Primary Care Guidelines

The video version of this podcast can be found here: ·       https://youtu.be/8Fnx4matnfkThis 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 2026 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 2026 can be found here: ·       https://www.nice.org.uk/guidance/published?from=2026-10-01&to=2026-10-31 The updated HealthTech guidance on Virtual reality technologies for treating agoraphobia or agoraphobic avoidance: early value assessment [HTG701] can be found here:·       https://www.nice.org.uk/guidance/htg701The updated HealthTech guidance on Digital technologies for managing non-specific low back pain: early value assessment [HTG712] can be found here:·       https://www.nice.org.uk/guidance/htg712The updated HealthTech guidance on Digitally enabled therapies for adults with anxiety disorders: early value assessment [HTG676] can be found here:·       https://www.nice.org.uk/guidance/htg676The NICE Technology appraisal on Insulin efsitora alfa for treating type 2 diabetes [TA1200] can be found here:·       https://www.nice.org.uk/guidance/ta1200TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is 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 2026, focusing on what is relevant in Primary Care only. This month, we have three areas to cover: a new once-weekly insulin for type 2 diabetes, digital technologies for managing low back pain, and digital treatments for certain mental health conditions.Right, let’s jump into it.Let's start with the new NICE technology appraisal on insulin efsitora alfa, also known as Onswik, for treating type 2 diabetes in adults.So, what is insulin efsitora alfa?It is a genetically engineered, ultra-long-acting basal insulin that works in a similar way to other basal insulins, but with one important difference: it is administered by subcutaneous injection once a week rather than once or twice a day.It is designed to provide relatively stable glucose control throughout the week.But how does a once-weekly insulin actually work?What makes efsitora interesting is that it is not simply conventional insulin formulated to be absorbed more slowly. Instead, its molecular structure has been modified to allow it to remain in the circulation for much longer.Like other insulins, efsitora binds to insulin receptors, with glucose-lowering mechanisms that are essentially the same as those of human insulin. The main difference is its pharmacokinetics, particularly how slowly it is cleared from the circulation.Now, let's look at the NICE recommendations.NICE recommends insulin efsitora alfa as an option for adults with type 2 diabetes who need basal insulin treatment.However, NICE says we should choose the least expensive suitable option, taking into account the benefits and disadvantages of the available insulins, administration costs and patient preferences.So, what are the potential advantages?Once-weekly injections may be particularly helpful for patients who need assistance with insulin administration, such as frail patients, people with learning disabilities, or those with visual, cognitive or dexterity problems.They may also benefit people who find daily injections difficult to manage, for example, those of working age.In terms of effectiveness, clinical trials showed that insulin efsitora alfa provides similar control to once-daily basal insulins.NICE also found that overall costs could be similar or lower, particularly when fewer injections reduce the need for nursing support.So, what does this mean for us in primary care?This gives us another basal insulin option for adults with type 2 diabetes, particularly when daily injections are difficult or require additional support.However, it does not mean that everyone taking daily basal insulin should be switched to a once-weekly preparation.Treatment should remain individualised, taking into account local prescribing arrangements.There are also some important practical considerations.First, dose titration is slower.Because efsitora remains in the circulation for so long, the full effect of a dose adjustment may take several weeks to become apparent, potentially around four weeks. We should therefore avoid making overly aggressive adjustments based on just a few high glucose readings.Second, hypoglycaemia remains an important risk, and the prolonged action of efsitora means that the effects of an excessive dose may persist for longer.And third, we need to be particularly careful about medication errors, as a once-weekly insulin could be confused with daily insulin preparations.Finally, you may have heard of another once-weekly insulin, insulin icodec.Both provide prolonged basal insulin activity, but their molecular designs differ, so they achieve their long duration of action through different mechanisms.Let’s now look at some NICE Health Tech guidance.The first one is the updated NICE HealthTech guidance on digital technologies for managing non-specific low back pain.This update extends the evidence generation period until March 2028, to allow for more evidence to be presented.So, what are these digital technologies?They are digital programmes that provide support for managing low back pain, including education, exercise programmes and advice on self-management.NICE recommends four technologies that can be used in the NHS while further evidence is collected, although, they must have appropriate regulatory approval and meet NHS England's standards.So, why does NICE recommend these technologies?The available evidence suggests that they may reduce pain, improve everyday functioning and provide more flexible access to treatment.They could also reduce waiting lists, physiotherapy referrals and GP appointments.For us in primary care, these technologies may offer another option to support patients with non-specific low back pain. However, availability will depend on local NHS pathways, and we should remember that digital treatment may not be suitable for everyone, particularly people with limited internet access or difficulties using digital technology.Otherwise, we should also continue to follow the usual NICE recommendations for managing low back pain, including identifying red flags, encouraging physical activity and supporting self-management.Let’s now look at the other two updated NICE HealthTech guidelines on digital treatments, which are for mental health conditions.Both updates extend the evidence generation period, and the first, and more relevant to primary care, is on digitally enabled therapies for adults with anxiety disorders.These are structured psychological treatments delivered through digital platforms, allowing patients to work through therapy programmes with support from a trained practitioner or therapist.NICE recommends five therapies that can be used in NHS Talking Therapies services while further evidence is collected, provided they have the appropriate NHS approval.The treatments cover conditions including generalised anxiety symptoms, social anxiety disorder, post-traumatic stress disorder and body dysmorphic disorder.The available evidence suggests that these therapies may reduce anxiety symptoms, offer more flexible access to treatment and require less therapist time, potentially helping to reduce waiting lists.However, more evidence is needed about their long-term effectiveness, recovery rates, relapse and impact on NHS resources.For us in primary care, the main message is that these therapies may offer another option for patients who prefer flexible access to psychological treatment.However, they are not simply self-help apps. They are delivered through NHS Talking Therapies services with professional support and monitoring, and they may not suit everyone.The second guideline covers virtual reality technology for treating agoraphobia or agoraphobic avoidance.NICE supports one technology, which uses virtual reality and CBT techniques to help patients gradually confront situations they find frightening, such as leaving home or entering public places.This recommendation is specifically for adults with psychosis and severe agoraphobic avoidance, and treatment must be supported by a mental health professional. So, this is mainly relevant to specialist mental health services in secondary care. However, it is useful for us to know that this choice exists when discussing treatment options with relevant patients.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 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/68bAZA9H9hQThis 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 a section of the NICE guideline on Thyroid disease: assessment and management [NG145], particularly the section on hyperthyroidism, always focusing on what is relevant in Primary Care only.I am not giving medical advice; this episode 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 clinical guideline on Menopause: identification and management[NG23] can be found here: ·       https://www.nice.org.uk/guidance/NG23 The resources consulted can be found here:Thyroid disease: assessment and management -NICE guideline [NG145] can be found here:·       https://www.nice.org.uk/guidance/NG145  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 NICE guideline on Thyroid disease, always focusing on what is relevant in Primary Care only.So let’s jump into it.Let’s now have a look at thyrotoxicosisFirst, we will have confirmed the diagnosis with a low TSH and raised FT4 and / or FT3.Then we will need to differentiate between thyrotoxicosis with hyperthyroidism (for example, Graves' disease or toxic nodular disease) and thyrotoxicosis without hyperthyroidism (for example, transient thyroiditis). We will do so by:●    measuring TSH receptor antibodies (TRAbs) to confirm Graves' disease. and●    considering technetium scanning of the thyroid gland if TRAbs are negative.We will only consider ultrasound for thyrotoxicosis if they have a palpable thyroid nodule. In terms of treatment, we need to be aware that transient thyrotoxicosis without hyperthyroidism like in thyroiditis usually only needs supportive treatment (for example, beta-blockers).Otherwise we can consider antithyroid drugs along with supportive treatment for adults with hyperthyroidism who are waiting for specialist assessment and further treatment, bearing in mind that the use of carbimazole is subject to MHRA advice on contraception (Drug Safety Update, February 2019) and risk of acute pancreatitis (Drug Safety Update, February 2019).Before starting antithyroid drugs, we will check a full blood count and liver function tests.Antithyroid drugs for hyperthyroidism secondary to a single or multiple toxic nodules, will normally be with a titration regimen of carbimazole.However, we will consider propylthiouracil for adults:●    who experience adverse reactions to carbimazole●    who are pregnant or trying to become pregnant within the following 6 months or●    with a history of pancreatitis.We will stop and do not restart any antithyroid drugs if a person develops agranulocytosis and we will refer to a specialist for further management options.For the monitoring of antithyroid drugs, we will check:●    TSH, FT4 and FT3 every 6 weeks until their TSH is within the reference range, then●    TSH every 3 months until antithyroid drugs are stopped, rechecking FT4 and FT3 if the TSH becomes suppressed at any stage.We will not monitor full blood count and liver function while taking antithyroid drugs unless there is a clinical suspicion of agranulocytosis or liver dysfunction.After stopping antithyroid drugs in adults, we will check:●    TSH within 8 weeks of stopping the drug, then●    TSH every 3 months for a year, then●    TSH once a year.●    Always rechecking FT4 and FT3 if the TSH becomes suppressed at any stage.In terms of the management and monitoring of subclinical hyperthyroidism, that is, when TSH is low and FT4 and FT3 are normal, We will seek specialist advice if they have:●    2 TSH readings lower than 0.1 Miu/litre at least 3 months apart and●    evidence of thyroid disease (for example, a goitre or positive thyroid antibodies) or symptoms of thyrotoxicosis.Otherwise, in untreated subclinical hyperthyroidism, we will check TSH every 6 months and if the TSH level is outside the normal range, we will also check FT4 and FT3.We will consider stopping TSH measurement if the TSH level stabilises (that is, we have 2 similar measurements within the normal range 3 to 6 months apartWe have come to the end of this episode. Remember that this is not medical advice and it is 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/djfeYkbyoYUThis 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 2026 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  Tracks: 00:00 – Introduction and welcome00:25 – Suspected sepsis02:13 – Psychosis and schizophrenia04:04 – KardiaMobile 6L05:38 – Thank you and good-bye 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 2026 can be found here: ·       https://www.nice.org.uk/guidance/published?from=2026-09-01&to=2026-09-30 The updated NICE guideline on Suspected sepsis in people aged 16 or over: recognition, assessment and early management [NG253] can be found here:·       https://www.nice.org.uk/guidance/ng253The updated NICE clinical guideline on Psychosis and schizophrenia in adults: prevention and management [DG178] can be found here:·       https://www.nice.org.uk/guidance/cg178The updated NICE Health Tech guidance on KardiaMobile 6L for measuring cardiac QT interval in adults having antipsychotic medication: early value assessment [HTG694] can be found here:·       https://www.nice.org.uk/guidance/htg694TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is 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 2026, focusing on what is relevant in Primary Care only. If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is 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 2026, focusing on what is relevant in Primary Care only.This month, we have brief updates in two areas: suspected sepsis, and psychosis and schizophrenia, including QT interval monitoring in people taking antipsychotic medication.Right, let’s jump into it.Let's start with the updated NICE guideline on suspected sepsis in adults.The main change is that NICE has updated its recommendations on procalcitonin testing.And let’s remember that procalcitonin is a blood biomarker that tends to rise in bacterial infection and sepsis, and it can help estimate the likelihood of bacterial infection.However, NICE does not recommend procalcitonin testing in primary care, so these updated recommendations mainly relate to hospital care.So, what are the main messages for us in primary care?The first is simple: we should think about sepsis early whenever someone has a possible infection and appears significantly unwell.Let’s also remember that sepsis can present non-specifically, that the patient may not have a fever, and that we should be particularly careful when the history is difficult to obtain, for example because of communication difficulties, cognitive impairment, learning disability, etc.We should also refer suspected neutropenic sepsis immediately for hospital assessment.The second point is structured assessment.In hospital and ambulance settings, NEWS2 is used to assess adults with suspected sepsis who are not pregnant and have not recently been pregnant.However, in general practice, we may not always formally calculate NEWS2, but the principle is the same: we should assess physiology, including respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, level of consciousness and overall clinical concern.And the third main message is escalation and safety-netting.If the patient has high-risk features, we should arrange emergency transfer to hospital, usually by 999 ambulance, and pre-alert secondary care.Let's now look at the updated NICE guideline on psychosis and schizophrenia in adults.For us in primary care, this update is unlikely to change routine practice, because it relates to rapid neuroleptisation in secondary care.Rapid neuroleptisation refers to the use of repeated doses of antipsychotic medication over a short period to quickly control severe agitation.So, what are the main messages here for us in primary care?First, we should refer early if we suspect emerging psychosis.And if someone presents with sustained psychotic symptoms for the first time, we should not start antipsychotic medication in primary care unless this is done in consultation with a consultant psychiatrist.Second, we should take physical health monitoring very seriously.People with psychosis or schizophrenia, especially those taking antipsychotics, have a higher risk of physical health problems. This is important because cardiovascular disease and metabolic disease are major contributors to reduced life expectancy in people with severe mental illness.Some antipsychotics can cause weight gain, worsen glucose control, increase the risk of diabetes, affect lipids, raise prolactin, cause movement disorders, and prolong the QT interval.So, once monitoring responsibility is transferred from secondary care, we should do at least annual physical health checks and cardiovascular risk assessments, including weight, waist circumference, pulse and blood pressure, HbA1c, lipids, lifestyle advice including smoking, diet, and physical activity.We will also enquire about possible movement disorders and check prolactin where relevant.And this area links quite nicely with another updated NICE HealthTech guidance on KardiaMobile 6L for QT interval monitoring in adults taking antipsychotic medication.First, what is KardiaMobile 6L?It is a small portable ECG device that records a 6 lead ECG using electrodes placed on the fingers and left leg or ankle.Unlike a standard 12 lead ECG, it is designed as a quick point of care test and can estimate the QT interval, helping identify people at risk of drug induced QT prolongation.The guidance supports KardiaMobile 6L as an option for QT interval measurement in adults taking antipsychotic medication, while further evidence is generated, and it should be used alongside standard clinical assessment.It is intended to improve access to QT monitoring and reduce the need for conventional 12 lead ECGs in suitable patients.For us in primary care, the overall approach remains unchanged.We should continue to assess risk factors, including electrolyte abnormalities, structural heart disease, interacting medicines and previous prolonged QT interval issues.If ECG monitoring is required, local pathways may increasingly use portable technologies such as KardiaMobile 6L, but abnormal or uncertain results still require clinical interpretation and perhaps confirmation with a standard 12 lead ECG.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 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/kmIhZKT8SA8This 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 a section of the NICE guideline on Thyroid disease: assessment and management [NG145], particularly the section on hypothyroidism, always focusing on what is relevant in Primary Care only.I am not giving medical advice; this episode 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 clinical guideline on Menopause: identification and management[NG23] can be found here: ·       https://www.nice.org.uk/guidance/NG23 The resources consulted can be found here:Thyroid disease: assessment and management -NICE guideline [NG145] can be found here:·       https://www.nice.org.uk/guidance/NG145  TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to go through the NICE guideline on Thyroid disease, always focusing on what is relevant in Primary Care only.So let’s jump into it.We will check TFTs if there is:●    a clinical suspicion of thyroid disease, bearing in mind that 1 symptom alone may not be indicative of thyroid disease●    type 1 diabetes or other autoimmune diseases, (but we will not offer testing only because of type 2 diabetes).●    new-onset AF●    depression or unexplained anxiety●    abnormal growth in children and young people, or with an unexplained change in behaviour or school performance.●    And we will be aware that in menopausal women symptoms of thyroid dysfunction may be mistaken for menopauseWe will not test for TFTs during an acute illness unless we suspect the acute illness is due to thyroid dysfunction, because it may affect the test results.So, what tests do we do as initial screening when thyroid dysfunction is suspected?This will depend on whether we suspect a primary cause, that is, a cause arising from the thyroid gland, or a secondary cause, that is, a cause arising from the pituitary gland.So, we will always measure TSH. Then, if a primary cause is suspected in an adult:●    if the TSH is high, that is, suggestive of hypothyroidism, we will need the free thyroxine (FT4) level●    if the TSH is low, that is, suggestive of hyperthyroidism, we will need FT4 and free tri-iodothyronine (FT3)However, if we suspect a secondary cause, that is, pituitary disease, or if we are testing a child or young person, we will need results for both TSH and FT4 and:●    If the TSH is low, that is, suggestive of hyperthyroidism, we will need FT3So, in summary, we test TSH and T4 in hypothyroidism but in hyperthyroidism we need to add FT3 too.We can repeat these tests if symptoms worsen or new symptoms develop (but no sooner than 6 weeks from the most recent test).We will also ask patients about their biotin intake because a high consumption of biotin from dietary supplements may lead to falsely high or low test results.Looking at the management, and monitoring different rules may apply to children and young people and given that we are likely to be getting advice from the paediatricians , I will not cover them here. If a recommendation applies to children, I will mention it, but otherwise this episode will focus on adults unless otherwise specifically stated.So, we are going to cover:●    Primary hypothyroidism: which is caused by an insufficient hormone production by the thyroid gland. In this situation the TSH is high, and FT4 is low.●    Subclinical Primary hypothyroidism: This can sometimes happen as a precursor of clinical hypothyroidism and it is when the TSH is high, but FT4 is normal.So let’s start with the management of primary hypothyroidismSo, for all people with confirmed primary hypothyroidism, that is, when we encounter a high TSH and a low FT4, we will:Check thyroid peroxidase antibodies (TPOAbs)But in adults, we will not repeat TPOAbs testing. If the antibody test is positive, it maybe worthwhile mentioning that NICE also recommends testing for coeliac disease in people with a diagnosis of autoimmune thyroid disease.For the actual management, for both adults and children, we will:Offer levothyroxine as first-line treatment and we will not routinely offer liothyronine or natural thyroid extract for primary hypothyroidism, either alone or in combination with levothyroxine, because there is not enough evidence that it offers benefits over levothyroxine monotherapy, and the long-term adverse effects are uncertain.We will start levothyroxine at a dosage of 1.6 micrograms per kilogram of body weight per day (rounded to the nearest 25 micrograms) for adults under 65 with primary hypothyroidism and no history of cardiovascular disease.However, if they are over 65 or with a history of cardiovascular disease, we will start levothyroxine at a dosage of 25 to 50 micrograms per day with titrationHow should we follow-up and monitor primary hypothyroidism?We will aim to maintain TSH levels within the reference range when treating with levothyroxine. If symptoms persist, we will adjust the dose to achieve optimal wellbeing, but we will avoid using doses that cause TSH suppression or thyrotoxicosis.We also need to be aware that the TSH level can take up to 6 months to return to normal for people who had a very high TSH or a prolonged period of untreated hypothyroidism.In terms of monitoring, we will need to measure TSH every 3 months until the level has stabilised (that is, until we have had 2 similar measurements within the reference range 3 months apart), and then once a year. But we will also check FT4 as well as TSH if they continue to have symptoms on levothyroxine.Let’s now look at subclinical hypothyroidismOnce we have confirmed subclinical hypothyroidism, with a high TSH and normal FT4, we will also check TPOAbs.In terms of the management, we will:take into account features that might suggest underlying thyroid disease, such as, for example, symptoms of hypothyroidism, or raised levels of thyroid autoantibodies.Consider levothyroxine if the TSH is 10 mlU/litre or higher on 2 separate occasions 3 months apart, monitoring as per in hypothyroidismWe will also consider a 6-month trial of levothyroxine for adults under 65 with subclinical hypothyroidism who have:●    a high TSH but lower than 10 mlU/litre on 2 separate occasions 3 months apart, and●    symptoms of hypothyroidism.If symptoms do not improve after starting levothyroxine, we will recheck the TSH and if the level remains raised, we will adjust the dose. If symptoms persist when TSH is within the reference range, we will stop levothyroxine and continue monitoring.So, how do we monitor untreated subclinical hypothyroidism and after stopping treatment?For them, we will check TSH and FT4:●    once a year if they have features suggesting underlying thyroid disease, such as previous thyroid surgery or raised levels of thyroid autoantibodies, or●    once every 2 to 3 years if they have no features suggesting underlying thyroid disease.We have come to the end of this episode. Remember that this is not medical advice and it is 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/HJBi-1DAS60This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in August 2026 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  Tracks: 00:00 – Introduction and welcome00:25 – Allergic rhinitis03:22 – Acne vulgaris07:21 – Thank you and good-bye There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·       Redcircle: https://redcircle.com/shows/primary-care-guidelines·       Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·       Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for August 2026 can be found here: ·       https://www.nice.org.uk/guidance/published?from=2026-08-01&to=2026-08-31 The updated NICE technology appraisal on 12 SQ-HDM SLIT for treating allergic rhinitis and allergic asthma caused by house dust mites [TA1045] can be found here:·       https://www.nice.org.uk/guidance/ta1045/The updated NICE technology appraisal on 12 SQ-Bet SLIT for treating moderate to severe allergic rhinitis or conjunctivitis caused by tree pollen in people 5 years and over [TA1087] can be found here:·       https://www.nice.org.uk/guidance/ta1087 The updated NICE guideline on Acne vulgaris: management [NG198] can be found here:·       https://www.nice.org.uk/guidance/ng198 The new updated NICE guideline on Heavy menstrual bleeding: assessment and management [NG88] can be found here:·       https://www.nice.org.uk/guidance/ng88TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in August 2026, focusing on what is relevant in Primary Care only. This month, we have only two areas to cover: updated guidance allergic rhinitis and conjunctivitis, and an update on acne vulgaris.Right, let’s jump into it.There are two updates on allergic rhinitis that are very similar, so let’s take them together.They both involve sublingual immunotherapy for allergic rhinitis, and both updates expand the eligible population to include younger children.The first one is Acarizax, for house dust mite allergic rhinitis.It was recommended for people aged 12 to 65 and it now also includes children aged 5 to 11 years.The second is Itulazax, for allergic rhinitis or conjunctivitis caused by tree pollen from the birch group.It was recommended for adults and it now includes people aged 5 years and over.In both cases, the symptoms need to be moderate to severe, the diagnosis needs to be supported by a positive sensitisation test, such as skin prick testing or specific IgE, and symptoms must persist despite symptom-relieving treatment.So, what are these treatments?As we said Acarizax is for house dust mite allergic rhinitis, while Itulazax is for birch-related tree pollen allergic rhinitis or conjunctivitis.Both are sublingual immunotherapy tablets.Acarizax contains house dust mite allergen extract and Itulazax contains birch pollen allergen extract.Both are placed under the tongue and work by gradually desensitising the immune system to the relevant allergen.So these are not just another antihistamine or nasal spray.They are allergen immunotherapy treatments, aiming to modify the immune response itself rather than simply providing temporary symptom relief.In usual care, allergic rhinitis, with or without conjunctivitis, is treated first with standard medicines, such as antihistamines and intranasal corticosteroids.These immunotherapy treatments come later, when symptoms remain moderate to severe and persistent despite standard treatment.It is worth saying that Acarizax is not recommended for allergic asthma, even when house dust mite allergy may be triggering it.Having asthma does not necessarily prevent someone from receiving Acarizax for rhinitis, but the NICE recommendation is not for asthma treatment itself.Itulazax is for tree pollen allergy from the birch group, and it can be given for allergic rhinitis, conjunctivitis, or both.Although these may not be treatments that GPs routinely prescribe, they are useful to know about because we will see children and adults with persistent allergic rhinitis despite antihistamines and nasal steroids, and , in those cases, these options may be relevant for specialist referral or discussion.Let’s now look at the updated NICE guideline on acne vulgaris.This update is quite focused and NICE has amended references to polycystic ovarian syndrome, because this condition is now called polyendocrine metabolic ovarian syndrome, or PMOS. This name change was agreed by global consensus and reflects that this is a whole-body metabolic and hormonal condition, not a disease defined by ovarian cysts.Additionally the recommendation on triamcinolone injections has been withdrawn, but this is relevant to specialist care.For us in primary care, the main acne management is otherwise unchanged so let’s give it a very quick overview.For drug treatment, NICE recommends a 12-week course of one first-line treatment option, depending on severity and patient preference.For many patients, we can use a fixed-combination topical treatment, such as adapalene with benzoyl peroxide, or tretinoin with clindamycin.Adapalene with benzoyl peroxide has the advantage that it does not contain an antibiotic, but for mild to moderate acne, we can also consider benzoyl peroxide with clindamycin.For moderate to severe acne, we should usually use a topical treatment together with an oral antibiotic, either lymecycline or doxycycline.If the person cannot use lymecycline or doxycycline, we can consider trimethoprim or an oral macrolide, such as erythromycin.Topical benzoyl peroxide alone can also be considered if the other options are contraindicated, or if the person wants to avoid topical retinoids or antibiotics.We should not use topical antibiotic monotherapy, oral antibiotic monotherapy, or a combination of topical and oral antibiotics, because of the risk of antimicrobial resistance.We should also explain that treatment can take 6 to 8 weeks before improvement become noticeable.Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning pregnancy, so effective contraception or an alternative treatment is needed for people of childbearing age.If hormonal contraception is wanted, we should consider the combined oral contraceptive pill in preference to the progestogen-only pill.We should then review first-line treatment at 12 weeks.If the treatment includes an oral antibiotic and the acne has cleared, we should consider stopping the antibiotic but continuing the topical treatment.If the acne has improved but has not completely cleared, we should consider continuing the oral antibiotic with the topical treatment for up to 12 more weeks.We should only continue antibiotic-containing treatment for more than 6 months in exceptional circumstances, with review every 3 months, and we should stop the antibiotic as soon as possible.We should refer if there is diagnostic uncertainty, acne conglobata, or nodulo-cystic acne. We should also consider referral if acne is not responding to treatment, or if acne is causing scarring, persistent pigmentary change, or significant psychological distress.For PMOS and acne, we should use a first-line acne treatment option first.If that is not effective, we should consider adding co-cyprindiol or an alternative combined oral contraceptive pill.For people using co-cyprindiol, we should review at 6 months and discuss continuation or alternative options.We should consider specialist referral if acne and PMOS are associated with hyperandrogenism, or if there is severe acne resistant to standard treatment.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 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/eQwGStVNHe4This 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 review a section of the NICE guideline on Hypertension in adults, 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 The NICE clinical guideline on Menopause: identification and management[NG23] can be found here: ·       https://www.nice.org.uk/guidance/NG23 The link to the visual aid on HRT and the likelihood of some medical conditions can be found here: ·       https://www.nice.org.uk/guidance/ng23/resources/incidence-of-medical-conditions-with-and-without-hrt-a-discussion-aid-pdf-13553199901 The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here: ·       https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf  The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:·       https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/ GP notebook on contracpetion and HRT: ·       https://gpnotebook.com/pages/gynaecology/hormone-replacement-therapy-hrt-and-contraceptionTranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.Hello and welcome, I’m Fernando, a GP in the UK. Today we’re doing a practical review of menopause, focusing on what is relevant in primary care only.We’ve recently covered the NICE guideline, so today we’ll keep things practical.We’ll look at key definitions, common prescribing pitfalls, HRT regimens, contraception while using HRT, and how to advise someone who wants to delay a period for a holiday.Right, let’s jump into it.Let’s start with some definitions first.Systemic HRT means HRT that is absorbed into the bloodstream and has effects throughout the body. The oestrogen can be oral, or transdermal.The progestogen can be oral, transdermal, or provided through a levonorgestrel intrauterine system.This is different from vaginal oestrogen, which is used locally for genitourinary symptoms. It is absorbed locally, with only a minimal amount absorbed into the bloodstream, so it is unlikely to have a significant systemic effect.Vaginal oestrogen can be used alone or with systemic HRT.Let’s look at the types of HRT, starting with combined HRT.Combined HRT means HRT with both oestrogen and progestogen.We use this in people with a uterus because unopposed systemic oestrogen increases the risk of endometrial hyperplasia and endometrial cancer.Combined HRT can be continuous or sequential.Continuous combined HRT means oestrogen and progestogen are taken together every day. The aim is no regular withdrawal bleed and it can be used when the person is postmenopausal, meaning at least 12 months since their last period or from around age 54 if the bleeding pattern is unclear.. Continuous combined HRT is not usually suitable during perimenopause or within 12 months of the last menstrual period, because it can cause irregular bleeding. In these cases, we would use sequential combined HRT, also called cyclical HRT.This means oestrogen is taken every day, and progestogen is usually taken for part of the month, usually giving a predictable monthly bleed.Another option for combined HRT is to prescribe an oestrogen-only preparation with a separate progestogen, for example, micronised progesterone which is usually given as Utrogestan in the UK.Common regimens are Utrogestan 200 mg at night for 12 days per 28-day cycle, usually days 15 to 26, for sequential combined HRT or, for a continuous combined HRT, 100 mg at night from days 1 to 25 of each 28-day cycle. Another progestogen option for endometrial protection is a 52 mg levonorgestrel intrauterine system, such as Mirena, which should be changed every 5 years when used for this purpose.Let’s now look at oestrogen-only HRT.This means oestrogen is given without progestogen and it is usually used in people who have had a total hysterectomy.But we should mindful of possible pitfalls. For example, after subtotal hysterectomy, some endometrial tissue may remain in the cervical stump. In that situation, progestogen may be still needed. Another important pitfall is a history of previous widespread endometriosis. This is because even after hysterectomy, residual endometriosis deposits can remain, so combined HRT may be advised here too. In these two cases, we should consider specialist advice before prescribing unopposed oestrogen.Oestrogen-only HRT can be oral or transdermal. Transdermal is often the first choice because it has a more favourable venous thromboembolism and stroke risk profile than oral oestrogen. The general principle is to use the lowest effective dose that controls symptoms.If symptoms are not controlled after a reasonable trial, or side effects occur, we can adjust the dose, change the route, or change the progestogen.In practice, we should allow around 3 months after starting or changing HRT before judging the full effect, unless there are significant issues.When starting HRT, we should explain the expected bleeding pattern. With sequential combined HRT, a regular withdrawal bleed is expected. With continuous combined HRT, the aim is no bleeding, but irregular bleeding can occur initially.Now let’s talk about contraception.The main message is simple: HRT is not contraception.If pregnancy is possible and not wanted, contraception still needs to be discussed.Non-hormonal contraception can obviously be used alongside HRT.A 52 mg levonorgestrel intrauterine system or Mirena, can be particularly useful because it can provide both contraception and endometrial protection when used with systemic oestrogen.Although Mirena is licensed for up to 8 years for contraception, for endometrial protection as part of HRT it is only effective for up to 5 years.If a Mirena intrauterine device is not possible, we need to remember that not all progestogen-only contraceptives can be used for endometrial protection with oestrogen-only HRT. For example, the progestogen-only pill, progestogen-only implant, and depot medroxyprogesterone acetate cannot be used for this.However, they can normally be used as contraception alongside HRT.On the other hand, combined hormonal contraception should not be used in combination with HRT.In eligible women under 50, combined hormonal contraception can be used as an alternative to HRT for symptom relief and bone protection, but not together with HRT.If a woman reaches 50 while using combined hormonal contraception, they are usually switched to a progestogen-only method, and then we should reconsider HRT options.And let’s finish with a practical question that often comes up: how to delay a predictable HRT withdrawal bleed for a holiday.In UK practice, we could treat this as a short-term HRT schedule adjustment, rather than routine period delay tablets.Here we would usually extend the progestogen-containing phase until after the holiday. That is because the bleed usually happens when the progestogen phase stops.So, for someone using transdermal or oral sequential combined HRT, if the holiday falls when they are due to bleed, the practical option is usually to continue the progestogen containing patches or tablets through the holiday.After the holiday, they switch back to the oestrogen-only patches or tablets and should expect a withdrawal bleed.We should not extend the oestrogen-only phase to delay bleeding, because that increases time on unopposed oestrogen.And we should not casually add high dose oral norethisterone on top of sequential combined HRT, because the patient may already be receiving progestogen in the combined phase, and extra norethisterone may add side effects and risk.If the patient uses separate daily oestrogen with cyclical progestogen, they simply continue the progestogen until after the holiday.Then they stop the progestogen, expect a withdrawal bleed, and return to the usual monthly schedule.This is an off-licence schedule adjustment, and we should explain that spotting can still happen, and they should seek review for heavy, persistent, or unusual bleeding.So that is it, a practical review of menopause.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/n-tqArOvxcIThis episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in July 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.  I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   Disclaimer:The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through   There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·       Redcircle: https://redcircle.com/shows/primary-care-guidelines·       Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·       Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for July 2026 can be found here: ·       https://www.nice.org.uk/guidance/published?from=2026-07-01&to=2026-07-30 The updated NICE guideline on low back pain and sciatica in over 16s: assessment and management [NG59] can be found here:·       https://www.nice.org.uk/guidance/ng59 The updated NICE guideline on Osteoporosis: risk assessment [NG259] can be found here:·       https://www.nice.org.uk/guidance/ng259 The new updated NICE guideline on Heavy menstrual bleeding: assessment and management [NG88] can be found here:·       https://www.nice.org.uk/guidance/ng88TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in July 2026, focusing on what is relevant in Primary Care only. This month, we have three areas to cover: updated guidance on low back pain and sciatica, updated guidance on heavy menstrual bleeding, and a brand-new guideline on osteoporosis risk assessment.Right, let’s jump into it.Let’s start with osteoporosis risk assessment.NICE says to assess fragility fracture risk in all people aged 50 and over, and in women who have experienced menopause, if they have had a previous fragility fracture or currently use, or frequently use, systemic glucocorticoids.It also says to consider assessment in all men aged 75 and over, all women aged 65 and over, and younger people with risk factors.These include 2 or more falls in the last year, hip fracture in a first-degree relative, BMI below 18.5, smoking, alcohol intake over 14 units per week, or other risk factors such as, for example, endocrine or gastrointestinal conditions, multiple myeloma, Parkinson’s disease, immobility, COPD, autoimmune disease, and CKD stage 4 or 5.For people under 50, the threshold is higher: we should assess risk after a previous hip or vertebral fragility fracture, 2 or more major osteoporotic fractures, or another major risk factor.For people aged 40 to 90, we should use FRAX or QFracture to estimate 10-year major osteoporotic fracture risk. For people aged 30 to 39, we should use QFracture.For people over 90, we should remember that FRAX assumes age 90, while QFracture calculates risk up to age 100.We should seek specialist advice for people under 30 or with rare bone diseases.We should offer DXA to people aged 30 and over with a previous hip or vertebral fragility fracture, a single major osteoporotic fragility fracture in the last 2 years, or 2 or more fragility fractures.We should also consider DXA when the 10-year major osteoporotic fracture risk is 10% or more.When starting treatment, we should usually do a baseline DXA unless it is not tolerated or feasible.If DXA is delayed, we should consider fast-tracking within 6 weeks if anabolic treatment is likely, or starting antiresorptive treatment if anabolic treatment is unlikely.NICE also discusses DXA-based vertebral fracture assessment, or VFA.What is VFA exactly? VFA is an extra spine image done using the DXA scanner to look for vertebral fragility fractures.We should consider VFA in men aged 70 and over and women aged 60 and over.In younger people, we should consider VFA during DXA if there has been a previous major osteoporotic fracture, signs or symptoms of vertebral fracture, systemic glucocorticoid use, or exceptionally low bone mineral density for age.For treatment decisions, we should consider FRAX or QFracture risk scores, DXA results if available, previous fragility fractures, and risk factors.For people aged 50 and over, and women who have experienced menopause, we should consider treatment after a previous hip or vertebral fragility fracture, or high-dose systemic glucocorticoids.We should also consider treatment with a T-score of minus 2.5 or less, or minus 1.5 or less if there is previous fragility fracture, systemic glucocorticoid use, or other risk factors.Treatment can also be considered without DXA if the person meets assessment criteria but DXA is not tolerated or feasible, for example in frail older people.If someone declines treatment, we should advise when and how to re-access the service if they change their mind or circumstances change.If 10-year risk is below 10%, we should reassess if circumstances change, or at 5 years.If 10-year risk is 10% or more, or DXA was done but treatment criteria were not met, we should do the same, but consider repeat DXA within 2 to 3 years if they were close to treatment criteria.Now let’s move to low back pain and sciatica.In this update NICE has withdrawn the recommendations on psychological therapy and combined physical and psychological programmes for low back pain or sciatica.The rest of the primary care approach is largely unchanged.We should think about alternative diagnoses, including red flags, cancer, infection, trauma, and inflammatory disease.Management may involve exercise programmes, with or without manual therapy.We should not routinely offer imaging. If referring, we should explain that imaging may still not be needed and that imaging should only be considered by a specialist if it is likely to change management.For self-management, we should encourage normal activities and consider group exercise programmes for suitable patients.Manual therapy, including manipulation, mobilisation, or massage, can be considered only as part of a package that includes exercise.For medicines, NICE says not to offer gabapentinoids, other antiepileptics, oral corticosteroids, benzodiazepines, or opioids for low back pain and sciatica.If prescribing NSAIDs, we should consider gastrointestinal, liver and cardio-renal toxicity, age, and other risk factors and use the lowest effective dose for the shortest possible time.Weak opioids, with or without paracetamol, can be considered for acute low back pain only if NSAIDs are contraindicated, not tolerated, or ineffective.But NICE says not to offer paracetamol alone for low back pain.It also says not to routinely offer opioids for acute low back pain, and not to offer opioids for chronic low back pain.Finally, let’s look at heavy menstrual bleeding.The update is about serum ferritin testing.Previously, NICE advised not to routinely test serum ferritin in women with heavy menstrual bleeding. That recommendation has now been removed because of the risk of iron deficiency.Heavy menstrual bleeding can have a major impact on quality of life, and management should focus on this rather than blood loss alone.If there are no related symptoms, NICE says we can consider pharmacological treatment without physical examination.However, we should offer examination if there is intermenstrual bleeding, pelvic pain, pressure symptoms, or if considering a levonorgestrel-releasing intrauterine system.We should a full blood count and use clinical judgement on ferritin.We should consider coagulation testing if heavy bleeding has been present since periods started and there is a personal or family history suggesting a coagulation disorder.We should not do female hormone or thyroid testing unless clinically indicated.We can start pharmacological treatment without investigating if history or examination suggests low risk of uterine or histological abnormality.If cancer is suspected, we should follow the NICE suspected cancer pathway.If investigations are needed, we should use history and examination to decide between hysteroscopy and ultrasound as the first line investigation.We should offer outpatient hysteroscopy if the history suggests submucosal or endometrial pathology, for example if there is persistent intermenstrual bleeding or risk factors for endometrial pathology.However we should offer pelvic ultrasound if the uterus is palpable abdominally, a pelvic mass is suspected, or examination is inconclusive or difficult.For suspected adenomyosis, with significant period pain or a bulky, tender uterus, we should offer transvaginal ultrasound in preference to transabdominal ultrasound or MRI.For no identified pathology, fibroids under 3 cm without cavity distortion, or suspected adenomyosis, we should consider a levonorgestrel-releasing intrauterine system first.If this is declined or unsuitable, we should consider tranexamic acid, NSAIDs, combined hormonal contraception, or cyclical oral progestogens.Progestogen-only contraception may suppress menstruation, which may also help.We should refer if treatment is unsuccessful, pharmacological treatment is declined, symptoms are severe, there are submucosal fibroids, or fibroids are 3 cm or more.While investigations or definitive treatment are being organised, tranexamic acid and NSAIDs can still be offered.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 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/2sD5P3AfRq0This 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 review a section of the NICE guideline on Hypertension in adults, 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/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 The NICE clinical guideline on Menopause: identification and management[NG23] can be found here: ·       https://www.nice.org.uk/guidance/NG23 The link to the visual aid on HRT and the likelihood of some medical conditions can be found here: ·       https://www.nice.org.uk/guidance/ng23/resources/incidence-of-medical-conditions-with-and-without-hrt-a-discussion-aid-pdf-13553199901 The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here: ·       https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf  The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:·       https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/ TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only.Today we will focus on early menopause, and premature ovarian insufficiency.In the previous three episodes, we covered diagnosis, symptom management and HRT risks and benefits in people aged 45 and over.Right, let’s jump into it.In terms of disease prevention, NICE says we should not offer combined or oestrogen-only HRT for the primary or secondary prevention of cardiovascular disease or for the purpose of dementia prevention.For cardiovascular risk reduction, and dementia prevention we should follow the relevant NICE guidelines on those subjects.Now let’s look at premature ovarian insufficiency, which applies to people under 40.Premature ovarian insufficiency is diagnosed in people under 40 based on symptoms, including no or infrequent periods and elevated FSH levels on 2 blood samples taken 4 to 6 weeks apart. We should not diagnose premature ovarian insufficiency based on a single blood test.If there is doubt about the diagnosis, we should seek specialist advice.For premature ovarian insufficiency, NICE says we should offer sex steroid replacement, unless it is contraindicated. This can be either HRT or a combined hormonal contraceptive.We should explain the importance of hormonal treatment until at least the age of natural menopause, unless there is a contraindication.We should advise that both HRT and combined oral contraceptives offer bone protection and that HRT may have a beneficial effect on blood pressure compared with a combined oral contraceptive.On the other hand,HRT is not contraception, so contraception still needs to be discussed if pregnancy is possible and not wanted.We should also explain that the baseline population risk of diseases such as breast cancer and cardiovascular disease increases with age, and is very low in people under 40.If hormonal treatment cannot be taken, we should still give advice on bone health, cardiovascular health, and symptom management and consider specialist referral if necessary.Let’s now look at early menopause, which is defined as menopause between the ages of 40 and 44.Here the benefits and risks of taking or not taking HRT are likely to sit between those for premature ovarian insufficiency and those for people aged 45 or over.In premature ovarian insufficiency, that is, before 40, the potential benefit of HRT is usually greater, because we are not only thinking about the risks of HRT but also the risks of not taking it, particularly in respect of bone health. As we know, HRT helps reduce fragility fracture risk.In early menopause, between 40 and 44, the same issue still applies, but to a lesser extent, so the balance of risks and benefits sits between premature ovarian insufficiency and menopause at 45 or over.In simple terms, the younger the person is at menopause, the more important it is to consider the health effects of not taking HRT. As always, the discussion should be tailored to the person’s age, circumstances, and individual risk factors.Now let’s look at starting and stopping HRT.Firstly, if the person has a medical condition that may be affected by HRT, we should consider seeking specialist advice before starting it.For symptoms control, we should offer combined HRT to people with a uterus and oestrogen-only HRT to people who have had a total hysterectomy and use the lowest effective dose.For people with a uterus, we should explain that vaginal bleeding is a common side effect during the first 6 months of taking systemic HRT, or within 3 months of changing the dose or preparation.They should also be advised to seek medical help promptly if unscheduled vaginal bleeding happens beyond these timeframes.There is limited evidence for unscheduled bleeding while on HRT, and NICE signposts the British Menopause Society guidance on unscheduled bleeding on HRT.Let’s have a look at what they say:The British Menopause Society guidance say that we should first assess the patient fully, including, amongst other things, the bleeding pattern, adherence, examination, BMI, and individual risk factors for endometrial cancer.Major risk factors include a BMI of 40 or more and some hereditary conditions. Minor risk factors include a BMI between 30 and 39, diabetes, and polycystic ovarian syndrome.In people at low risk, if bleeding occurs within 6 months of starting HRT, or within 3 months of changing it, we will adjust the progestogen or HRT preparation, for 6 months in total, before arranging further investigations.If unscheduled bleeding continues in low-risk women, after six months of adjustments, we could request an urgent transvaginal ultrasound. We should also do this if bleeding first occurs more than 6 months after starting HRT, or more than 3 months after changing treatment, and also if bleeding is heavy, prolonged, or if there are 2 minor risk factors.An urgent suspected cancer referral is recommended if there is 1 major risk factor or 3 minor risk factors for endometrial cancer, regardless of bleeding pattern or timing.Now let’s go back to the NICE guideline and look at stopping HRT.NICE says we should offer a choice between gradually reducing treatment or stopping it immediately. Gradually reducing it may decrease recurrence of symptoms in the short term but it makes no difference in the long term.Finally, systemic HRT should be stopped in people diagnosed with breast cancer.What should we cover during an HRT review?We should encourage nationally recommended health screening and, at 3 months, we should review the effect of HRT on menopausal symptoms.After that, treatment should be reviewed annually, unless there is a clinical reason to review sooner, such as poor response or side effects. If HRT is not effective or tolerated, we should seek specialist advice.So that is it, a review of a section of the NICE guideline on the menopause.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/i9b7QqtmcAsThis 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 May 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.  I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   Disclaimer:The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through  There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·       Redcircle: https://redcircle.com/shows/primary-care-guidelines·       Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·       Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for June 2026 can be found here: ·       https://www.nice.org.uk/guidance/published?from=2026-06-01&to=2026-06-30The new Technology appraisal guidance [TA694] Bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia can be found here:·       https://www.nice.org.uk/guidance/ta694The updated NICE guideline on Ectopic pregnancy and miscarriage: diagnosis and initial management [NG126] can be found here:·       https://www.nice.org.uk/guidance/ng126 The updated NICE guideline on Postnatal care [NG194] can be found here:·       https://www.nice.org.uk/guidance/ng194 The new updated NICE guideline on Multiple sclerosis in adults: management [NG220] can be found here:·       https://www.nice.org.uk/guidance/ng220 TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in June 2026, focusing on what is relevant in Primary Care only. This month, the main update is the guidance on bempedoic acid with ezetimibe, although we will also briefly touch on ectopic pregnancy and miscarriage, postnatal care, and multiple sclerosis.Right, let’s jump into it.And let’s start with the new guidance on bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia.But first, what is bempedoic acid?Bempedoic acid is a relatively new oral, non-statin lipid-lowering drug used to reduce LDL cholesterol.It works in the liver by inhibiting cholesterol production earlier in the pathway than statins.Because it is activated mainly in the liver rather than skeletal muscle, it can be useful when statins are not tolerated, particularly because of muscle symptoms.The result is reduced cholesterol synthesis in the liver and increased clearance of LDL cholesterol from the blood.Bempedoic acid is usually given with ezetimibe because the two drugs work in complementary ways.Bempedoic acid reduces cholesterol production in the liver, while ezetimibe reduces cholesterol absorption from the intestine.Together, they lower LDL cholesterol more than either drug alone, and they provide an all-oral option for people who cannot tolerate statins.Now let’s look at the NICE guidance.In the NICE guideline, bempedoic acid with ezetimibe is an option for adults with primary hypercholesterolaemia or mixed dyslipidaemia only when statins are contraindicated or not tolerated, and ezetimibe alone has not controlled LDL cholesterol well enough.The evidence shows LDL cholesterol reduction, with cardiovascular outcome evidence.In practical terms, this is not a replacement for statins as first-line lipid-lowering treatment.NICE describes the usual pathway as statins first, with ezetimibe added if LDL cholesterol is not lowered enough.NICE also notes that there was no direct comparison with PCSK9 inhibitors such as alirocumab or evolocumab, and indirect comparison suggested bempedoic acid may be less effective than these options.However, a useful practical point is that bempedoic acid is an oral treatment, whereas alirocumab and evolocumab are given by subcutaneous injection.Despite those uncertainties, NICE concluded that bempedoic acid with ezetimibe is a cost-effective option for people with primary hypercholesterolaemia or mixed dyslipidaemia, where statins are contraindicated or not tolerated, and ezetimibe alone does not control LDL cholesterol well enough.Let’s now move to the updated guideline on ectopic pregnancy and miscarriage.The main change affects secondary care, but it is useful for us to know that anti-D immunoglobulin prophylaxis is no longer offered for ectopic pregnancy, miscarriage, or threatened miscarriage up to and including eleven weeks and six days’ gestation.However, from twelve weeks and zero days to twelve weeks and six days, anti-D remains relevant for RhD-negative pregnant people.And while we are here, we should remember that in any woman of reproductive age with non-specific symptoms, we should consider pregnancy and think about offering a pregnancy test.We should also refer to early pregnancy assessment services if there is bleeding or pain, and the pregnancy is of 6 weeks or more, or the pregnancy is of uncertain gestation. The urgency will depend on the clinical situation.If the pregnancy is under 6 weeks, there is bleeding but no pain, and there are no risk factors such as previous ectopic pregnancy, NICE recommends expectant management.We should advise them to return if bleeding continues or pain develops, to repeat a urine pregnancy test after 7 to 10 days, and to return if it is positive.A negative test will mean the pregnancy has miscarried.Let’s now touch on the updated guideline on postnatal care.For GP practice, the June 2026 update itself probably changes very little.NICE has added a recommendation to offer vitamin K prophylaxis for babies, linking to the intrapartum care guideline.For primary care, the main practical message is unchanged: the 6-to-8-week postnatal check remains an opportunity to assess maternal physical and mental health, contraception, pelvic floor and perineal problems, bleeding, safeguarding, feeding, and the baby’s wellbeing and development.And finally, the updated guideline on multiple sclerosis.The main change is diagnostic: the guideline now refers to specialist criteria known as the McDonald criteria, and NICE has removed the old statement that MS should not be diagnosed solely on MRI findings.But this does not affect us in primary care.For us, the practical message is that we should think of MS when there are focal neurological symptoms evolving over more than 24 hours, lasting days or weeks, often improving afterwards, and not explained by other common diagnoses.However, we should not routinely suspect MS from fatigue, dizziness, or vague sensory symptoms alone.We should then refer suspected MS cases to neurology, and secondary care will make the diagnosis following specific criteria.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/lgHKxBVz6kEThis 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 review a section of the NICE guideline on Hypertension in adults, 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 The NICE clinical guideline on Menopause: identification and management[NG23] can be found here: ·       https://www.nice.org.uk/guidance/NG23 The link to the visual aid on HRT and the likelihood of some medical conditions can be found here: ·       https://www.nice.org.uk/guidance/ng23/resources/incidence-of-medical-conditions-with-and-without-hrt-a-discussion-aid-pdf-13553199901 The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here: ·       https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf  The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:·       https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/ TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only.Today we will focus on HRT risks and benefits in people aged 45 and over.In the next episode, we’ll cover early menopause, meaning people aged 40 to 44, and premature ovarian insufficiency, which refers to those aged under 40. In the previous two episodes, we covered diagnosis, treatment choices, and symptom management.Right, let’s jump into it.So let’s start by looking at the effects of HRT on specific health outcomes.When discussing the risk of individual medical conditions, NICE recommends using its HRT discussion aid to explain risks and benefits more clearly. The link to this aid is in the episode description. It presents the information as the number of cases per 1,000 people over a 5- or 10-year period. So, in practice, the message is more nuanced than simply saying that HRT is safe or unsafe.Let’s first look at the effects that are similar with combined and oestrogen-only HRT.For people aged 45 or over, we will explain that neither combined HRT or oestrogen-only HRT is likely to affect life expectancy.Equally, for people without coronary heart disease, the risk of developing it or mortality from it does not increase with either combined HRT or oestrogen-only HRT.For osteoporosis, fragility fracture risk is reduced while on either combined HRT or oestrogen-only HRT and the benefit is maintained during treatment, but decreases once HRT stops. It may continue for longer in people who take HRT for longer. There is also limited evidence that HRT improves muscle mass and strength.Neither combined HRT or oestrogen-only HRT increases the risk of developing type 2 diabetes and it has no adverse effect on blood glucose.And finally, for venous thromboembolism, route matters. The risk is not increased with transdermal HRT, but it is increased with oral HRT, both combined and oestrogen-only.And now let’s review the specific effects of combined HRT, which is given to people with a uterus.And we will start looking at the Breast cancer risk first, which varies depending on the person’s risk factors.With combined HRT, breast cancer risk increases, and this increase rises with duration of use.In addition, the risk is higher while taking HRT compared to having taken it in the past and, after stopping HRT, the risk goes down, but it can persist for at least 10 years.NICE says there is a very small increase in the risk of death from breast cancer too.The type of combined HRT also matters.Breast cancer risk is lower with sequential combined HRT than with continuous combined HRT, but it is still higher than without HRT.There is not enough evidence that any specific progestogen carries a higher risk of breast cancer.Contrary to what happens with breast cancer, for endometrial cancer, continuous combined HRT reduces risk whereas sequential combined HRT may slightly increase it, and this increases with the duration of use, fewer days of progestogen per cycle, or a higher dose of oestrogen.For ovarian cancer there is a very slight increase in risk with combined HRT, but we should explain that the baseline population risk in women under 60 is very low.For dementia, the risk might increase if it is started at the age of 65 or over.For stroke, we should explain that the baseline population risk in women under 60 is very low.Stroke risk is unlikely to increase with combined HRT that includes transdermal oestrogen, but it increases with combined HRT containing oral oestrogen.This increase rises with higher oestrogen dose and longer duration of treatment, for example if used for more than 5 years.The risk is also higher when HRT is started at a later age, and may be higher in Black people.So, in summary, combined HRT is used in people with a uterus, breast cancer risk is increased and rises with duration of use, continuous combined HRT reduces endometrial cancer risk, and transdermal treatment has a more favourable profile for stroke and VTE risk than oral treatment.Let’s now move to oestrogen only HRT, remembering that this is the option recommended for people who have had a total hysterectomy.Starting with breast cancer, the discussion is different from combined HRT.Oestrogen-only HRT causes very little or no increase in breast cancer risk or breast cancer mortality.For endometrial cancer, the key point is that oestrogen-only HRT should not be used in people with a uterus precisely because it increases the risk of endometrial malignancy.Ovarian cancer risk increases very slightly after 5 years of oestrogen-only HRT, and rises with longer use, regardless of the route. However, the baseline risk in women under 60 is very low.For dementia, NICE says that the risk is unlikely to increase.For stroke, the route of oestrogen matters.Stroke risk increases with oral oestrogen-only HRT, and this increase rises with the dose of oestrogen and if started after the age of 60.However, stroke risk is unlikely to increase with transdermal oestrogen-only HRT.So, in summary, oestrogen-only HRT is generally used after total hysterectomy, breast cancer risk is very little or not increased, and transdermal treatment has a more favourable profile for stroke and VTE risk than oral treatment.So that is it, a review of a section of the NICE guideline on the menopause.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.