Primary Care Guidelines

The video version of this podcast can be found here:·      https://youtu.be/4NysH3aEPMMThis video refers to guidelines produced by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I neutropenia always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners.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=ecJGF5QCuMLQ6hrk My summary of the guidance consulted can be found here:·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84The resources consulted can be found here:·      Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage·      Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0·      Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf·      King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdfTranscriptIf 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. Today we are going to cover what to do when we encounter a high haematocrit, including initial assessment, follow up and management, always focusing on what is relevant in Primary Care only.I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description.Right, let’s jump into it.And we will start by saying that haematocrit measures the proportion of blood volume taken up by red blood cells. It can be expressed either as a percentage—from 0 to 100 or as a decimal proportion, from 0 to 1. Because it reflects the relative volumes of red cells and plasma, the haematocrit is influenced not only by the absolute number of red blood cells but also by the amount of circulating plasma. Any change in either component will affect the final value.A high haematocrit raises the possibility of polycythaemia. Polycythaemia can be diagnosed when the haematocrit is greater than 0.52 in men and greater than 0.48 in women. These thresholds help identify affected people, but they do not, by themselves, tell us the cause.Polycythaemia is sometimes referred to as erythrocytosis, but this is not entirely accurate. Erythrocytosis specifically refers to an increased number of red blood cells in the circulation. Polycythaemia, on the other hand, is defined by a raised haematocrit, not by a direct count of red blood cells. As a result, it is possible to have a high haematocrit without true erythrocytosis.This distinction matters because there are two types of polycythaemia. The first is absolute polycythaemia, where an increased red cell mass is genuinely present, that is, true erythrocytosis. The second is relative or apparent polycythaemia, where the haematocrit is high not because there are more red cells, but because the plasma volume is reduced. Dehydration, diuretics, or plasma loss can all create this picture, leading to a raised haematocrit despite a normal red cell mass. It is also common in obese men, and it is also associated with smoking, alcohol, hypertension and stress. Despite the potentially reversible causes of relative or apparent polycythaemia, these patients are also at risk of occlusive vascular episodes.On the other hand, we have absolute polycythaemia, which reflects a true increase in red cell mass. This can be divided into primary and secondary causes.The primary cause is Polycythaemia Vera (PV). Well over 90% of patients with PV have an acquired mutation in the JAK2 gene, which plays an important role in regulating erythropoiesis. Because of this mutation, the bone marrow becomes hypersensitive to growth signals and produces red blood cells even when erythropoietin levels are low. In other words, these patients do not need as much erythropoietin to drive red cell production.The main features of Polycythaemia Vera are therefore:• a positive JAK2 mutation test,• a low serum erythropoietin level.Polycythaemia Vera is also commonly associated with low ferritin, because the accelerated and unregulated production of red cells consumes large amounts of iron.Being a myeloproliferative disorder, Polycythaemia Vera may also show raised white blood cells and/or platelets, reflecting the involvement of the bone marrow.Secondary polycythaemia, on the other hand, results from a physiological increase in erythropoietin production. The kidneys release more erythropoietin in response to reduced oxygen levels, so secondary polycythaemia can be an appropriate response to chronic hypoxia, as seen in COPD, congenital or acquired heart disease, and in smokers.It can also be an inappropriate response when erythropoietin is produced by tumours, such as certain renal or liver tumours, or even uterine fibroids, which can secrete erythropoietin autonomously.Other possible causes of secondary polycythaemia include anabolic steroids and testosterone therapy, as androgens stimulate erythropoietin production through hormonal pathways.In cases of secondary polycythaemia, the pattern is different:• the JAK2 mutation is negative,• erythropoietin levels are high, and• ferritin, white blood cells and platelets are normal.So what do we do when we receive a high haematocrit result? Well, Criteria for urgent referral are a haematocrit greater than 0.60 in men or greater than 0.56 in women. We should also refer urgently if the patient has had a recent thrombosis, shows any abnormal bleeding, or reports neurological or visual symptoms. These features raise concern for hyperviscosity or an underlying myeloproliferative disorder, both of which require immediate specialist assessment.If the criteria for urgent referral are not met, the next step is to confirm the result by repeating the blood test. In order to differentiate between apparent and absolute polycythaemia, the blood sample should be taken without a tourniquet, and we should ensure that the patient has not been fasting, is well hydrated, and has been advised about alcohol intake and smoking, as these factors can artificially raise the haematocrit.In this repeat blood test, we should request:• A repeat full blood count, to confirm whether the raised haematocrit is persistent and to check for associated abnormalities in white cells or platelets.• A blood film, which can reveal morphological clues to myeloproliferative disease or other haematological disorders.• We should screen for diabetes, hyperlipidaemia and hypertension, as these cardiovascular risk factors often coexist with secondary causes of polycythaemia and may contribute to vascular complications.• As mentioned earlier, we should also check Ferritin, to assess iron stores, which may be depleted in Polycythaemia Vera due to increased red cell production.• and finally renal and liver function tests, since kidney or liver disease may contribute to secondary polycythaemia or influence erythropoietin production.Additionally, if we suspect absolute polycythaemia, the following tests should be done:• Genetic testing for the JAK2 mutation, which is positive in the great majority of patients with Polycythaemia Vera.• And erythropoietin levels, which help distinguish primary from secondary causes, being low in PV and elevated in secondary polycythaemia.However, in the UK, JAK2 mutation testing and serum erythropoietin levels are not routinely available in primary care. In most areas, these investigations are carried out by haematology teams, as they form part of the specialist work-up for myeloproliferative disorders. While some regions may allow primary-care access, this is not standard practice, and therefore, if absolute polycythaemia is suspected or the haematocrit rema

The video version of this podcast can be found here: ·      https://youtu.be/TQB5tJvM0VMThis video refers to guidelines produced by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do if thrombocytopenia is found, always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners.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 My summary of the guidance consulted can be found here:·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84The resources consulted can be found here:·      Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage·      Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0·      Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf·      King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdfTranscriptIf 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. Today we are going to cover what to do when we encounter thrombocytopenia on a full blood count, always focusing on what is relevant in Primary Care only. I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description. Right, let’s jump into it.Thrombocytopenia is the platelet count is low, which is defined as a platelet count below 150 × 10⁹ per litre.But before we assume a true low platelet count, we need to remember that thrombocytopenia can often be an artefact. This happens when platelets clump together in the EDTA sample tube, giving a falsely low automated count.So, the first step is always to confirm the result with a repeat full blood count and a blood film. The blood film not only rules out platelet clumping but can also provide important clues about the underlying cause.There are many potential causes of thrombocytopenia so, let’s have a look at them:First, we have alcohol excess. Chronic alcohol use can directly suppress bone marrow production and shorten platelet lifespan. It is also frequently associated with chronic liver disease, where the spleen often becomes enlarged due to portal hypertension destroying more platelets than usual — a process known as hypersplenism. Then we have recreational drugs, which can also impair platelet production or trigger immune-mediated destruction.Then, travel history is also very important. Malaria, for example, often presents with thrombocytopenia, sometimes even before fever or parasitaemia becomes obvious. Tuberculosis can also cause thrombocytopenia, either through bone marrow involvement or immune-mediated mechanisms.Then we should consider liver and renal disease.In chronic liver disease we have already explained that hypersplenism is the most common cause of thrombocytopenia in liver disease.In renal disease, platelet lifespan is reduced because uraemia makes platelets more fragile, causing them to break down more quickly. In addition, bone marrow suppression may also occur.Then we have medications as another common culprit.NSAIDs, heparin, digoxin, quinine, anti-epileptics, antipsychotics and proton pump inhibitors are all recognised causes. Most drug-induced thrombocytopenia is caused by either: • immune-mediated platelet destruction, or • direct suppression of platelet production in the bone marrow.Heparin is the main exception because it causes thrombocytopenia through a unique immune reaction that activates platelets, leading to their consumption and a fall in the platelet count.Another possible cause are nutritional deficiencies, especially vitamin B12 and folate deficiency, which can impair bone marrow production and lead to thrombocytopenia, often alongside other cytopenias.We also need to consider viral causes. For example, Epstein–Barr virus frequently causes a temporary drop in platelets, which typically resolves within a few weeks. HIV and hepatitis B or C can cause persistent thrombocytopenia either through direct bone marrow suppression, immune-mediated destruction, or associated splenomegaly.Then, malignancy is also on the list, because both haematological cancers and solid tumours can infiltrate or suppress the bone marrow.Then we have bone marrow failure syndromes, such as aplastic anaemia, which will often present with thrombocytopenia together with anaemia and neutropenia.Another cause is immune thrombocytopenic purpura, or ITP, which is an autoimmune condition that destroys platelets. In adults, ITP can be acute or chronic, and the platelet count can fall to very low levels even when the patient looks otherwise well.Finally, autoimmune conditions such as SLE can present with thrombocytopenia as part of a broader immunological process. Now that we have had a look at the causes, how should we manage these patients?We have already mentioned that we should confirm thrombocytopenia with a repeat FBC and blood film. If the thrombocytopenia is confirmed, we will need to check if there are urgent criteria. First of all, we should arrange urgent same-day hospital assessment when the platelet count is below 20 × 10⁹ per litre and any concerning clinical features are present. These include:• Active bleeding, even if minor, because bleeding risk rises sharply at very low platelet levels. • An abnormal blood film, such as the presence of blasts suggesting acute leukaemia, or red cell fragments suggesting microangiopathic haemolysis, as these findings indicate potentially life-threatening conditions. • And finally an altered consciousness or confusion, which may point to serious systemic illness, intracranial bleeding, severe infection, or thrombotic microangiopathy.We should make an urgent outpatient haematology referral if the platelet count is below 50 × 10⁹ per litre, even without symptoms. This is because at this level, the risk of spontaneous bleeding increases, and many underlying causes — such as ITP, bone marrow failure, or haematological malignancy — require urgent assessment.Additionally, when the platelet count is below 50, it is unsafe to continue antiplatelet agents or anticoagulants, so these should be stopped unless a specialist advises otherwise.We should also make an urgent outpatient haematology referral when the platelet count is between 50 and 100 and certain concerning features are present. These include splenomegaly, lymphadenopathy, other cytopenias, pregnancy, or planned surgery. This is because all of these situations increase the risk of serious underlying disease or increase the risk of bleeding.However, if the platelet count is above 50 and none of the urgent referral criteria are present, we should then arrange the following baseline investigations:Firstly, we begin with a repeat full blood count and a blood film to confirm the thrombocytopenia, rules out platelet clumping, and look for abnormal cell morphology.Then we will check Vitamin B12 and folate levels to rule out deficiency.Ferritin and iron studies are also helpful, given that iron deficiency can occasionally contribute to low platelets.Inflammatory markers, such as ESR and CRP, which can suggest infection, inflammation, or an underlying autoimmune process.An autoimmune profile to exclude autoimmune-mediated platelet destruction.Renal, liver and thyroid function tests to identify chronic liver disease, renal failure and thyroid disease given that both hypo- and hyperthyroidism — can contribute to thrombocytopenia.Then, viral serology for HIV, hepatitis B and hepatitis C as these viruses can be associated thrombocytopenia.And finally, we should perfo

The video version of this podcast can be found here: ·      https://youtu.be/lhtciu3O8tcThe video on raised bilirubin pattern can be found here:·      https://youtu.be/ndAus37PfsEThe video on hepatitic pattern abnormal LFTs can be found here:·      https://youtu.be/rIX46swVSfgThis episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that 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 cover what to do when we encounter abnormal LFTs with a cholestatic pattern, always focusing on what is relevant in 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 My summary guide can be downloaded here:·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS The resources consulted can be found here:BSG- British Society of Gastroenterology:·      bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests·      Guidelines on the management of abnormal liver blood tests (bsg.org.uk)o  First published on:o  BMJ article:o  Guidelines on the management of abnormal liver blood tests | Gut (bmj.com) 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. Today we are going to cover what to do when we encounter abnormal LFTs with a cholestatic pattern, always focusing on what is relevant in Primary Care only.  This episode is based on the British Society of Gastroenterology guidelines on abnormal Liver function tests. A link to it is in the episode description. Right, let’s jump into it.And let’s start by remembering that there are three common patterns of abnormal liver function tests or LFTs:A cholestatic pattern, normally showing a high ALP and GGT, which is what we will concentrate on today. An isolated raised bilirubin with otherwise normal liver tests.And a hepatitic pattern, with a raised ALT and AST indicating hepatocellular injury. By the way, if you are interested in finding out more about the last two types, make sure to watch the corresponding episodes on this channel. The links are in the episode description.As we have said, LFTs showing a cholestatic pattern normally present with a high ALP and GGT.Alkaline phosphatase, or ALP, is produced mainly in the liver but is also found in bone, intestines, kidneys and the placenta. Levels are physiologically higher in childhood because of rapid bone growth, and in pregnancy due to placental production. Raised ALP can come from either hepatic or non-hepatic sources.The main source of non-hepatic ALP is bone. ALP increases in bone disease because it is produced by osteoblasts, the cells responsible for forming new bone. Any condition that increases osteoblast activity or bone turnover—such as healing fractures, Paget’s disease, bone metastases, or vitamin D deficiency—causes osteoblasts to increase their activity, releasing more ALP into the circulation.We should remember that the most common cause of an asymptomatic, non-hepatic raised ALP is vitamin D deficiency. And let’s remember that vitamin D deficiency increases bone turnover because low vitamin D reduces calcium absorption from the gut. To maintain normal calcium levels, parathyroid hormone rises and stimulates bone breakdown to release calcium. This increase in bone remodelling activates osteoblasts leading to a rise in ALP.But as we are focusing on liver function tests, what is the source of a raised hepatic ALP? From a pathophysiological perspective, hepatic ALP rises when bile flow is impaired, also known as cholestasis. And, why does cholestasis cause a rise in ALP? It happens because alkaline phosphatase is found in high concentration in the cells lining the bile ducts. When bile flow is impaired, pressure builds up in the biliary system and the bile duct epithelium becomes irritated. This stimulates these cells to produce and release more ALP into the bloodstream. This is the reason why ALP rises in, for example, gallstone disease, strictures, or cholangitis.On the other hand, γ-glutamyltransferase, or GGT, is found in the liver but not in bone. Therefore, when ALP is raised, measuring GGT helps determine whether the source is hepatic or non-hepatic. A raised ALP with a normal GGT suggests a bone-related cause, whereas a raised ALP with a raised GGT supports a hepatic origin and should prompt further assessment of cholestatic liver disease.GGT rises in cholestasis because it is also highly concentrated in the cells lining the bile ducts. When pressure builds up in the biliary system, these cells release more GGT into the bloodstream. In addition, cholestasis causes oxidative stress because retained bile acids are toxic to liver cells. In response, the liver increases GGT production, as GGT is involved in antioxidant and detoxification pathways, leading to the characteristic rise in cholestatic liver disease.A high GGT can also be due to obesity, excess alcohol, or medications. In obesity and NAFLD, fat accumulation within the liver creates oxidative stress, so the liver up-regulates GGT to protect hepatocytes from free radical damage. In this context, an elevated GGT reflects metabolic stress rather than structural cholestasis. In alcohol use, ethanol metabolism produces toxic intermediates that also generate oxidative stress, which further stimulates GGT production as part of the liver’s detoxification response.We will not go into detail on how to proceed with an isolated raised ALP, that is, with a normal GGT, as today we are focusing on cases where there is clear hepatic involvement, meaning that both ALP and GGT are high in a true cholestatic pattern.How should we investigate and manage these patients?When we manage patients with any abnormal liver function tests, we must begin by recognising red flags that require urgent action. According to the British Society of Gastroenterology guidelines, if there are signs of synthetic liver failure – such as unexplained clinical jaundice, a low albumin, or a raised INR – or if there is a suspicion of malignancy, for example unexplained weight loss or marked cholestasis, then the patient should be urgently referred or admitted for specialist assessment.If the pattern is cholestatic, we will proceed with a full liver screen. This is because cholestatic abnormalities are often related to structural biliary disease, autoimmune cholestatic conditions, or infiltrative disorders, and these require a broader diagnostic approach than simple repeat testing.What tests should be done in a full liver screen?A full liver screen should include an ultrasound scan of the liver and biliary tree, which is the first-line imaging test. Ultrasound helps identify biliary dilatation, gallstones, strictures, masses, or features of chronic liver disease. In addition to imaging, blood tests should include hepatitis B and C screening, an autoantibody screen, serum immunoglobulins, ferritin and transferrin saturation, and, often and where clinically appropriate, a coeliac screen, alpha-1 antitrypsin levels, and caeruloplasmin. These tests collectively help detect autoimmune cholestatic diseases such as primary biliary cholangitis, metabolic conditions such as haemochromatosis or Wilson’s disease, and chronic viral hepatitis.It is also worth emphasising that this full liver screen is recommended not only for cholestatic abnormalities but also for patients who present with a hepatitic pattern, as the BSG guideline advises a comprehensive assessment irrespective of the pattern or the degree of derangement once initial red flags have been excluded.The management in primary care is fairly simple, because the British Society of Gastroenterology recommends that once initial investigations have been completed, these patients should be referred to secondary care for further assessment. This applies both when a cholestatic picture come with abnormalities in the liver screen and also if the ALP and GGT remain

The video version of this podcast can be found here: ·      https://youtu.be/3QL2R2IV83oThis video refers to guidelines produced by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do if thrombocytosis is found, always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners.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 My summary of the guidance consulted can be found here:·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84The resources consulted can be found here:·      Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage·      Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0·      Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf·      King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdfTranscriptIf 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. Today we are going to cover what to do when we encounter thrombocytosis on a full blood count, always focusing on what is relevant in Primary Care only. I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description. Right, let’s jump into it.Thrombocytosis is when the number of platelets is high, which is usually defined as a raised platelet count above 450 × 10⁹/L.But before moving on, let’s clarify the terminology: should we call it thrombocytosis or thrombocythemia? There is an important difference. Thrombocytosis is much more common and arises as a secondary response to another condition, which is why it is also known as reactive thrombocytosis. In contrast, thrombocythemia, also called primary or essential thrombocythemia, is far less common and represents a myeloproliferative disorder in which the bone marrow produces platelets in an uncontrolled, abnormal way.Another important distinction is that patients with reactive thrombocytosis have normal platelets, so their risk of thrombosis and bleeding is relatively low. On the other hand, patients with thrombocythemia have abnormal platelets, which increases their risk of both blood clots and bleeding complications. From a clinical perspective, thrombocythemia often presents with splenomegaly and a platelet count greater than 1000 × 10⁹/L.So, let’s have a look at the possible causes. Causes of thrombocytosis include:• Iron Deficiency Anaemia: which is one of the most common causes of reactive thrombocytosis. When iron levels are low, the bone marrow increases its overall activity in an attempt to compensate for the anaemia. Although iron deficiency limits the production of red blood cells, platelet production is not restricted in the same way. As a result, the bone marrow produces more platelets. In addition, inflammatory signals associated with chronic iron deficiency can further stimulate thrombopoietin pathways, increasing platelet numbers even more. This is why thrombocytosis often resolves once the iron deficiency is corrected. • Another cause is Malignancy, because some tumours release inflammatory cytokines that eventually increase platelet formation. This reactive response is common in several solid cancers, particularly the “LEGO” cancers, that is: • Lung • Endometrium • Gastric • and Oesophageal cancer • Another cause is general Inflammation, where cytokines stimulate excessive platelet production. • Also Infection, which can cause transient reactive thrombocytosis. • Post-splenectomy and hyposplenism, such as in coeliac disease, since the spleen normally helps remove circulating platelets. • Post-operative states, where inflammation and stress responses increase platelet counts. • And finally, a primary myeloproliferative disorder, such as essential thrombocythemia.How should we respond to thrombocytosis?The criteria for urgent haematology referral are:• A platelet count exceeding 1000 × 10⁹/L, which raises concern for a myeloproliferative disorder and a significant risk of thrombosis.• Splenomegaly, which may indicate a primary haematological process such as essential thrombocythemia or myelofibrosis.• A recent history of thromboembolism, as thrombocytosis can contribute to recurrent clotting events.• A platelet count above 600 × 10⁹/L in a patient at high risk of thromboembolism or cardiovascular disease, since the combination significantly increases clinical risk.• Neurological symptoms, which may reflect microvascular complications associated with very high platelet counts.• Any signs of malignancy, given that multiple cancers can cause reactive thrombocytosis.• any other significant abnormal full blood count indices, which may suggest a bone marrow disorder rather than a reactive process.• And finally, if there is Abnormal bleeding. And let’s stop here for a moment and discuss how it is possible that thrombocytosis can be associated to a high risk of both thrombosis and bleeding.On one hand, thrombosis risk in thrombocytosis is due to the high number of circulating platelets, which makes clots more likely. In addition, inflammation causing reactive thrombocytosis can also create a prothrombotic environment. Together, these factors increase the thrombosis risk.On the other hand, bleeding risk in thrombocytosis can occur for two main reasons. First, in primary or essential thrombocythemia, the platelets produced by the bone marrow are structurally and functionally abnormal and these abnormal platelets do not work effectively, so clot formation is impaired. Secondly, thrombocytosis may affect the von Willebrand factor. Von Willebrand factor is a protein that helps platelets stick to damaged blood vessels and to each other, making it essential for the first steps of clot formation. However, when platelet counts become very high, the excess platelets bind and remove the most active forms of von Willebrand factor from the circulation. This leads to a functional depletion known as acquired von Willebrand syndrome. It explains the paradoxical situation in which a patient can have thrombocytosis and yet be at increased risk of bleeding.If none of the urgent referral criteria are present, we will investigate for underlying causes by arranging the following initial tests:• A repeat full blood count, to confirm that the thrombocytosis is persistent.• A blood film, which may reveal abnormal platelet morphology or other features suggestive of a myeloproliferative process.• Inflammatory markers such as ESR and CRP, since inflammation is a common cause of reactive thrombocytosis.• Ferritin and iron studies, as iron deficiency frequently elevates platelet counts.• And we will consider a coeliac screen, because coeliac disease can lead to hyposplenism or iron deficiency, both of which are associated with thrombocytosis.If the patient is asymptomatic and no obvious cause is identified, we will repeat the full blood count 4 to 6 weeks later. If the thrombocytosis persists above 450 × 10⁹/L, we will refer to haematology routinely for further assessment.So that is it, a review of the assessment and management of thrombocytosis.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/p6YSowcUuEoThis episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in December 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 December 2025 can be found here: ·      https://www.nice.org.uk/guidance/published?from=2025-12-01&to=2025-12-31&ndt=Guidance&ndt=Quality+standard The updated guideline on Child maltreatment: when to suspect maltreatment in under 18s [CG89] can be found here:·      https://www.nice.org.uk/guidance/ng253 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 December 2025, focusing on what is relevant in Primary Care only.And this time we have just one updated guideline that is relevant to us in General Practice: the guideline on when to suspect maltreatment in children.Right, let’s jump into it.In December 2025, NICE updated the guideline Child maltreatment: when to suspect maltreatment in under 18s. The core change in this update is the addition of a definition of the term “independently mobile.”Before this update, the NICE guideline used the term “independently mobile” in several key recommendations, but did not define what that term meant. We were expected to interpret it based on our own judgement. This led to variation in practice, particularly when assessing injuries such as bruises, lacerations, and abrasions. Different clinicians could reasonably reach different conclusions about whether a child met this threshold, even when looking at the same clinical picture.The term was sometimes difficult to interpret as to whether it meant rolling, crawling, bottom-shuffling, cruising, or walking, given that there was no shared or agreed definition in the guideline.The definition has been developed using a formal consensus process and “independently mobile” is now clearly defined as a child who can move around independently without support, rather than relying on being placed or carried. Therefore, a child should be considered independently mobile if they can do any of the following:crawlbottom shufflepull themself up into a standing position using an object, for example, furnituremove into a standing position unaidedcruise (that is, move from place to place holding onto an object, for example, furniture)climb, for example onto furniture or stairswalk using a push-along walkeror walk unaided.Children under 12 weeks typically lack the muscle strength, coordination and neurological maturity needed for independent mobility. However, age alone should not be used to determine whether a child is independently mobile. This definition has now been added in three areas, specifically in recommendations on: • bruising and petechiae, • lacerations, abrasions and scars, • and burn or scald injuries.Compared with the previous version, the key difference is clarity, not threshold. The level of concern for injuries has not been raised or lowered. Instead, we now have a shared understanding of which children fall into the higher-risk group when assessing unexplained or concerning injuries.Otherwise no other major changes were made to recommendations on child abuse and neglect.Right, this is the end of the update itself. And, as we have a brief episode today, let’s now look at a brief summary of this guideline. And the first thing to say is that the aim of the guideline is to help us recognise features that should raise concern and prompt further safeguarding action. We are not expected to confirm abuse, but to recognise the risks and act appropriately.Let’s now briefly review some examples of when to suspect or consider maltreatment. These are situations that may need urgent safeguarding action or discussion with local safeguarding leads.We should suspect maltreatment when there are injuries with no explanation, or an explanation that does not fit, especially: – bruising, cuts, abrasions, burns or scalds in a child who is not independently mobile, – bruises with clear shapes, such as hands, grips, or ligatures, – burns or scalds with clear patterns or signs of forced immersion, – multiple injuries or injuries of different ages, – injuries that are symmetrical or in unusual locations, – and injuries that are in areas normally covered by clothing.We should also suspect maltreatment with serious injuries without adequate trauma, including: – fractures, especially multiple fractures or rib fractures in infants, – fractures of different ages, – intracranial injury without a major accidental cause, – retinal haemorrhages or unexplained eye injuries, – and spinal, abdominal, or chest injuries that are unexplained, even if there are no external signs.Additionally, we should suspect sexual abuse when there are clear indicators, including: – genital, anal, or perianal injury without an accidental explanation, – and pregnancy in a child under 13 years, which is a strong indicator of maltreatment.Pregnancy in 13- to 15-year-olds should prompt assessment for sexual abuse.We should suspect neglect when there are strong indicators, such as: – repeated failure to provide basic care, food, warmth, or safety, – and failure to seek medical help that puts the child at risk.We should also consider possible neglect, if there is, for example: – poor hygiene or inappropriate clothing, – an unsafe home environment, – missed immunisations or health reviews, – and severe or ongoing infestations,And we should be concerned if parents or carers: – fail to give essential medication, – repeatedly miss important appointments, – or do not seek medical help when appropriate.Also, Poor school attendance without a clear reason and repeated or unusual healthcare attendances, especially across multiple services, should also raise concern.Additionally, we should consider fabricated or induced illness when: – reported symptoms do not match clinical findings, – and when symptoms only occur in the presence of carers, and investigations are repeatedly normal.We should consider maltreatment when there are behavioural or emotional concerns, such as: – sudden changes in behaviour, – extreme fear, withdrawal, or aggression, – self-harm or eating problems without a clear cause, – sexualised behaviour that is not age appropriate, – repeated self-harm, and ongoing wetting or soiling not explained by a medical condition.We should also consider maltreatment when there are concerning parent–child interactions, including: – hostility, rejection, or lack of emotional warmth, – unrealistic expectations of the child, – and refusal to allow the child to speak alone when appropriate.Running away from home or living away from caregivers without agreement should also raise concern.And to end, the key messages for us are that we should follow safeguarding procedures and seek advice early. A pattern over time is often more important than a single event and we should trust our professional judgement and discuss concerns if we are unsure.Remember that this is not an exhaustive list, but a summary of some relevant cases to

The video version of this podcast can be found here: ·      https://youtu.be/ndAus37PfsEThe video on hepatitic pattern abnormal LFTs can be found here:·      https://youtu.be/rIX46swVSfgThis episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that 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 cover what to do when in respect of an isolated high bilirubin with otherwise normal liver function tests, always focusing on what is relevant in 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 My summary guide can be downloaded here:·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS The resources consulted can be found here:BSG- British Society of Gastroenterology:·      bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests·      Guidelines on the management of abnormal liver blood tests (bsg.org.uk)o  First published on:o  BMJ article:o  Guidelines on the management of abnormal liver blood tests | Gut (bmj.com)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. Today we are going to cover what to do when we encounter an isolated high bilirubin with otherwise normal liver function tests, always focusing on what is relevant in Primary Care only.  This episode is based on the British Society of Gastroenterology guidelines on abnormal Liver function tests. A link to it is in the episode description. Right, let’s jump into it.And let’s start by remembering that there are three common patterns of abnormal liver function tests or LFTs:An isolated raised bilirubin with otherwise normal liver tests, which is what we will concentrate on today.A cholestatic pattern, normally showing a high ALP and GGT.And a hepatitic pattern, with a raised ALT and AST indicating hepatocellular injury. By the way, if you are interested in finding out more about this particular type, make sure to watch the corresponding episode on this channel. The link is in the episode description.Let’s also remember that bilirubin is the by-product of the breakdown of haemoglobin. When red blood cells are broken down, bilirubin is produced and released into the bloodstream. It exists in two forms: unconjugated bilirubin and conjugated bilirubin. Unconjugated bilirubin is water-insoluble and travels to the liver bound to albumin. Once in the liver, it is converted into conjugated bilirubin, making it water-soluble so it can be excreted into bile.A high unconjugated bilirubin level is usually due to increased production, as in haemolysis, or reduced conjugation within the liver. A high conjugated bilirubin level, on the other hand, is normally due to liver disease or biliary obstruction, where the liver is unable to process or excrete bilirubin normally.Many path labs will routinely report only the total bilirubin, but they will provide a breakdown into conjugated and unconjugated fractions if the level is abnormal or if it is specifically requested.Under normal circumstances, the majority of bilirubin should be conjugated. Therefore, if most of the bilirubin is unconjugated, and there is no evidence of haemolysis, the cause is almost always Gilbert’s syndrome. In Gilbert’s syndrome, the enzyme responsible for conjugating bilirubin has reduced activity. As a result, unconjugated bilirubin accumulates, often fluctuating with fasting, stress, illness, or dehydration. Importantly, it is not associated with liver disease or ill health, and patients should be fully reassured that it is a benign lifelong condition. But we will come back to that a little later.How do we manage these patients?When we manage patients with any abnormal liver function tests, we must start by recognising red flags that require urgent action. According to the BRITISH SOCIETY OF GASTROENTEROLOGY guidelines, if there are signs of synthetic liver failure – for example, unexplained clinical jaundice, a low albumin, or a raised INR – or if there is a suspicion of malignancy, such as unexplained weight loss or marked cholestasis, then these patients should be urgently referred or admitted for specialist assessment.For patients whose only abnormality is an isolated raised bilirubin, and who have no worrying clinical signs, we can follow a more measured primary care approach:First, we will request a full blood count (FBC) and repeat liver function tests (LFTs) on a fasting sample, asking specifically for the breakdown of conjugated and unconjugated bilirubin. The repeat sample should be fasting because in conditions like Gilbert’s syndrome the unconjugated bilirubin tends to rise further when the liver’s conjugating capacity is challenged.So, why does fasting raise bilirubin in Gilbert’s syndrome?Firstly, because there is reduced hepatic energy availability. During fasting, blood glucose falls and the liver prioritises essential metabolic functions. Bilirubin conjugation is not a high-priority process, so the already-reduced enzyme activity present in Gilbert’s syndrome becomes even less effective.Secondly, there is increased bilirubin production because fasting slightly increases the breakdown of haemoglobin and other haem-containing proteins, increasing bilirubin entering the system. And thirdly, there is reduced hepatic uptake of bilirubin from the bloodstream because of changes in liver blood flow and transporter activity.If after the repeat sample, the unconjugated bilirubin rises further on a fasting sample, and there is no evidence of haemolysis (for example, no anaemia), then Gilbert’s syndrome is the likely diagnosis. The BRITISH SOCIETY OF GASTROENTEROLOGY guidelines emphasise that for the pattern “isolated raised bilirubin with otherwise normal liver tests”, Gilbert’s syndrome is the most common cause.If there is associated anaemia, this should prompt consideration of haemolysis rather than Gilbert’s. In that scenario we should request a reticulocyte count and LDH (and possibly haptoglobin). This is because when haemolysis occurs, red blood cells are broken down more quickly than normal. This increased red-cell turnover releases large amounts of haemoglobin, which is then converted into unconjugated bilirubin. As a result, the unconjugated bilirubin rises in the bloodstream. To confirm haemolysis, we check a reticulocyte count, which will be high because the bone marrow is trying to replace the destroyed red cells, and LDH, which is released from damaged red cells and therefore increases too. We may also check haptoglobin, which binds free haemoglobin and becomes low when haemolysis is present.If haemolysis is suspected, the patient should be referred to a haematologist, because haemolysis can have many underlying causes and diagnosing the exact cause requires specialist tests that are not usually available in primary care.However, if the isolated raised bilirubin persists and the cause remains unclear, or if any additional liver function test abnormalities emerge, then we should follow the British Society of Gastroenterology guideline recommendation for further investigation. This may mean following the pathway for a hepatitic pattern or a cholestatic pattern, depending on the case.But in any event:We should consider a liver ultrasound scan to exclude biliary obstruction or structural liver disease.We will consider a full liver screen. And what is a full liver screen? Apart from the ultrasound scan already mentioned, this should include hepatitis B and C screening, an autoantibody screen, serum immunoglobulins, both ferritin and transferrin saturation and, often, a coeliac screen, alpha-1-antitrypsin levels and caeruloplasmin.And finally, we will consider re-checking whether there is any evidence of haemolysis by repeating the reticulocyte count and LDH if haemolysis is still suspected.And eventually, the decision will be between monitoring versus referral.If after a

The video version of this podcast can be found here: ·     https://youtu.be/w4d4qc7aHn4This 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.This video also refers to a number of medical articles on ADHD published by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover ADHD treatment options, especially in adults, always focusing on what is relevant in Primary Care only. The information is based on a number of published medical articles. The links to them are below.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 resources consulted can be found here: 1. NICE. Attention deficit hyperactivity disorder: diagnosis and management (NG87): https://www.nice.org.uk/guidance/ng87?utm2. Ostinelli EG et al. “Comparative efficacy and acceptability of pharmacological, psychological, and neurostimulatory interventions for ADHD in adults: a systematic review and component network meta-analysis.” The Lancet Psychiatry, 2025. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00360-2/fulltext?utm3. Gosling CJ et al. “Benefits and harms of ADHD interventions: umbrella review of systematic reviews and meta-analyses.” BMJ, 2025. https://www.bmj.com/content/391/bmj-2025-085875?utm4. Cortese S et al. “Attention-deficit/hyperactivity disorder (ADHD) in adults.” World Psychiatry, 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12434367/?utm5. Wakelin C et al. “A review of recent treatments for adults living with attention-deficit/hyperactivity disorder.” 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10730462/?utm6. Kooij JJS et al. “Updated European Consensus Statement on diagnosis and treatment of adult ADHD.” European Psychiatry, 2019. https://pubmed.ncbi.nlm.nih.gov/30453134/?utmhttps://www.cambridge.org/core/journals/european-psychiatry/article/updated-european-consensus-statement-on-diagnosis-and-treatment-of-adult-adhd/707E2A36539213CF85EACCA576F47427?utm7. Nimmo-Smith V et al. “Non-pharmacological interventions for adult ADHD: a systematic review.” Psychological Medicine, 2020. https://pubmed.ncbi.nlm.nih.gov/32036811/?utmhttps://www.cambridge.org/core/journals/psychological-medicine/article/nonpharmacological-interventions-for-adult-adhd-a-systematic-review/538F70FB89C5B687F4A75E7431E63B38?utm8. Mechler K et al. “Evidence-based pharmacological treatment options for ADHD in children, adolescents and adults.” Neuroscience & Biobehavioral Reviews, 2022. https://www.sciencedirect.com/science/article/pii/S016372582100142X?utm9. AWMF S3 Guideline. “Attention-Deficit/Hyperactivity Disorder (ADHD) in Children, Young People and Adults.” 2020. https://register.awmf.org/assets/guidelines/028_D_G_f_Kinder-_und_Jugendpsychiatrie_und_-psychotherapie/028-045eng_S3_ADHS_2020-12-abgelaufen.pdf?utm10. Wolraich ML et al. “Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.” Pediatrics, 2019. https://publications.aap.org/pediatrics/article/144/4/e20192528/81590/Clinical-Practice-Guideline-for-the-Diagnosis?utm11. Faraone SV et al. “The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder.” Neuroscience & Biobehavioral Reviews, 2021. https://pubmed.ncbi.nlm.nih.gov/33549739/?utmhttps://www.sciencedirect.com/science/article/pii/S014976342100049X?utmhttps://www.adhd-federation.org/publications/international-consensus-statement.html?utm12. CADDRA. Canadian ADHD Practice Guidelines, Version 4.1. 2020. https://www.caddra.ca/canadian-adhd-practice-guidelines/?utm13. Therapeutics Initiative. “ADHD in adults.” Therapeutics Letter 144, 2023. https://www.ti.ubc.ca/2023/09/29/144-adhd-adults/?utm14. May T et al. “The Australian evidence-based clinical practice guideline for ADHD.” Australian Journal of General Practice / AADPA, 2023. https://adhdguideline.aadpa.com.au/?utmhttps://pmc.ncbi.nlm.nih.gov/articles/PMC10363932/?utm15. Coghill D & colleagues / Australian Prescriber. “Pharmacological management of attention deficit hyperactivity disorder in children and adolescents.” Australian Prescriber, 2025. https://australianprescriber.tg.org.au/articles/pharmacological-management-of-attention-deficit-hyperactivity-disorder-in-children-and-adolescents.html?utm16. Thapar A et al. “Attention-deficit/hyperactivity disorder.” Nature Reviews Disease Primers, 2024. https://www.nature.com/articles/s41572-024-00495-0?utmTranscriptIf 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. Today we are going to talk about ADHD treatment options, especially in adults, always focusing on what is relevant in Primary Care only. I have based this episode on a number of published medical articles. The links to them are in the episode description. Right, let’s jump into it.Modern guidelines emphasise that ADHD management is multimodal — including psychoeducation, environmental adaptations, psychological interventions, and, where indicated, medication.For children and adolescents, NICE and other guidelines recommend starting with psychoeducation and behavioural or parent training, then adding medication when impairment remains significant.However, for adults, guidelines are very clear: medication is usually first-line when symptoms cause persistent, moderate to severe impairment, supported by psychoeducation and practical help.So, when is medication indicated?For children and adolescents, medication — usually methylphenidate — is recommended only when ADHD is clearly diagnosed, the impairment is significant, and non-drug approaches aren’t enough. In other words, it’s generally reserved for moderate to severe ADHD, rather than mild cases.However, for adults, medication is indicated when there is a clear diagnosis of ADHD with symptoms present since childhood, even if they were never recognised at the time. The symptoms must be causing clinically significant impairment, and other conditions — like depression, bipolar disorder, or substance misuse — shouldn’t fully explain what’s going on. And finally, the person needs to want to try medication after discussing the risks and benefits.Guidelines such as NICE and the European consensus explicitly state that, in adults, medication is the main evidence-based treatment for core ADHD symptoms, offered alongside education and support.Which medications should we use, and how effective are they?There are two main classes.First, stimulants, such as methylphenidate in various modified-release forms, and amphetamine formulations like lisdexamfetamine.Second, non-stimulants, including atomoxetine, guanfacine—which has more evidence in children and adolescents—and others like bupropion, clonidine, and viloxazine, though adult data for these are more limited.A landmark meta-analysis of randomised trials found that, in adults, amphetamines produced the largest improvements in clinician-rated symptoms. They were at least as well tolerated as methylphenidate, and more effective than atomoxetine and modafinil.A recent BMJ umbrella review, which examined multiple meta-analyses, concluded that in the short

The video version of this podcast can be found here: ·      https://youtu.be/aDbEwtY3hw0This video refers to a number of medical articles on ADHD published by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover ADHD increasing incidence, especially in adults, always focusing on what is relevant in Primary Care only. The information is based on a number of published medical articles. The links to them are below.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 resources consulted can be found here: 1.   Shah P et al. “Potential impact of social media and COVID-19 restrictions on adult attention-deficit rates.” BJPsych Bulletin, 2025. https://pubmed.ncbi.nlm.nih.gov/41208391/2.   Adult Psychiatric Morbidity Survey 2023–24, Chapter 9: ADHD (NHS England, 2024).https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/survey-of-mental-health-and-wellbeing-england-2023-24/attention-deficit-hyperactivity-disorder?utm3.   McKechnie DGJ et al., UK primary-care database study, 1998–2018 – summarised by NIHR as “Significant rise in ADHD diagnoses in the UK” (2023). https://www.nihr.ac.uk/news/significant-rise-adhd-diagnoses-uk?utm4.   Gimbach S et al. “ADHD medicine consumption in Europe after COVID-19.” Public Health / Pharmacoepidemiology, 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC10854136/?utm5.   Rzeszutek M et al. “Global Trends in ADHD Medication Use: Multiple Contexts and Populations.” Journal of Clinical Medicine, 2025. https://www.mdpi.com/2077-0383/14/20/7338?utm6.   Martin AF et al. “The changing prevalence of ADHD? A systematic review.” Journal of Affective Disorders, 2025. https://www.sciencedirect.com/science/article/pii/S0165032725008638?utm7.   Staley BS et al. “ADHD Diagnosis, Treatment, and Telehealth Use in Adults — United States, 2023.” MMWR (CDC), 2024. https://www.cdc.gov/mmwr/volumes/73/wr/mm7340a1.htm?utm8.   Butt DA et al. “Prevalence and Incidence Trends of Attention Deficit Hyperactivity Disorder in Canada.” Canadian Journal of Psychiatry, 2024. https://journals.sagepub.com/doi/10.1177/07067437231213553?utm9.   Therapeutics Initiative. “ADHD in adults.” Bulletin 144, 2023. https://www.ti.ubc.ca/2023/09/29/144-adhd-adults/?utm10. Bradlow RCJ et al. “Adult attention deficit hyperactivity disorder in Australia: how its current commercial model for diagnosis and treatment is encouraging misdiagnosis.” Medical Journal of Australia, 2025. https://www.mja.com.au/journal/2025/223/8/adult-attention-deficit-hyperactivity-disorder-australia-how-its-current?utm11. Woon LSC et al. “Online interest in ADHD predicts ADHD medication prescriptions in Australia from 2004 to 2023: a time-series analysis revealing COVID-19-related acceleration.” (2025). https://pmc.ncbi.nlm.nih.gov/articles/PMC12138142/?utm12. May T et al. “The Australian evidence-based clinical practice guideline for ADHD.” Australian Journal of General Practice / Australian guidelines consortium, 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10363932/?utm13. Cortese S et al. “Attention-deficit/hyperactivity disorder (ADHD) in adults.” World Psychiatry / World Psychiatric Association, 2025. PMC+2Wiley Online Library+2 https://pmc.ncbi.nlm.nih.gov/articles/PMC12434367/?utmTranscriptIf 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. Today we are going to talk about the increasing number of ADHD diagnoses, especially in adults, always focusing on what is relevant in Primary Care only. I have based this episode on a number of published medical articles. The links to them are in the episode description. Right, let’s jump into it.And the first question to ask is: why are we covering this topic now?You may be aware that in the UK, the government has recently announced a formal review into surging mental-health and neurodevelopmental diagnoses, including ADHD and autism. This has sparked media coverage and public debate: are we seeing a real increase in ADHD, or are normal struggles being unnecessarily medicalised?In other words, is this an epidemic of overdiagnosis, or does the rise in cases simply reflect that we’re starting to catch up with reality?So now, it’s more important than ever to look at what the research actually shows, especially around adult ADHD diagnoses. And although we in primary care are not directly responsible for the full diagnosis and treatment process, the way we assess and support these patients at their first point of contact can make a huge difference. It shapes how they experience their care, whether they feel understood, and whether they receive the guidance and support they need.Let’s start by reminding ourselves that attention-deficit/hyperactivity disorder, or ADHD, is a neurodevelopmental condition that affects a person’s ability to regulate attention, manage impulses, and maintain consistent levels of activity.In adults, ADHD often looks very different from the stereotype of a hyperactive child. Adults tend to present with chronic distractibility, difficulty organising tasks, emotional impulsivity, forgetfulness, restlessness, and problems sustaining attention at work or in relationships. These symptoms can have real-world consequences, including difficulties with work and relationships, financial problems, and a persistent sense of underachievement.The consensus is that ADHD is highly heritable and is associated with higher rates of anxiety, depression, and substance misuse. It’s also linked to measurable differences in executive brain function. And by this, we mean that the prefrontal cortex — the area responsible for focus, planning, impulse control, and emotional regulation — works differently in people with ADHD. Brain-imaging studies have repeatedly shown altered activity in this area.So what this really means is that ADHD symptoms aren’t just behavioural. They reflect real differences in brain function.Importantly, ADHD is not a condition people usually “grow out of.” For around two-thirds of children with ADHD, symptoms continue into adulthood, although sometimes in a more subtle or internalised form.So, why are adult ADHD diagnoses increasing?Research shows that adult ADHD is now better recognised. Historically, many adults — especially women — were simply missed in childhood because their symptoms were less disruptive, or because diagnostic criteria were focused on school performance rather than adult functioning.A recent study from the UK found that adult referrals for ADHD assessment increased threefold between 2019 and 2023, with peaks during and after the COVID-19 pandemic. This is likely because the pandemic disrupted daily routines and removed coping structures, making previously manageable symptoms more difficult, and prompting more adults to seek help.As diagnoses have increased, some people — including medical professionals — have expressed concerns that the condition might be overdiagnosed. After all, clinicians have always been wary of patients self-diagnosing, and the fact that some ADHD assessments rely on self-reported symptoms can create doubts for those who aren’t familiar with how structured and evidence-based these assessments actually are.The numbers are stark. A large 20-year UK primary-care cohort study found that recorded ADHD diagnoses increased roughly twenty-fold, while ADHD medication prescribing rose fifty-fold. Some of the biggest proportional increases were seen in adults, particularly men aged 18 to 29.Is this surprising? Not necessarily. ADHD is more common than many people realise. Multiple published reviews estimate the prevalence in children and adolescents to be between two and eight percent, and a major 2023 re-analysis placed it at 5.41 percent.However, many studies showing steep increases in diagnosis have still reported prevalence rates well below this expected fi

The video version of this podcast can be found here: ·      https://youtu.be/dZpq3W-lkSQThis 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 November 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 November 2025 can be found here: ·      https://www.nice.org.uk/guidance/published?from=2025-11-01&to=2025-11-30&ndt=Guidance&ndt=Quality+standard The new guideline on suspected sepsis in people aged 16 or over can be found here:·      https://www.nice.org.uk/guidance/ng253 The new guideline on suspected sepsis in under 16s can be found here:·      https://www.nice.org.uk/guidance/ng254 The new guideline on suspected sepsis in pregnant or recently pregnant people can be found here:·      https://www.nice.org.uk/guidance/ng255 The visual summary for suspected sepsis: evaluation and management, all ages, settings and population groups can be found here:·      https://www.nice.org.uk/guidance/ng253/resources/suspected-sepsis-managing-and-evaluating-risk-all-settings-pdf-15494830813 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 November 2025, focusing on what is relevant in Primary Care only.And this time we have three brand-new guidelines on a single topic: Sepsis. There are three separate guidelines because each one focuses on a different group: people aged 16 and over, children and young people under 16, and those who are pregnant or recently pregnant.Right, let’s jump into it.And we will start by saying that we will focus on the recommendations for people over 16 but I’ll also point out what’s different for the under-16 group and for pregnant people.If infection is suspected, the first question to ask ourselves is: Could this be sepsis? And then assess for a potential source, for risk factors, and for any signs of clinical concern in circulation, breathing, or behaviour, ideally using a structured system.The main 6 observations that we should assess are: temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation. However, we need to remember that some groups of people with sepsis may not develop a raised temperature and that, in terms of oximetry, poor peripheral circulation due to shock can make peripheral oxygen saturation difficult to measure. Additionally, we need to be aware that some pulse oximeters can underestimate or overestimate readings, especially if the level is borderline and that overestimation has been reported in people with dark skin.Additionally, we should examine for:mottled or ashen appearancecyanosis skin rashes, particularly non-blanching petechial or purpuric rashes and any breach of skin integrity as the source of infectionWe should always keep in mind groups who are more vulnerable: people over 75, those with frailty or co-morbidities, learning disabilities, immunosuppression, indwelling lines or catheters, recent surgery or invasive procedures, and those with adverse social or economic factors that may delay presentation.In hospital or ambulances, the National Early Warning Score 2, or NEWS2, is recommended. NEWS2 measures the same six values, temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation.  and then assigns points based on how abnormal they are. I will not go through every score and its clinical implications but there is NEWS2 calculator app reproduced from the Royal College of Physicians that I would really recommend downloading.However, in primary care we can consider NEWS2 or any other structured observation tool. The guideline gives us a set of criteria to assess the risk of severe illness. There are high risk and moderate risk criteria. The high-risk criteria for people over 16 are as follows: ·      A new altered mental state·      A respiratory rate of 25 breaths per minute or more·      New need for oxygen to maintain saturation more than 92% (or more than 88% in chronic hypercapnic respiratory failure)·      A Systolic BP of 90 mmHg or less or more than 40mmHg below normal·      A heart rate of more than 130 beats per minute·      Not passed urine in previous 18 hours, or for catheterised patients, passed less than 0.5 ml/kg of urine per hour·      Mottled or ashen appearance·      Cyanosis and·      A non-blanching petechial or purpuric rashThese are the high-risk criteria only. For simplicity, I will not go through all the moderate risk criteria, but they are similar to the high-risk ones but with values slightly less abnormal.Once sepsis is suspected, for primary care, the key point is to arrange rapid referral or admission to hospital. In remote or rural areas where transfer exceeds one hour, the guideline states that systems should exist so GPs can give the first dose of antibiotics when high-risk criteria are met.For borderline or uncertain cases, we should provide clear safety-netting, and ensure patients and carers understand warning symptoms and when to seek help.Let’s quickly touch on sepsis in children.Risk stratification for children is a lot more complex and is based on age bands — under 5, 5 to 11, and 12 to 15 — each with its own physiological thresholds. Because of the complexity, I will not go through all the high-risk criteria here, but we need to remember that severity is judged not just on vital signs, but on age-appropriate risk criteria combined with history, examination and clinical judgement.Adult early-warning scores such as NEWS2 should not be applied to children.If a child meets any high-risk criterion, they require urgent admission to hospital.For lower-risk children, we must still decide between safe management in the community with safety-netting or urgent admission if concerns arise. For this, communication must be tailored to the child and their carers, with clear explanations as to what to do if the situation does not improve.Let’s now move to people who are pregnant, or within six weeks postpartum. They fall under a separate guideline because pregnancy changes physiology and the pattern of infection.For pregnant or recently pregnant people, NEWS2 is not appropriate either. Instead, we should use a pregnancy-specific risk table with high-risk, moderate-to-high-risk, and low-risk criteria.These criteria include the usual physiological markers but they use pregnancy-specific thresholds and they also emphasise obstetric sources of infection, such as endometritis, wound infections, urinary infection, retained products, and mastitis.Again, I will not go through all the criteria here but NICE has produced a visual summary of the risk criteria for all groups. The link to it is in the episode description. Going back to the assessment of suspected sepsis for people that are pregnant or recently pregnant, if any high-risk criterion is present, emergency admission will be required.For us in primary care, the key points are that pregnancy or up to six weeks postpartum automatically places the patient in a higher-risk group, we must use pregnancy-specific criteria rather th

The video version of this podcast can be found here: ·      https://youtu.be/rIX46swVSfgThis episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology and a number of NHS organisations in the UK. Here I focus on the hepatitic pattern of abnormal LFTs. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that 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 review the interpretation, initial follow up management, of adults presenting with a hepatitic pattern in their LFT’s, always focusing on what is relevant in Primary Care only. This episode is based on the British Society of Gastroenterology guidelines on LFTs. A link to it 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 My summary guide can be downloaded here:·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS The resources consulted can be found here:BSG- British Society of Gastroenterology:·      bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests·      Guidelines on the management of abnormal liver blood tests (bsg.org.uk)o  First published on:o  BMJ article:o  Guidelines on the management of abnormal liver blood tests | Gut (bmj.com)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. Today we are going to go through the interpretation, initial follow up management, of adults presenting with a hepatitic pattern in their LFT’s, always focusing on what is relevant in Primary Care only. This episode is based on the British Society of Gastroenterology guidelines on LFTs. A link to it is in the episode description. Right, let’s jump into it.We have to start by remembering that liver disease develops silently and at earlier stages liver enzymes may be normal, and, if they are high, the degree of abnormality is not necessarily related to the severity of the underlying condition.We also need to remember that AST and ALT are enzymes present in the liver cells and the levels increase in response to cell injury or death. ALT is considered more liver-specific while AST is also present in skeletal, cardiac and smooth muscle and so may be elevated in patients with an MI or myositis.An AST:ALT ratio of >1 is a non-invasive marker of liver fibrosis. In early liver disease, AST and ALT can be normal, but the high AST:ALT ratio is usually present even if both values are normal.So, what should we do when confronted by abnormal LFTs?First of all, we should not think that the extent of abnormality of the LFTs correlates necessarily with the severity of the problem. Common conditions leading to chronic liver disease like NAFLD, and hepatitis C are frequently associated with only mild or moderate LFT abnormalities.Also, we should not think that the duration of the abnormal LFTs is a reflection of clinical significance, so repeating the LFTs hoping that they will improve is not necessarily the way to go. We need to remember that in many chronic liver diseases such as hepatitis C and NAFLD, the LFTs returning to normal do not necessarily imply the resolution of the disease.Therefore, the recommendation is that most patients with abnormal LFTs should have a full liver screen irrespective of level and duration of the abnormality.What is a full liver screen?This should include an USS, hepatitis B and C screening, an autoantibody screen, serum immunoglobulins, both ferritin and transferrin saturation and, often, a coeliac screen, alpha-1-antitrypsin levels and caeruloplasmin.And finally, let’s remember that there are three common patterns of abnormal LFTs:An Isolated raised bilirubin with otherwise normal liver testsA Cholestatic pattern: normally showing a high ALP and GGTA Hepatitic pattern: with a raised ALT and AST indicating hepatocellular injury, like, for example, viral hepatitis, NAFLD, and ARLD. The hepatitis pattern is the section that we will concentrate on today.The three most common causes of liver disease are alcohol-related liver disease, non-alcoholic fatty liver disease and viral hepatitis.How do we manage these patients?First of all, if there are signs of synthetic liver failure like unexplained clinical jaundice, a low albumin or a high INR or if there is suspicion of malignancy, for example because of weight loss or marked cholestasis, we should urgently refer or admit the patient.If the patient has a hepatitic picture with a high ALT and AST, the management will depend on the level of liver fibrosis, which we can estimate using non-invasive fibrosis markers.The majority of patients presenting with a hepatitic pattern will have either NAFLD or ARLD.So let’s start with NAFLD.Following a liver USS, for patients with NAFLD or liver disease of unknown cause, we will estimate the risk of fibrosis using the FIB4 or NAFLD fibrosis score. These scores have cut off points for low, intermediate and high risk of fibrosis.If there is a low risk of advanced fibrosis, we will just manage the risk factors in Primary Care and reassess periodically, generally every 2 to 5 years. In primary care, the treatment for NAFLD is weight loss, alcohol advice, the reduction of cardiovascular risk and the management of co-morbidities.If the risk of fibrosis is intermediate, these patients should have second-line tests such as an enhanced liver fibrosis blood test, also known as an ELF test, or imaging such as a FibroScan or elastography.However, patients with very high scores representing a high risk of fibrosis, should be referred to hepatology without waiting to do an ELF test, Fibroscan or elastography.Let’s now look at ARLD. For patients with ARLD we will assess their alcohol intake, using the AUDIT C or the full AUDIT questionnaire if necessary. Depending on the severity of the alcohol intake, we will give them a brief intervention, refer them to alcohol services or to hepatology for further investigations.The treatment of ARLD is to stop drinking harmfully, and for many this usually means complete abstinence. Weight loss sometimes also helps because there is a synergy between alcohol and obesity. For example, when the BMI is >35, the risk of liver disease doubles for any given alcohol intake.But, finally, what should we do if the patient has a hepatitic pattern with a high ALT and AST without an obvious cause, that is, when the liver screen is normal and there is no evidence of NAFLD on USS or excess alcohol?In those cases, we will need to re-examine the history to exclude potential drug-induced causes. Also, ultrasound is only sensitive for steatosis when hepatocytes are more than 30% steatotic so patients with milder steatosis might have a normal USS. So, if these patients are obese or have metabolic risk factors and we suspect that they may still have NAFLD despite the normal USS, we should assess them in accordance with the NAFLD pathway.But at the end of the day, if AST or ALT remain high without an obvious cause, we will need to refer them to secondary care for further investigations.So that is it, a review of abnormal LFTs with a hepatitic pattern.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/goK_Q4P2qpkThis video refers to guidelines produced by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I neutropenia always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners.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 My summary of the guidance consulted can be found here:·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84The resources consulted can be found here:·      Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage·      Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0·      Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf·      King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.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. Today we are going to cover neutropenia, including initial assessment, follow up and management, always focusing on what is relevant in Primary Care only. I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description. Right, let’s jump into it.Neutrophils are the most numerous subtype of white blood cell and they are the body’s first responders to bacterial infections.Neutropenia is when the neutrophil count is low. A normal neutrophil count in adults ranges from 2.0 to 7.5. However, an isolated low neutrophil count is extremely common in clinical practice. A result between 1.5 and 2.0 × 10⁹/l, while technically below the normal reference range, is rarely clinically significant. Many healthy people fluctuate in this borderline range due to factors such as minor viral infections, recent exercise, or simply natural day-to-day variation in blood counts.We also have to remember that normal ranges differ across populations. People of Afro-Caribbean or Middle Eastern heritage often have a normal baseline neutrophil count between 1.0 and 1.8 × 10⁹/l. This is known as constitutional or ethnic neutropenia, which is of no clinical consequence. It is a benign, lifelong finding and does not increase susceptibility to infection. For these patients, referral is usually only needed if the neutrophil count falls below 1.0 × 10⁹/l on repeat testing.For everybody else and for the purpose of this episode, we will define neutropenia as a neutrophil count below 1.5.Possible causes of neutropenia are as follows:• first we have drugs: such as phenytoin, carbimazole, antipsychotics, and co-trimoxazole, which can suppress neutrophil production in the bone marrow or trigger immune-mediated neutrophil destruction. Some drugs are directly toxic to the bone marrow, while others induce antibody formation against neutrophils.• then we have Malignancy: including conditions like myeloma or any cancer that infiltrates the bone marrow. This reduces the marrow’s ability to produce neutrophils. Additionally, chemotherapy and radiotherapy further compound this by damaging rapidly dividing cells, leading to predictable and sometimes profound neutropenia.• Also Vitamin B12 and folate deficiency: which impair DNA synthesis. Because neutrophils and their precursors divide rapidly, they are particularly sensitive to this.• then we have Iron deficiency: which reduces the efficiency of haematopoiesis in general. Although iron deficiency is normally associated with anaemia, iron is also required for normal development of all blood cell lines, including neutrophils. Severe or prolonged deficiency can therefore lead to mild neutropenia.•Another cause ca be Autoimmune diseases: which can cause neutropenia through immune-mediated destruction by autoantibodies that target neutrophils or their precursors.• then we have viral infections: including EBV, HIV, and hepatitis B and C, which can directly suppress bone marrow activity or cause redistribution of neutrophils from the bloodstream into tissues. Many other viruses also transiently inhibit neutrophil production during acute illness, making mild neutropenia very common.• Also, another possible cause is excess alcohol: which is toxic to the bone marrow and can impair the proliferation and differentiation of myeloid precursors. Chronic alcohol use is also associated with nutritional deficiencies, particularly folate, compounding the effect on marrow function.• then we have Liver disease and cirrhosis: which can lead to neutropenia through hypersplenism causing increased sequestration and destruction of blood cells in the spleen. Another mechanism is metabolic effect of cirrhosis on overall bone marrow function. And finally, as we have already explained there is:• Ethnic variation: like constitutional or ethnic neutropenia in people of Afro-Caribbean and Middle Eastern descent. Again, this is a benign inherited pattern without any impairment in immune function. How should we manage these patients? We should send the patient to hospital as an emergency if:• There is any evidence of sepsis, because neutropenic patients are at high risk of overwhelming infection. This means they can deteriorate rapidly, often without the typical signs of infection.• Additionally, we should also send the patient to hospital as an emergency if the neutrophil count is below 1.0 × 10⁹/l and any of the following factors are present:– First, if the patient is on chemotherapy. This is because chemotherapy-induced neutropenia can progress quickly, and these patients are at particularly high risk. In this setting, infection can become severe within hours leading to sepsis.– Also, if there is lymphadenopathy because enlarged lymph nodes raise concern for an underlying haematological malignancy, such as lymphoma or leukaemia, or for a significant viral infection causing significant bone marrow involvement.– Also if there is splenomegaly because an enlarged spleen suggests increased sequestration and destruction of blood cells, or infiltration by malignancy or infection. Splenomegaly with neutropenia can be suggestive of serious conditions such as myeloproliferative disorders, autoimmune cytopenias, or advanced liver disease with hypersplenism.– And finally, we should also send the patient to hospital as an emergency if the neutrophil count is below 1.0 × 10⁹/l if there are other cytopenias. For example, if anaemia or thrombocytopenia is also present, this points toward a significant bone marrow problem which increases the risk of complications.We should make an urgent haematological referral on a cancer pathway if:• The neutrophil count is below 0.5 × 10⁹/l and the patient is otherwise well. This is because a neutrophil count this low is concerning even in the absence of symptoms. Counts below 0.5 significantly increase the risk of serious infection, and they also raise the possibility of an underlying bone marrow disorder. Conditions such as acute leukaemia, myelodysplastic syndromes, or bone marrow infiltration can initially present with isolated severe neutropenia before other clinical signs appear.If the neutrophil count is above 0.5 × 10⁹/l and the patient is clinically well, we can safely take a stepwise approach. The first action is to repeat the blood test within one week, as many cases of mild neutropenia are transient. At the same time, and as part of the initial work-up, which other investigations should we request? We should investigate the underlying cause by organising the following tests:• As already mentioned, a repeat full blood count.This in ord

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