Podcast - NICE News - February 2025

The video version of this podcast can be found here:

·      https://youtu.be/yHcuYMRLF_4

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.

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 February 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

 

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

 

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

 

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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 February 2025 can be found here:

 

·      https://www.nice.org.uk/guidance/published?from=2025-02-01&to=2025-02-28&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered in this episode can be found here:

 

The NICE guidance on early and locally advanced breast cancer: diagnosis and management [NG101] can be found here:

 

·      https://www.nice.org.uk/guidance/ng101

The NICE guidance on advanced breast cancer: diagnosis and treatment [CG81] can be found here:

 

·      https://www.nice.org.uk/guidance/cg81

The NICE quality standards Ovarian cancer [QS18] can be found here:

 

·      https://www.nice.org.uk/guidance/qs18

The NICE guidance on tobacco: preventing uptake, promoting quitting and treating dependence [NG209] can be found here:

 

·      https://www.nice.org.uk/guidance/ng209

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 February 2025, focusing on what is relevant in Primary Care only.

 

In today’s episode, we’ll be covering updates in smoking cessation, breast cancer, and ovarian cancer.

Right, let’s jump into it.

Let’s start with smoking cessation and management for everyone aged 12 and over. The latest evidence review includes new guidance on cytisinicline.

But before moving forward:

What is Cytisinicline?

Cytisinicline (also called cytisine) is a plant-derived substance used as a smoking cessation aid. It is similar in structure to nicotine and acts as a partial agonist of nicotinic receptors. Cytisinicline  or Cytisine has been used in Eastern Europe for decades and now it has gained interest here too.

It has a dual Mechanism of Action, one by reducing nicotine withdrawal symptoms by mildly stimulating the nicotinic receptors and the other by competing with nicotine for the receptors, reducing the pleasurable effects of smoking and decreasing craving.

Compared to varenicline or Champix, Cytisinicline has a shorter half-life (~4.8 hours), meaning it needs more frequent dosing, initially every 2 hours but gradually reducing in frequency until stopped.

Most side effects are mild to moderate and tend to occur early in treatment. These include:

• Gastrointestinal like Nausea, vomiting, dry mouth, and dyspepsia and
• Neurological like Headache, , sleep disturbances, fatigue and irritability

Cytisinicline should not be used:

• During Pregnancy and breastfeeding (as safety is not well established)
• For people aged 66 and over
• In Severe cardiovascular disease, with a caution in patients with arrhythmias, unstable angina, or uncontrolled hypertension) primarily because of a rare but potential side effect of Mild increases in blood pressure and heart rate and
• In Severe psychiatric conditions (such as untreated major depression or schizophrenia, though evidence is still emerging)

We should avoid concurrent use of nicotine replacement therapy products, as cytisinicline already occupies nicotinic receptors and combining with nicotine may increase side effects. Equally, combination with other Smoking Cessation Drugs like Varenicline and Bupropion is not recommended due to overlapping mechanisms.

So NICE has reviewed the evidence for cytisinicline, leading to new and updated stop-smoking interventions. Let’s have a look at them.

A variety of interventions are available, including behavioural support, medicinally licensed products, and nicotine-containing e-cigarettes.

Behavioural support may include individual or group support, as well as very brief advice.

Medicinally licensed products include cytisinicline, varenicline, and bupropion, as well as short- and long-acting nicotine replacement therapy,.

Another option is the use of nicotine-containing e-cigarettes and finally

We have the Allen Carr’s Easyway seminar, which involves elements of CBT and relaxation exercises.

Cytisinicline, varenicline, and bupropion should not be offered to people under 18, during pregnancy, or while breastfeeding. For young people aged 12 and over who are smoking and dependent on tobacco, nicotine replacement therapy should be considered alongside behavioural support.

When combined with behavioural support, all these interventions are more likely to be effective.

However, Interventions less likely to be effective, even when combined with behavioural support, include bupropion, short-acting nicotine replacement therapy used alone, and long-acting nicotine replacement therapy also when used alone.

We will give, cytisinicline, varenicline,  bupropion and NRT or before they stop smoking.

In terms of timing of prescribing, bupropion should be started with a quit date set within the first two weeks of treatment. For cytisinicline, the quit date should be within the first five days of treatment. Nicotine replacement therapy should start the day before the quit date, and varenicline should begin with a quit date set within the first one to two weeks of treatment.

To support smoking cessation in primary care, we will offer to measure patients’ exhaled carbon monoxide levels at each contact. These measurements can serve as motivation to quit smoking and provide feedback on progress.

Some medicines are affected by smoking (or stopping smoking) in terms of their metabolism, efficacy and adverse effects, including medications such as clozapine, olanzapine, theophylline, and warfarin. Therefore, we should monitor these drugs when smoking habits change, adjusting the dosage as needed.

We will advise people that stopping smoking in one go is the best approach. However, for patients who are not ready to quit smoking in one step, we will discuss harm reduction strategies. Cutting down or temporarily abstaining from smoking with or without the use of nicotine replacement therapy can be beneficial. We will reassure patients that medicinally licensed nicotine-containing products are a safe and effective way to reduce tobacco consumption, increasing the likelihood of quitting in the long term and also helping to prevent compensatory smoking. Examples of compensatory smoking is inhaling more deeply or smoking more of each cigarette to compensate for smoking fewer cigarettes.

And let’s also quickly cover the issue of smokeless tobacco, which is any product containing tobacco that is placed in the mouth or nose but not burned. It is typically used in England by people of South Asian family origin.

For people using smokeless tobacco, we will ensure they are aware of the associated health risks, including cardiovascular disease, oropharyngeal cancers, and periodontal disease. A brief intervention should be used to advise them to stop.

In terms of Preventing relapse We will discuss coping strategies and practical ways to avoid returning to smoking at each contact. If needed, we will offer a further course of varenicline, nicotine replacement therapy, or bupropion to prevent relapse. However, as of February 2025, this remains an off-label use of bupropion.

Now, let’s move to the next clinical area, breast cancer, focusing on updated recommendations for identifying, managing, and reducing the risk of lymphoedema. These updates apply to both early and advanced breast cancer.

Patients undergoing breast cancer treatment should be informed about their risk of developing lymphoedema. This includes explaining that there is no consistent evidence linking an increased risk of lymphoedema to air travel, travel to hot countries, manicures, hot tubs, or sports injuries. Similarly, there is no consistent evidence suggesting that medical procedures such as blood tests, injections, intravenous medicines, or blood pressure measurement on the treated side increase the risk of lymphoedema.

Patients should also be informed that physical activity may improve their overall quality of life and that there is no indication that exercise causes or worsens lymphoedema. Importantly, compression therapy should not be offered as a preventive measure but only as active treatment.

If lymphoedema does develop, we will ensure that patients are referred to a specialist lymphoedema service for assessment and discussion of management options.

Once lymphoedema is diagnosed:

• We will address underlying factors, such as nodal disease or cellulitis.
• Compression therapy should be the first-line treatment and
• If compression therapy is not suitable or comfortable, patients may wish to consider kinesiology tape as an alternative.

The third and final area refers to ovarian cancer.

There is an updated quality standards on ovarian cancer which states that adults with a total lifetime risk of five percent or more of developing ovarian cancer should have a discussion about risk-reducing surgery. This five percent risk threshold is calculated based on either a strong family history of ovarian cancer or a specific pathogenic variant.

And let’s look at some definitions:

A strong family history is defined as having one or more close relatives, such as a grandmother, mother, sister, or daughter on the same side of the family with ovarian cancer.

In these cases, referral to genetic services should be considered. These services should then assess their risk of developing ovarian cancer and discuss potential interventions.

Risk-reducing surgery may include bilateral salpingo-oophorectomy, removing both fallopian tubes and ovaries, but another option is a hysterectomy with bilateral salpingo-oophorectomy, which also reduces the risk of endometrial cancer.

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.