The video version of this podcast can be found here:

·      https://youtu.be/SA7pJQLlmvg

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in August 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

 

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

 

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 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-08-01&to=2024-08-31&ndt=Guidance&ndt=Quality+standard

 

The links to the current guidance can be found here:

Diabetic retinopathy: Management and monitoring:

·      https://www.nice.org.uk/guidance/ng242

Abaloparatide for treating osteoporosis after menopause:

·      https://www.nice.org.uk/guidance/ta991

National Osteoporosis Guideline Group (NOGG) clinical guideline for the prevention and treatment of osteoporosis:

·      https://www.nogg.org.uk/full-guideline

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in August 2024, focusing on what is relevant to Primary Care only.

 

We are going to cover just two areas, the treatment of osteoporosis and the management of diabetic retinopathy, so it is a brief episode.

 

Let’s jump into it.

 

The first area is a technology appraisal on Abaloparatide for treating osteoporosis after the menopause.

And you may be thinking, Abaloparatide, is this really something that we need to know about in Primary Care?

And the answer is yes. And let’s see why.

And we will start by saying that treatments of osteoporosis can be broadly divided into 2 types:

·    antiresorptive treatments (which slow the rate of bone breakdown), such as our usual bisphosphonates and

·    anabolic (or bone-forming) treatments.

Treatment with anabolic skeletal agents result in rapid and greater fracture risk reductions than bisphosphonates. So, if we are used to prescribing bisphosphonates for the majority of our patients, who should be getting anabolic agents instead?

And the guidelines stipulate that people with a very high fracture risk should be referred for the consideration of these agents. According to the National Osteoporosis Guideline Group, 'very high risk' is defined as a FRAX-based fracture probability that exceeds the intervention threshold by 60%.

So, looking at this diagram based on FRAX, we can see how patients can fall into the different risk categories depending on their scores.

Apart from the patients already in the very high risk of fractures, we should also consider additional clinical risk factors for patients in the high-risk category, (e.g., frequent falls, or a very low spine Bone Mass Density) in case that they may move them from high to very high risk of fracture.

So, in summary, we need to be aware that these anabolic drugs exist and that they are recommended for people with a very high risk of fractures so that when we see such patients, we refer them appropriately to get these drugs.

Existing anabolic treatments are Romosozumab and Teriparatide and, following this technology appraisal, NICE recommends Abaloparatide too.

These anabolic agents can only be taken for a limited time between 12 and 24 months depending on the drug, and afterwards patients will continue to receive an antiresorptive treatment (such as an oral bisphosphonate).

Although abaloparatide is licensed for 'treatment of osteoporosis in postmenopausal women', we must also include trans men and non-binary people registered female at birth.

The next area is a brand-new NICE guideline on Diabetic retinopathy, its management and monitoring. It is mostly aimed at the diabetic retinal screening service and ophthalmologists but it also covers some areas of diabetic care that affects us in primary care. Let’s have a look at it.

1.   Firstly, we should always discuss with patients that good long-term diabetic control can have long-term benefits for their vision.

2.   Then the second recommendation refers to the effects on retinopathy of a rapid reduction in HbA1c.This is because there is some, although limited, evidence about the potential risk of worsening retinopathy from treatments that result in a rapid, substantial drop in HbA1c. Early worsening of diabetic retinopathy does not necessarily mean that the treatment is harmful in the long term but, instead, it highlights the need for close monitoring. NICE therefore recommended that an ophthalmologist should assess the patient before intensive glycaemic treatment is started, and then closely monitors for changes afterwards.

3.   We know that both HbA1c and blood pressure levels can be used to predict the likelihood of retinopathy progression. So, the third recommendation is that ophthalmologists should have access to a person's HbA1c and blood pressure records.

4.   Additionally, NICE has highlighted that the presence of renal disease can also influence retinopathy progression. The evidence for this is of low quality, but is supported by clinical experience.

5.   Also, we know that managing blood pressure in hypertensive patients can reduce retinopathy progression, so achieving good blood pressure control is important. However, we must also be aware that reducing blood pressure with antihypertensives in people who do not have hypertension has no such positive effect.

6.   There is some evidence that fenofibrate is beneficial for people with type 2 diabetes in respect of retinopathy progression. However, there is no evidence on other outcomes such as visual acuity or quality of life. NICE therefore recommends that it should be ophthalmologists who initiate fenofibrate for this indication. There is no evidence for people with type 1 diabetes, so they are not included in the recommendation.

7.   NICE has recommended further research about statins preventing retinopathy progression, because there is no strong evidence to this effect.

8.   The rest of the recommendations are entirely for secondary care and cover areas such as cataract surgery as well as recommendations of the treatment and frequency of monitoring for both proliferative and non-proliferative diabetic retinopathy and diabetic macular oedema.

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 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.

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