0The first episode can be found here: ·      https://youtu.be/nguVbiQc5WwThis episode makes reference to guidelines produced by the European Association of Urology. 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 them.My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the recommendations by the European Association of Urology (EAU) on male hypogonadism, focusing on what is relevant in Primary Care only. The links to the guideline is in the episode description. Today’s episode covers the clinical presentation, interpretation of test results, and a brief overview of the management.The previous episode focused on the definition, classification, causes, and clinical associations of male hypogonadism.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 EAU sexual and reproductive health full guideline can be found here:·      https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/male-hypogonadismThe EAU pocket guideline can be found here:·      https://d56bochluxqnz.cloudfront.net/documents/pocket-guidelines/EAU-Pocket-on-Sexual-Reproductive-Health-2025.pdf 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’m Fernando, a GP in the UK. In today’s episode, we’ll I go through the recommendations by the European Association of Urology (or EAU) on male hypogonadism, focusing on what is relevant in Primary Care only. The link to the guideline is in the episode description. In today’s episode, we’ll focus on late-onset hypogonadism, its presentation, interpretation of test results, and a brief overview of the general management.If you haven’t already, I recommend that you check the previous episode where we cover the definition, classification, causes, and clinical associations of male hypogonadism. Right, let’s jump into it.The diagnosis of functional hypogonadism is based on the exclusion of an organic or structural cause. The main causes suggested for functional hypogonadism are obesity, comorbidities and ageing, with the first two accounting for most cases. This is because the evidence shows that chronic comorbidities can interfere with the HP testicular axis leading to functional hypogonadism. In fact, the role of ageing in hypogonadism up to age 80 years seems relatively small.Late onset hypogonadism is a term that is used, frequently incorrectly to describe the declining testosterone production due to ageing or simply the detection of hypogonadism in adults. However, the truth is that late onset hypogonadism is in fact a broad clinical entity including adult-onset forms which can have an organic or functional origin and can be primary or secondary. Late onset hypogonadism is frequently diagnosed in the absence of an identifiable organic cause, and it becomes more prevalent with age. By definition LOH must comprise both persistent specific symptoms and biochemical evidence of testosterone deficiency.The mainstay of LOH diagnosis includes signs and symptoms consistent with hypogonadism coupled with biochemical evidence of low morning total testosterone levels on two or more occasions, measured in fasting conditions.In the history, we will take note of specific symptoms associated with hypogonadism. Symptoms can be grouped into three main categories: sexual, physical, and psychological. Examples of sexual Symptoms include:Reduced libido Erectile dysfunction Fewer spontaneous erectionsLess frequent sexual activity or masturbation andDelayed ejaculationExamples of Physical Symptoms areReduced ability to perform vigorous activities Difficulty walking more than 1 kilometre Hot flushesLower energy levels andReduced physical strengthAnd finally, examples of Psychological Symptoms includeLow mood Loss of motivation General fatigueDifficulty concentrating andsleep disturbancesAs we can see, some of these symptoms are non-specific and need to be taken in context with the clinical and biochemical state. Also, headache and/or visual disturbance may indicate a pituitary related disorder. As part of the physical examination, BMI and the measurement of waist circumference are strongly recommended for everyone. This is because of the strong association between hypogonadism and obesity. Testicular and penile size, as well the presence of sexual secondary characteristics can also provide useful information regarding the overall androgen status. Finally, digital rectal examination (DRE) should be performed before testosterone therapy or to support suspicion of hypogonadism where we would normally expect reduced prostatic volume.How should we investigate male hypogonadism? The main initial test is obviously serum testosterone. Testosterone levels are produced in a circadian variation, which may persist in ageing men. Testosterone levels are also potentially influenced by food intake therefore, serum total testosterone should be measured in fasting conditions and in the morning, usually between 07.00 and 11.00 o’clock. A confirmatory measurement should always be undertaken in the case of an abnormal value.A testosterone of 12 nmol/L should be considered as a possible threshold for starting testosterone therapy in the presence of typical symptoms.If abnormal total testosterone levels are found, we should check LH and FSH along with prolactin (PRL) in order to investigate possible underlying conditions and exclude possible organic causes. Let’s look at these tests individually:FSH and LH levels can help differentiate between the diagnosis of primary or secondary hypogonadism. In primary hypogonadism, testosterone will be low and gonadotropins will be high, In secondary hypogonadism, testosterone will be low and gonadotropins will be low or inappropriately normal.Due to its negative influence on libido, PRL should also be considered as a first-line screening test in patients with reduced sexual desire. In addition, contrast-enhanced pituitary MRI scanning, as well as other pituitary hormone evaluations, is required in the presence of specific symptoms such as visual disturbances, headache and when hyperprolactinemia is confirmed. We also need to be aware that total testosterone values may change as a function of circulating SHBG levels. Let’s now look at the factors that may affect SHBG concentrations:Common Conditions That Increase SHBG include:Certain drugs, like anticonvulsants, oestrogens, and thyroid hormoneHyperthyroidismLiver diseaseAgeingSmoking andHIV or AIDSA high SHBG can lead to lower free testosterone, even if total testosterone looks normal.Conversely, and although not connected to hypogonadism, Conditions That Decrease SHBG levels include:Drugs like glucocorticoids, testosterone, or anabolic steroidsHypothyroidismObesityCushing’s syndromeInsulin resistance, as seen in metabolic syndrome or type 2 diabetes andNon-alcoholic fatty liver disease (NAFLD) and related conditionsA low SHBG can lead to higher free testosterone, and it may be a sign of underlying metabolic issues.Therefore, Understanding SHBG levels is important because it helps us interpret total testosterone results more accurately, especially in men with metabolic or endocrine disorders.In clinical conditions that may affect SHBG levels, checking free testosterone can be considered. However, there is currently no consensus on threshold values, so this remains an area of uncertainty.Having considered all this, let’s look at a Step-by-Step Approach to Evaluating Male Hypogonadism.Firstly, we will Start with a clinical suspicion, so if a man presents with symptoms like fatigue, low libido, erectile dysfunction, or reduced muscle mass, we should consider hypogonadism.As initial lab test for hypogonadism, we will check total testosterone, ideally in a morning fasting sample (between 7–11 AM).If the result:Is low or borderline, we will repeat the testosterone to confirm it and add LH, FSH, prolactin and possibly SHBG and free testosterone depending on our clin

The video version of this podcast can be found here: ·      https://youtu.be/OcxWFhMAbPQThis episode makes reference to guidelines produced by the European Association of Urology. 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 them.My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the recommendations by the European Association of Urology (EAU) on male hypogonadism, focusing on what is relevant in Primary Care only. The links to the guideline is in the episode description. Today’s episode covers the definition, classification, causes, and clinical associations of male hypogonadism. The next episode will focus on the clinical presentation, interpretation of test results, and a brief overview of the management.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=ecJGF5QCuMLQ6hrkThe EAU sexual and reproductive health full guideline can be found here:·      https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/male-hypogonadismThe EAU pocket guideline can be found here:·      https://d56bochluxqnz.cloudfront.net/documents/pocket-guidelines/EAU-Pocket-on-Sexual-Reproductive-Health-2025.pdf 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’m Fernando, a GP in the UK. In today’s episode, we’ll I go through the recommendations by the European Association of Urology (or EAU) on male hypogonadism, focusing on what is relevant in Primary Care only. The link to the guideline is in the episode description. In today’s episode, we’ll cover the definition, classification, causes, and clinical associations of male hypogonadism. In the next episode, we’ll focus on the clinical presentation, interpretation of test results, and a brief overview of the management.Right, let’s jump into it.Male hypogonadism is a clinical condition characterised by symptoms (with or without physical signs) and confirmed by low testosterone levels. Hypogonadism is linked to reduced testicular function, leading to decreased production of androgens (such as testosterone) and/or impaired sperm production. This may result from a primary problem within the testes (that is, primary hypogonadism) or from insufficient stimulation by the hypothalamic–pituitary axis (or secondary hypogonadism). In rare cases, it may be due to reduced cellular response to testosterone. Hypogonadism can negatively affect various organ systems and overall quality of life. This episode focuses on the management of adult male hypogonadism, also known as late-onset hypogonadism (LOH), although it may include some comments on congenital or pre-pubertal forms of the condition.The prevalence of LOH increases with age, with the major causes being obesity, other co-morbidities (e.g., diabetes) and overall poor health. Ageing accounts for a low percentage of hypogonadism, as there is only a small gradual decline in testosterone, up to the age of 80 years, in healthy ageing men. There is a high prevalence of LOH within specific populations, including patients with obesity, type 2 diabetes (T2DM), metabolic syndrome (MetS), cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), renal disease and cancer. In particular low testosterone levels are relatively common in men with T2DM and in those with metabolic abnormalities.Klinefelter syndrome, a trisomy associated with a 47,XXY karyotype, is the most prevalent genetic cause of primary hypogonadism, with a global prevalence of 1/500-1,000 live male births. However, < 50% of individuals with Klinefelter syndrome are diagnosed during their lifetime.Male hypogonadism can be classified according to the cause into primary hypogonadism or secondary hypogonadism. A compensated or subclinical form of hypogonadism, characterised by normal testosterone and a high LH, has also been reported but the clinical significance of this condition is unclear. The classification of hypogonadism has also been divided into two broad categories: ‘Classical or Organic’ and ‘Functional’. Classical hypogonadism includes: congenital or acquired diseases causing structural and/or irreversible impairment of the pituitary and/or testes. Functional hypogonadism is diagnosed in the absence of any recognised organic abnormality and it is mainly a consequence of co-morbidities. It should be treated first by improving the underlying condition (e.g., anorexia in a younger male). Late onset hypogonadism represents an even broader clinical entity including adult-onset forms which can have an organic or functional origin and can be primary or secondary. Late onset hypogonadism is in the majority of cases diagnosed in the absence of an identifiable organic cause. By definition LOH must comprise both persistent specific symptoms and biochemical evidence of testosterone deficiency.Finally, as we said earlier, in rare cases, it may be due to reduced cellular response to testosterone and its metabolites.The European association of urology guideline maintains a classification of Primary and Secondary Hypogonadism, with special reference to LOH. Classifying hypogonadism by its underlying cause will also help guide treatment options. For example, in secondary hypogonadism, both fertility and testosterone levels can potentially be restored with proper therapy. In contrast, primary hypogonadism usually requires testosterone replacement, which can impair fertility by suppressing the hypothalamic–pituitary–testicular (HPT) axis. We need to remember that when hypogonadism develops after puberty—especially as men age—its symptoms may be mild and often mistaken for normal ageing.Let’s now look at some common causes for the three main categories of male hypogonadism. Please note that this list is not exhaustive.In Primary Hypogonadism we can have congenital and acquired causes.Common congenital causes of primary hypogonadism include:Klinefelter syndrome – the most commonOther chromosomal disorders, like Down syndromeAnd also, conditions like sickle cell disease, amongst othersAcquired causes of primary hypogonadism include:Drug-related like, for example, inChemotherapy drugs and Testosterone synthesis blockers like ketoconazoleDirect testicular damage, like, for example:Bilateral orchidectomy or testicular traumaRadiation to the testes andInfective or autoimmune orchitis And finally systemic diseases that affect the testes, like for example:Chronic illnessesCushing’s syndromeHIV andCancers like lymphoma or testicular cancerIn Secondary Hypogonadism we also have congenital and acquired causes.Congenital causes of secondary hypogonadism include:Haemochromatosis andOther genetic or idiopathic causes Acquired causes of secondary hypogonadism include:Drugs that suppress the hypothalamus or pituitary, like for example:Oestrogens and progestogensTestosterone or anabolic steroids Drugs that increase prolactin Opiates and CorticosteroidsLocal problems in the brain, like, for example:Head traumaTumours in the pituitary or hypothalamusSurgery or radiation to the pituitary gland andInfections or inflammation in the brainAnd finally systemic conditions that affect brain hormone control, such as, for example:Type 2 diabetes and metabolic syndromeChronic organ failureHIVRheumatoid arthritis and other chronic inflammatory diseasesCushing’s syndrome andEating disordersI will only touch briefly on the Androgen Resistance or Reduced Testosterone Activity type, where testosterone levels may be normal, but the body can't respond properly to it.Causes include:Genetic conditions affecting androgen receptorsDrugs that interfere with testosterone functionHigh levels of SHBG (sex hormone-binding globulin), which reduces free testosterone andConditions like coeliac disease, which can also interfere with hormone actionLet’s now look in more detail into comorbidities associated with male hypogonadismAnd the first one is obesity. Low testosterone levels are common in obese men. Male hypogonadism is associated with a greater percentage of fat mass and low testosterone levels are strongly associated with

The video version of this podcast can be found here: ·      https://youtu.be/nguVbiQc5WwThis episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE" and Public Health England. 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 them.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 the recommendations on H Pylori testing and treatment, focusing on what is relevant in Primary Care only. It is based on the NICE guideline on Gastro-oesophageal reflux disease and dyspepsia in adults (CG184) and the quick reference guide on the subject by Public Health England. The links to them are in the episode description. 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  Eradication regimens: First-line treatmentOffer people who test positive for H pylori a 7‑day, twice-daily course of treatment with:·      a PPI and·      amoxicillin and·      either clarithromycin or metronidazole. Choose the treatment regimen with the lowest acquisition cost, and take into account previous exposure to clarithromycin or metronidazole. Offer people who are allergic to penicillin a 7‑day, twice-daily course of treatment with:·      a PPI and·      clarithromycin and·      metronidazole. Offer people who are allergic to penicillin and who have had previous exposure to clarithromycin a 7‑day course of treatment with:·      a PPI and·      bismuth and·      metronidazole and·      tetracycline. Second-line treatmentOffer people who still have symptoms after first-line eradication treatment a 7‑day, twice-daily course of treatment with:·      a PPI and·      amoxicillin and·      either clarithromycin or metronidazole (whichever was not used first line). Offer people who have had previous exposure to clarithromycin and metronidazole a 7‑day course of treatment with:·      a PPI and·      amoxicillin and·      tetracycline (or, if a tetracycline cannot be used, levofloxacin).Offer people who are allergic to penicillin (and who have not had previous exposure to a fluoroquinolone antibiotic) a 7‑day, twice-daily course of treatment with:·      a PPI and·      metronidazole and·      levofloxacin.Offer people who are allergic to penicillin and who have had previous exposure to a fluoroquinolone antibiotic a 7‑day course of:·      a PPI and·      bismuth and·      metronidazole and·      tetracycline. 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 NICE clinical guideline on Gastro-oesophageal reflux disease and dyspepsia in adults (CG184) can be found here: ·      https://www.nice.org.uk/guidance/cg184 The NICE recommendations organised by site of cancer on the guideline Suspected cancer: recognition and referral can be found here: ·      https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer#upper-gastrointestinal-tract-cancers The Public Health quick reference guide on Helicobacter pylori in dyspepsia: test and treat can be found here: ·      https://www.gov.uk/government/publications/helicobacter-pylori-diagnosis-and-treatmentTranscriptIf 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’m Fernando, a GP in the UK. In today’s episode, we’ll I go through the recommendations on H Pylori testing and treatment, focusing on what is relevant in Primary Care only. It is based on the NICE guideline on Gastro-oesophageal reflux disease and dyspepsia and the quick reference guide on the subject by Public Health England. The links to them are in the episode description. Right, let’s jump into it.What is helicobacter pylori and why is it relevant?Helicobacter pylori (also commonly referred to as simply H. pylori) is a gram-negative bacterium that colonises the human gastric mucosa. It’s usually acquired in childhood and persists unless treated.Now, in terms of prevalence, we see big differences between developed and developing countries:·      In developing countries, prevalence can exceed 70–80% in adults, largely due to poor sanitation, crowded living conditions, and limited access to clean water.·      In contrast, in developed countries, the prevalence is much lower—usually around 20–40%—and continues to decline. Better hygiene, sanitation, and widespread antibiotic use are key reasons for this.Overall, socioeconomic status, living conditions, and age are the main factors influencing prevalence.So why is H. pylori important?H Pylori plays a key role in the development of chronic gastritis and peptic ulcer disease and is a major risk factor for gastric adenocarcinoma and MALT lymphoma.Here’s how it works: H. pylori infection reduces mucosal defences and increases gastric acid secretion, which together lead to ulcer formation, particularly in the stomach and duodenum. On top of that, the ongoing presence of the bacteria triggers a chronic inflammatory response that causes chronic gastritis. Chronic gastritis, over time, can progress to atrophic gastritis, then intestinal metaplasia, then dysplasia—and eventually, adenocarcinoma.Now, let’s look at MALT lymphoma—MALT stands for mucosa-associated lymphoid tissue—H. pylori infection stimulates the development of this tissue in the stomach, which isn’t normally there. The chronic stimulation by the bacteria drives B-cell proliferation and can eventually lead to malignant transformation into low-grade B-cell lymphoma. Interestingly, in early-stage MALT lymphoma, H. pylori eradication alone can lead to regression of the lymphoma. That really highlights how central the bacterium is in the disease process.So, how do we test for H. pylori?The main options are the urea breath test and stool antigen test. There's also serology, though we are advised against using that routinely.The urea breath test is the most accurate, but it needs a prescription and staff time to carry out—so it’s not always practical in primary care. In most cases, we’ll use a stool antigen test instead.We need to remember that recent or ongoing PPI use can reduce the bacterial load and increase the chance of a false-negative result—particularly with breath and stool tests. So, if the patient has been on a PPI, we should stop it and leave a two-week washout period before testing.The H Pylori serology test has a low cost but also a lower accuracy so it is not recommended for most patients, and positive results should be confirmed by a second test such as a Urea Breath Test, or biopsy. H Pylori serology has very good negative predictive value in low prevalence developed countries and it is most useful in patients with acute gastrointestinal bleed, to confirm a negative urea breath test or stool antigen test when there is a possibility that blood and PPI use would make those test results unreliable. Serology testing detects IgG antibodies, so it does not differentiate active from past infection. Near patient H Pylori serology testing is not recommended and only locally validated laboratory-based serology are acceptable. Additionally, Public Health England states that we should not use serology testing post eradication therapy or in children and the elderly. What does NICE say about when to test?H. pylori testing is addressed in two areas of the NICE guideline:– Uninvestigated and functional dyspepsia and – Peptic ulcer diseaseLet’s look at dyspepsia first.And to clarify, the term dyspepsia is used broadly in primary care—it includes recurrent epigastric pain, heartburn or acid reflux, with or without bloating, nausea, or vomiting.For these patients—if there are no alarm symptoms—we follow a ‘test a

The video version of this podcast can be found here: ·      https://youtu.be/GelDVWruIlAThe link to the video on updated migraine management can be found here:·      https://youtu.be/LumBxN-yFmIThis 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 the updated NICE recommendations on the diagnosis and management of cluster headaches, focusing on those that are relevant to Primary Care only. It is based on the clinical guideline on headaches in over 12s: diagnosis and management [CG150]. 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 updated clinical guideline Headaches in over 12s: diagnosis and management [CG150] can be found here: ·      https://www.nice.org.uk/guidance/cg150 The MHRA advice on the use of topiramate can be found here: ·      https://www.gov.uk/drug-safety-update/topiramate-topamax-introduction-of-new-safety-measures-including-a-pregnancy-prevention-programme The NICE recommendations organised by site of cancer on the guideline Suspected cancer: recognition and referral can be found here: ·      https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer#brain-and-central-nervous-system-cancers 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’m Fernando, a GP in the UK. In today’s episode, we’ll I go through the updated NICE recommendations on the diagnosis and management of cluster headache, focusing on what is relevant in Primary Care only. It is based on the NICE guideline on headaches or CG150 and the link to it is in the episode description. Right, let’s jump into it.Cluster headaches are a primary headache disorder. Let’s remember that we classify headache disorders as either primary or secondary. The cause of primary headaches isn’t well understood, so we group them by clinical pattern. The most common primary headache disorders are tension-type headache, migraine, and cluster headache.By the way, if you are interested in the updated management of migraines, check the corresponding episode on this channel. The link to it is in the episode description.Secondary headaches are due to underlying disorders including medication overuse headache, giant cell arteritis, raised intracranial pressure, and infection.Headaches are very common and there’s often concern about possible underlying causes from both patients and healthcare professionals.So, firstly, let’s look at when we need to consider further investigations or referral.The NICE cancer guideline says that we should suspect a brain or a central nervous system malignancy in·      adults if there is progressive, sub‑acute loss of central neurological function. We will refer them urgently for direct access, MRI scan of the brain to be done within 2 weeks. Alternatively, we can refer for a CT scan if MRI is contraindicated·      In children and young people with newly abnormal central neurological function, we will arrange instead a very urgent specialist referral, that is, an appointment within 48 hours. There are some headache features that should also instigate further investigations or referral. The list is long and it includes symptoms such as:worsening headache with feversudden‑onset headache reaching maximum intensity within 5 minutesnew‑onset neurological or cognitive dysfunctionhead trauma within the past 3 monthsheadache triggered by cough, sneeze or exercise or anorthostatic headache, that is, a headache that changes with postureAdditionally, we will consider further investigations or referral for people who present with new‑onset headache and:compromised immunity,a history of malignancy orvomiting without other obvious cause.Once secondary causes of headaches have been excluded, then we’ll know that we are dealing with a primary headache. But, how do we differentiate cluster headache from other primary headaches such as migraine or tension-type headache?Well, we will diagnose it according to the headache clinical features. So, let’s have a look at these features, and compare them with what we would expect in migraine and tension-type headache.Let’s look at the pain location first. In cluster headache the pain location is unilateral, usually around the eye, above the eye and along the side of the head or face. In migraine it can be unilateral or bilateral and in tension-type headache it is usually bilateral.The pain quality in cluster headache is variable. It can be sharp, boring, burning, throbbing or tightening. In migraine the pain is usually pulsating, although in young people it can also be throbbing or banging and in tension-type headache it is pressing or tightening and generally non‑pulsating.The pain intensity in cluster headache is severe or very severe whereas in migraine it is moderate or severe and in tension-type headache it is mild or moderate.When it comes to the effect on activities, there is restlessness or agitation in cluster headache. In migraine it is aggravated by, or causes avoidance of, routine daily activities whereas tension type headache is not normally aggravated by routine activities.And finally, the duration of cluster headache is usually 15 minutes to 3 hours whereas in migraine it is usually 4 to 72 hours in adults, but sometimes shorter, from about 1 hour in young people. In tension-type headache it is usually anything from 30 minutes to continuous.Cluster headache also usually presents with associated symptoms and we can consider them to help with the diagnosis.For example, in cluster headache, on the same side as the headache we can find:a red or watery eyea swollen and or drooping eyelida constricted pupilnasal congestion or a runny noseand forehead and facial sweatingOn the other hand, common associated symptoms in migraine are unusual sensitivity to light or sound as well as nausea and vomiting. Additional, migraine can also have symptoms of aura, which can occur with or without headache.Typical aura symptoms include speech disturbance, visual symptoms such as flickering lights, spots or lines and partial loss of vision; and also, sensory symptoms such as numbness or pins and needles. Generally, aura symptoms:are fully reversibledevelop over at least 5 minutesand last 5 to 60 minutesHowever, we need to remember that tension type headache usually does not have any other associated symptoms.If we look at the frequency of the headache, we can classify cluster headache in either episodic or chronic.Episodic cluster headache has a frequency from once every other day to 8 times a day with a pain-free period of more than 1 month andChronic cluster headache is the same, that is, from once every other day to 8 times a day but with a continuous pain-free period of less than 1 month in a 12-month period.And let’s remember that both migraine and tension-type headache can also be episodic when it happens fewer than 15 days per month or chronic when it is 15 or more days per month for more than 3 months.Let’s now look at the management of cluster headacheAnd first of all, for people with a first bout of cluster headache we should consider neuroimaging, discussing with or referring to a specialist if necessary.As the actual treatment for acute cluster headache, we will offer oxygen and/or a subcutaneous or nasal triptan. Currently, nasal triptans are unlicensed for this and the subc

The video version of this podcast can be found here: ·      https://youtu.be/LumBxN-yFmIThis 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 June 2025 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 June 2025 can be found here: ·      https://www.nice.org.uk/guidance/published?from=2025-06-01&to=2025-06-30&ndt=Guidance&ndt=Quality+standardThe updated clinical guideline Headaches in over 12s: diagnosis and management  [CG150] can be found here: ·      https://www.nice.org.uk/guidance/cg150 The MHRA advice on the use of topiramate can be found here: ·      https://www.gov.uk/drug-safety-update/topiramate-topamax-introduction-of-new-safety-measures-including-a-pregnancy-prevention-programme 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’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in June 2025, focusing on what is relevant in Primary Care only.We’ve got another short episode today, as there is just one updated clinical guideline relevant to us, the guideline on headaches in people over 12.Right, let’s jump into it.The update to the guideline makes only a very small change. NICE has changed the strength of recommendations on migraine prevention. Now, topiramate and propranolol are ‘consider’ options, alongside amitriptyline, whereas previously, only amitriptyline was a ‘consider’ option, and the other two were actively ‘offered’. This change better reflects the balance between benefits and harms with these three medicines.And that is it. Given how straightforward this update is, let’s take the opportunity to review the overall management of migraine.And we will start by saying that Headaches are among the most common neurological problems seen by GPs. They’re debilitating, and a major cause of time off work or school. They also represent a substantial burden on society.We classify headache disorders as either primary or secondary. The cause of primary headaches isn’t well understood, so we group them by clinical pattern. The most common primary headache disorders are tension-type headache, migraine, and cluster headache.Secondary headaches are due to underlying disorders. Examples include medication overuse headache, giant cell arteritis, raised intracranial pressure, and infection. Medication overuse headache often occurs in people already taking medication for a primary headache disorder.The greatest health and social burden of headaches is caused by primary headaches and medication overuse headache.Many people with headache don’t have an accurate diagnosis. Diagnosis can be difficult, and there’s often concern about possible underlying causes from both patients and healthcare professionals. By improving recognition of primary headache disorders, we’ll manage headaches better, improve quality of life, and reduce unnecessary investigations.Now, let’s review the acute treatment of migraine with or without aura.For this, we should offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol depending on our clinical judgement.For young people aged 12 to 17, we’ll consider a nasal triptan instead of an oral one. Currently, this is off-label in under-18s, except for nasal sumatriptan.If someone prefers to take only one medicine, we’ll consider monotherapy with an oral triptan, NSAID, aspirin at 900 mg, or paracetamol, depending on their circumstances. And again, for 12 to 17-year-olds, we’ll consider a nasal triptan.Because of the link with Reye’s syndrome, we should not offer aspirin to under-16s.When prescribing a triptan, we’ll start with the lowest-cost option, and try alternatives if it’s not effective.We should consider using an antiemetic alongside other acute migraine treatments, even if the person doesn’t have nausea or vomiting.If oral preparations, or nasal preparations in young people, are ineffective or not tolerated, we’ll consider non-oral metoclopramide or prochlorperazine. If we do use one of these, and a non-oral NSAID or triptan hasn’t been tried, we’ll consider adding one.We need to be aware of special warnings and precautions for metoclopramide and prochlorperazine as per the BNF, and we should discuss the benefits and risks with the patient.At present, only buccal prochlorperazine is licensed for migraine. Other preparations are only licensed for nausea and vomiting. Rimegepant (an oral calcitonin gene-related peptide [CGRP] inhibitor placed on or under the tongue) is recommended as an option for the acute treatment of migraine with or without aura in adults, only if:at least 2 triptans were tried and they did not work well enough ortriptans were contraindicated or not tolerated, and NSAIDs and paracetamol were tried but did not work well enough.We should not offer ergots or opioids for acute migraine treatment.Now let’s turn to prophylactic treatment.We will consider propranolol, topiramate, or amitriptyline to prevent migraine. This decision should follow a full discussion of benefits, risks, and suitability.We will take into account the following factors:People with depression and migraine could be at an increased risk of using propranolol for self-harm so we should use caution when prescribing it. ·      We’ll follow MHRA guidance on topiramate: it should not be used for migraine prophylaxis in pregnancy or in women of childbearing potential unless the Pregnancy Prevention Programme conditions are fulfilled. That includes using highly effective contraception. The link to the MHRA advice is in the episode description.·      For amitriptyline, we need to follow guidance on the prescribing of antidepressants and the management of medicines associated with dependence or withdrawal symptoms.·      Currently, topiramate and amitriptyline are unlicensed for migraine in children and young people.If the first prophylactic treatment doesn’t work or isn’t tolerated, we should discuss trying another. If necessary, we move on to the third option, unless there are safety concerns.We will not offer gabapentin for migraine prevention.If all three options, propranolol, topiramate, and amitriptyline, are ineffective, not tolerated, or unsuitable, we’ll consider a course of up to ten acupuncture sessions over five to eight weeks.We can advise that the food supplement riboflavin 400 mg daily may help reduce migraine frequency and intensity for some people.Calcitonin gene-related peptide (CGRP) inhibitors are recommended for preventing episodic or chronic migraine in adults with at least four migraine days per month, but only if at least three other preventive medicines haven’t worked, aren’t tolerated, or are unsuitable due to safety concerns. Of these agents, only atogepant is oral—the others are injectables.Rimegepant is another Calcitonin gene-related peptide (CGRP) inhibitor which is placed on the tongue or under the tongue and which is recommended for preventing episodic migraine in adults who have between four and fourteen migraine attacks per month, but only if at least three preventive treatments haven’t worked or are unsuitable. It’s

The video version of this podcast can be found here: ·      https://youtu.be/HQnpwZFnedgThis channel may make reference to guidelines produced by a number of NHS organisations. 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 them.My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the diagnosis and primary care management of polycystic ovarian syndrome (PCOS), focusing on what is relevant in Primary Care only. For this advice I have looked at the published advice on the NHS Health website, North East London ICB and Health Improvement Scotland. The links to this guidance can be found below.In the previous episode, I covered the initial assessment and investigations of PCOS.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 link to the PCOS information on the NHS Health website can be found here:·      https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/ The link to the PCOS guideline by Primary Care North East London ICB can be found here:·      https://primarycare.northeastlondon.icb.nhs.uk/wp-content/uploads/2025/01/Pathway-Polycystic-Ovary-Syndrome-10_2024.pdfThe link to the PCOS information by Right Decisions for Health and Care - Healthcare improvement Scotland can be found here:·      https://rightdecisions.scot.nhs.uk/ggc-clinical-guidelines/gynaecology/gynaecology-guidelines/guidelines-a-z-all-gynaecology-guidelines/polycystic-ovarian-syndrome-622/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.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 will go through the primary care management of polycystic ovarian syndrome (PCOS), focusing on what is relevant in Primary Care only. For this advice I have looked at the published advice on the NHS website, North East London ICB and Health Improvement Scotland. The links to them are in the episode description.If you haven’t already, I recommend that you watch the previous episode where I cover the initial assessment and diagnosis. Right, let’s jump into it.And let’s start by reminding ourselves of the referral recommendations. We should consider endocrinology referral if:There are severe symptoms such as signs of virilisation or rapidly progressing hirsutismWhen testosterone is significantly elevated, defined as greater than 5 nanomoles per litre or more than twice the upper limit of normal orAbnormal levels of DHEA or dehydroepiandrosterone, androstenedione, or 17-hydroxyprogesterone, which could indicate the possibility of alternative diagnoses such as congenital adrenal hyperplasia, Cushing’s syndrome, or androgen-secreting tumours.Otherwise, the Management of PCOS is symptom-driven, so we should identify the patient's main concern, whether it's menstrual irregularity, hirsutism, fertility, or metabolic risk.Also, we should not neglect psychological wellbeing given that many women with PCOS are at increased risk of anxiety, depression, and body image issues. We should therefore screen for symptoms of anxiety and depression as well as other mental health conditions, and offer appropriate management if indicated. For all patients, lifestyle modification is the first-line of treatment, especially in those who are overweight. A weight reduction of even 5 percent can restore ovulation, reduce androgen levels, and improve insulin sensitivity. Women should be counselled that although PCOS is associated with weight gain, it does not inherently make weight loss more difficult. Referral to local weight management services may be appropriate and could be advised.Cardiovascular disease risk should be assessed by assessing individual risk factors and we should counsel patients on possible long-term complications including T2DM, hypertension, hyperlipidaemia, CVD, obstructive sleep apnoea and endometrial cancer. Screening for type 2 diabetes is recommended, especially if they have a BMI over 25 or additional risk factors such as age over 40, gestational diabetes, or a family history of diabetes.Although HbA1c is usually preferred for the diagnosis of diabetes for practical reasons, the North East London Primary care guideline recommend testing with OGTT instead.Let’s stop here for a moment and ask ourselves, why would OGTT be preferred in PCOS?There are two main reasons:Firstly, because HbA1c can miss impaired glucose tolerance given that postprandial glucose spikes may occur early in the disease process, even before fasting glucose or HbA1c becomes abnormal.Also, HbA1c Can Miss Early Glucose Dysregulation, especially in younger women and those with mild or intermittent abnormal glycaemia. So this is why an OGTT may be preferred over HbA1c in these situations.But let’s go back to the general management. And, as we said earlier, the treatment should be symptoms driven. So, let’s now look at the treatment in specific clinical scenarios.From a practical perspective, we should check whether the patient is pregnant or trying to get pregnant. If they are, we should:·      Stop any hormonal treatment ·      Offer preconception counselling (including high dose folic acid 5mg if obese) ·      Refer them to fertility or obstetric services depending on the situation and ·      If pregnant, we should also organise an OGTT Fertility treatment in secondary care may include ovulation induction with drugs such as clomiphene or letrozole. If these fail, gonadotrophins or laparoscopic ovarian drilling may be considered.But, if the patient is not pregnant and not planning to get pregnant, we will check which symptom they are most concerned about and treat each patient holistically according to their concerns. This could be:·      Acne·      Hirsutism or·      Oligo or amenorrhoeaLet’s have a look at the management of acne first.For this we can offer:·      The combined hormonal contraceptive if appropriate, ·      Any other acne treatment as per dermatology guidelines or·      We could prescribe spironolactone checking baseline U&Es and considering ongoing monitoring if clinically indicated, for example, if they are >45 or have other relevant comorbidities. Although this is an unlicensed use, the North East Primary care guidelines advocate their use in general practice.But spironolactone is a potassium sparing diuretic. Why does it work in acne?There are two ways. By blocking androgen receptors and by reducing androgen production in the ovaries and adrenal glands. Since androgens stimulate oil production in the sebaceous glands, blocking their action leads to less sebum, which reduces the clogged pores and the inflammation that cause acne. Let’s now look at the treatment options for hirsutism. They are:·      Hair removal methods e.g. shaving, waxing, and laser ·      The combined hormonal contraceptive, considering dianette, which is a combination of Cyproterone acetate and Ethinylestradiol, a synthetic estrogen ·      Metformin, which should be considered over inositol for hirsutism and central adiposity·      And finally the BNF also states that, for hirsutism, topically applied eflornithine (Vaniqa®) is of some benefit in reducing facial hair growth and should be used for 3 months prior to referral for laser treatment of hirsutism.What do we need to know about eflornithine or Vaniqa?Eflornithine inhibits specific hair follicle enzymes slowing down the rate of hair growth, making facial hair appear finer, lighter, and less noticeable over time.Key points that we need to about it is that:It does not remove existing hair but reduces regrowth speed.Effects may take 8 weeks or more to become noticeable.It’s often used alongside other hair removal methods like plucking or laser.And once treatment is stopped, hair growth usually returns to baseline.Eflornithine is particularly useful for women with mild-to-moderate facial hirsutism who prefer a non-hormonal, non-systemic option.But we have also just said that Metformin should be considered over inositol for hirsutism and central adiposity.But, why? And what are inositols? And how do we prescribe them?Well, in the UK, ino