Podcast description
My name is Fernando Florido and I am a GP in the United Kingdom. With this episode I am starting a new series on the monthly “NICE News” bulletin, which will include any new guidance published in that month as well as any updates, also in that particular month, to already published guidelines. However, I will only address guidance which is relevant to Primary Care.
In today’s episode, I go through the NICE Guidance and advice published in January 2023.
There is a YouTube version of this and other episodes that you can access here:
NICEGP YouTube channel:
The Full NICE News bulleting for January 2023 can be found at:
· https://www.nice.org.uk/guidance/published?from=2023-01-01&to=2023-01-31
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Transcript
Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.
With today’s episode I am starting a new series on the monthly “NICE News” bulletin, which will include any new guidance published in that month as well as any updates to already published guidelines, also updated in that month. However, I will only address guidance which is relevant to Primary Care. In today’s episode, I go through the NICE Guidance and advice published in January 2023.
Remember that there is also a Youtube version of these episodes so have a look in the episode description.
The first update that we are looking at affects the guidance on Diabetes in pregnancy
And the new updated quality statements are as follows:
Statement 1 Women with diabetes who are of childbearing potential are offered preconception planning advice at diabetes care reviews. So they do not need to be planning a pregnancy to get the advice, just being of childbearing age should prompt us to inform them of the importance of preconception smoking cessation, medication safety, trying to ensure their HbA1c levels are below 48 mmol/mol before pregnancy and taking high-dose folic acid before and for the first 12 weeks of pregnancy.
Statement 2 Diabetic pregnant women need to be seen in a joint antenatal diabetic clinic as soon as possible after conception, and ideally by 10 weeks' gestation.
Statement 3 Pregnant women with type 1 diabetes are offered continuous glucose monitoring. Remember that that there are two types of continuous glucose monitoring (CGM) systems: real-time CGM (rtCGM) and intermittently scanned (isCGM). Current rtCGM systems automatically transmit a continuous stream of glucose data to the patient, provide alerts and active alarms, and transmit glucose data (trend and numerical) in real time to a receiver, smart watch, or smartphone. The current isCGM system provides the same type of glucose data but requires the user to purposely scan the sensor to obtain information, and it does not have alerts and alarms. Both CGM technologies have significant advantages over self-monitoring of blood glucose; however, differences in the features and capabilities of the two approaches must be considered when guiding patient selection of the system that meets their individual needs.NICE recommends rtCGM (but isCGM can be offered if they prefer it or are unable to use rtCGM).
Statement 4 Women diagnosed with gestational diabetes are offered postnatal testing of blood glucose levels and referred to the National Diabetes Prevention Programme.
So, women who were diagnosed with gestational diabetes and whose blood glucose levels returned to normal after the birth should be offered:
· a fasting plasma glucose test ideally between 6 and 13 weeks after the birth to exclude diabetes
· if this has not been done earlier, a fasting plasma glucose test should be done after 13 weeks, or an HbA1c test if a fasting plasma glucose test is not possible
· a referral into the National Diabetes Prevention Programme.
Statement 5 Women diagnosed with gestational diabetes who have negative postnatal testing for diabetes after the birth are offered annual HbA1c testing.
The next update refers to the guideline on chronic heart failure in adults
And the new quality statements are:
Statement 1 Adult patients with suspected heart failure have their N‑terminal pro‑B‑type natriuretic peptide (NT‑proBNP) measured in Primary Care.
Statement 2 Adult patients with a very high N‑terminal pro‑B‑type natriuretic peptide (NT‑proBNP) level, that is, over 2,000 ng/litre (236 pmol/litre), should have a transthoracic echocardiography within 2 weeks, or 6 weeks if they have a high NT‑proBNP level, which is defined as between 400 and 2,000 ng/litre (47 to 236 pmol/litre)
Statement 3 Adult patients with chronic heart failure who have reduced ejection fraction receive all appropriate medication at target or optimal tolerated doses. These medications include ACE inhibitors, ARBs, beta-blockers, MRAs, SGLT2i and ARNIs (angiotensin receptor neprilysin inhibitors) and they need to be started and increased in accordance with individual health needs, including monitoring for side effects after each increase in dose.
Statement 4 Adult patients with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication.
Statement 5 Adult patients with chronic heart failure have a review of their condition at least every 6 months.
Statement 6 Adult patients with chronic heart failure receive a personalised programme of cardiac rehabilitation.
The next topic is not an update but a completely brand new published guidance on transcutaneous electrical stimulation of the trigeminal nerve for ADHD
And, although this is fairly specialised, I have included it here because I have found it very interesting and it will help us advice patients accordingly.
We know that attention deficit hyperactivity disorder (ADHD) is a heterogeneous disorder characterised by the core symptoms of hyperactivity, impulsivity and inattention, which are judged excessive for the person's age or level of overall development. Symptoms are usually evident in childhood and may persist into adulthood.
We also know that treatment for ADHD may be non-pharmacological, pharmacological or a combination of both. Non-pharmacological treatment includes cognitive behavioural therapy and parent‑training programmes (for parents of children and young people with ADHD). Pharmacological treatment includes central nervous system stimulants such as methylphenidate and amphetamines, and non-stimulants such as atomoxetine.
The procedure that is being appraised by NICE here is transcutaneous electrical stimulation of the trigeminal nerve for ADHD
In this procedure, an external trigeminal nerve stimulation device is worn on the clothes and attached by wires to a single-use adhesive patch which is worn overnight. The patch contains 2 electrodes placed over the left and right V1 branches of the trigeminal nerve on the forehead. The stimulator bilaterally stimulates the trigeminal nerve for approximately 8 hours. In a typical treatment course, stimulation is given nightly for approximately 4 weeks. Treatment duration may vary; a clinical response may take longer, and continued therapy may be needed.
The mechanism of action is not completely understood. The trigeminal nerve connects to regions of the brain that may be associated with selective maintenance of attention and arousal, and it is thought that its stimulation improves the symptoms of ADHD.
Although this seems to be a fairly innocuous treatment, NICE has concluded that the evidence on the safety and efficacy of this procedure is inadequate and therefore they recommend that it should only be used in the context of research.
And finally, the last update refers to the guidance on smoking tobacco
In January 2023, in the section on identifying and referring pregnant women for stop-smoking support, the number of carbon monoxide tests recommended for women with low readings and no history of smoking has been reduced.
So now we will provide routine carbon monoxide testing at the first antenatal appointment and at the 36-week appointment to assess every pregnant woman's exposure to tobacco smoke. We will also provide carbon monoxide testing at all other antenatal appointments if the pregnant woman:
We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye
