Guidelines Live 2019 was a great success—what were the best bits from the most popular clinical streams?
The sessions in the cardiovascular stream covered hypertension, tailoring antithrombotic protection in cardiovascular patients, and the ABC cardiovascular plan. The NHS Long term plan has set ambitious targets for reduction in cardiovascular disease (CVD) over the next 10 years. The CVD prevention strategy is focused on the detection and treatment of high-risk conditions including atrial fibrillation (AF), raised blood pressure, and cholesterol—termed ‘the ABC of CVD’. The key messages from the three sessions were aligned to this core theme.
The session on hypertension focused on the recently updated NICE hypertension guideline, which recommends that people aged under 80 years with an initial clinic blood pressure (BP) between 140/90 mmHg and 180/120 mmHg and subsequent ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) of 135/85 mmHg or higher should be considered for treatment. Those aged 80 and over should be considered for treatment if their BP is over 150/90 mmHg.
Tailoring of antithrombotic protection in people with existing cardiovascular disease was discussed, with emphasis on the importance of considering the addition of low-dose rivaroxaban therapy to standard secondary prevention therapy in people with coronary artery disease or symptomatic peripheral arterial disease who are at high risk of ischaemic events.
The talk on ABC cardiovascular plan focused mainly on the ‘A’ and ‘C’ elements: AF and cholesterol. There is a need to reduce the burden of AF-related stroke by seeking to find those with AF who are undiagnosed, offering anticoagulation to those at high risk of stroke, using the correct dose of anticoagulant therapy, and monitoring ongoing treatment. In people taking lipid-lowering therapy for both primary and secondary prevention of CVD the aim should be to lower non-HDL cholesterol by more than 40%.
The three presentations on acne, psoriasis, and pharmacist-led eczema clinics in primary care had in common their use of different guidelines, which each shared remarkably similar aims and cross-speciality working. Another similarity was the emphasis on anti-inflammatory therapy and, where possible, avoiding the use (and certainly overuse) of antibiotics.
The session on acne focused on how topical retinoids are fundamental to the treatment of all types and severity of acne and should be tailored to treat inflammatory papules and pustules only for as long as the inflammation persists.
In psoriasis, a full clinical assessment is required because of the connection between the skin manifestations and the systemic inflammation in blood vessels, joints, and metabolic system, not least to identify significant and treatable arthritis, which may need early referral to prevent permanent damage.
The session on eczema highlighted the role of the practice pharmacist in the management of eczema and how pharmacists can support patients to manage their condition as well as bringing cost savings to the practice.
The diabetes stream included sessions covering different aspects of the management of diabetes including supporting patients with dietary choices, adapting management in frailty, and the guideline recommendations about pharmacological management.
The talk on dietary management focused on how to help patients understand the impact of their dietary choices with the use of infographics that show how common foods affect blood sugar compared with a teaspoon of table sugar. Careful dietary management can lead to drug-free diabetes remission, which in turn can help to reduce diabetes drug spend for the practice.
Frailty is a serious but manageable complication of diabetes and this session covered how to assess frailty, understand the impact of frailty on those with diabetes, and manage diabetes in line with the individual’s frailty status, including the practical implications on targets, treatment choice, and de-intensification.
The final session in the diabetes stream provided an overview of guidance on the pharmacological management of type 2 diabetes, highlighting key similarities and differences between the different guidelines. The session also included practical advice on how practice pharmacists can support management of patients with diabetes to improve clinical outcomes and reduce GP workload.
Antibiotic stewardship and resistance was the theme of the first two talks in the infection stream, starting with the startling fact that over 20% of Escherichia coli urinary tract infections are resistant to co-amoxiclav and that the number of resistant bloodstream infections has increased by 32% over a 4-year period. Another useful tip was that certain antibiotics, including nitrofurantoin, don’t reach high levels in the kidneys and therefore should not be used for pyelonephritis, even if the infecting organism is sensitive to them.
The theme of antibiotic resistance continued in a presentation from a representative from Antibiotic Research UK who presented case studies of patients with multiply resistant infections. There was plenty of practical advice and the offer of help for patients who could be signposted to Antibiotic Research UK for individual help, or given one of their downloadable leaflets.
The next talk was on sexually transmitted infections (STIs) and HIV. We were reminded that all London GPs are in an area of high or very high HIV prevalence and that tests should be considered for every patient, particularly if there is an indicator condition or a suggestion of seroconversion. New guidelines for chlamydia were covered, as well as the less well-known infection Mycoplasma genitalium, and the difficulties of helping patients to access sexual health services that are increasingly unavailable.
The last talk was from a GP who has had Lyme disease and subsequently sat on the NICE guideline development group. While steering clear of the controversial topic of chronic Lyme disease, the presentation included a very useful and easy-to-follow guide about when to suspect Lyme disease, how to investigate it, and when to continue investigating despite an initial negative test. Treatment was also discussed as well as use of the NICE guideline algorithm to guide management.
The women’s health stream covered three very topical areas— contraception, menopause, and heavy menstrual bleeding (HMB).
The talk on contraception focused on the recent FSRH guidelines on combined hormonal contraception, and overweight, obesity, and contraception. This included the reminder that some contraceptive methods become less effective at a certain body weight rather than body mass index (BMI), so a tall patient may run into problems at a BMI lower than might be expected.
The session on the menopause inevitably discussed the problem of supply of hormone replacement therapy (HRT) and how our prescribing decisions may be guided more by what is available than anything else. The talk made it clear that the menopause is a clinical decision, with blood tests not being useful in those aged over 45 years, and that vaginal oestrogen is very low risk and can be used on a long-term basis.
A joint talk between a pharmacist and GP covered the topic of HMB. The NICE guidance makes it clear that not all women will need investigations, but those with risk factors or concerning symptoms in the history should go straight for a hysteroscopy rather than a scan first. A lively debate followed about the role of pharmacists in primary care for the initial assessment of women with HMB.