The video version of this podcast can be found here:

·       https://youtu.be/eQwGStVNHe4

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 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-contraception

Transcript

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. 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-tqArOvxcI

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 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/ng88

Transcript

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 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/2sD5P3AfRq0

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 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/

Transcript

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. 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/i9b7QqtmcAs

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 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=2026-06-30

The 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/ta694

The 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

Transcript

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 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/lgHKxBVz6kE

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 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/

Transcript

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. 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.

The video version of this podcast can be found here:

·       https://youtu.be/2zTvO-QuDNE

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 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 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/

Transcript

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. 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 symptom management and treatment risks.

In the last episode we covered diagnosis, and treatment choices and in future episodes we will cover the other sections of the guideline.

Right, let’s jump into it.

We will start by covering the management of menopausal symptoms in people aged 40 or over. This is because, for people under 40, we should follow the separate NICE guideline on premature ovarian insufficiency.

Let’s look at the various possible symptoms one by one.

For vasomotor symptoms, such as hot flushes and sweats, NICE says we should offer HRT. Menopause-specific CBT can also be considered and used in addition to or instead of HRT.

Fezolinetant is also recommended as an option when HRT is unsuitable.

Fezolinetant is not HRT. It works through receptor pathways involved in temperature regulation. Although recommended as an option, in practice, it may well be specialist initiated only, depending on local prescribing guidance.

NICE says we should not routinely offer SSRIs, SNRIs, or clonidine as first-line treatment for vasomotor symptoms alone.

Now let’s look at genitourinary symptoms.

For people with no history of breast cancer, we should offer vaginal oestrogen, including in people who are already using systemic HRT.

We should explain that serious adverse effects are very rare and that symptoms often return when vaginal oestrogen is stopped, but treatment can be restarted if necessary.

Vaginal oestrogen is absorbed locally and a minimal amount is absorbed systemically, which is unlikely to have a significant effect throughout the body.

Types of vaginal oestrogen include creams, gels, vaginal tablets, pessaries, or rings. They can be used alone, or with non-hormonal moisturisers or lubricants.

If vaginal oestrogen is contraindicated, or the person prefers not to use it, we should then just consider non-hormonal vaginal moisturisers or lubricants.

If vaginal oestrogen, moisturisers, or lubricants have not worked, NICE says we should consider vaginal prasterone or oral ospemifene.

These medicines are not started routinely in primary care, and their use will depend on local formulary and prescribing guidance.

For people with genitourinary symptoms and overactive bladder, or recurrent urinary tract infections, NICE signposts their specific guidance in those areas.

For people with a personal history of breast cancer and genitourinary symptoms, we should initially only offer non-hormonal moisturisers or lubricants.

If symptoms continue despite this, vaginal oestrogen can be considered and used with a non-hormonal moisturiser or lubricant. However, this is an off-label use so we should seek specialist advice before initiating them, particularly if the patient is taking aromatase inhibitors as adjuvant treatment for breast cancer.

Patients should be made aware that it is unknown whether vaginal oestrogen affects the risk of breast cancer recurrence, given that only a minimal amount is absorbed systemically.

For people with oestrogen receptor-negative breast cancer, vaginal oestrogen is unlikely to increase the risk recurrence.

On the other hand, for people with oestrogen receptor-positive breast cancer, NICE says the risk of recurrence could potentially increase. However, adjuvant treatments, such as tamoxifen, would reduce any such potential impact.

For depressive symptoms associated with menopause, NICE says we can consider HRT if the symptoms do not meet the criteria for depression, and started around the same time as other menopause-associated symptoms.

CBT can also be considered for depressive symptoms which are associated with vasomotor symptoms.

However, if someone has depression, we should also follow the NICE guideline on depression.

For sleep problems, such as night-time awakening associated with vasomotor symptoms, menopause-specific CBT can be considered, either alone of alongside other options, including HRT.

For low sexual desire associated with menopause, NICE says we can consider testosterone supplementation if HRT alone is not effective.

However, in the UK, testosterone use for this indication is off-label, and prescribing depends on local formulary guidance. So, as GPs, we should consider specialist advice, although ongoing prescribing may sometimes continue in primary care.

Before offering treatment for the menopause, we should consider referral if there are contraindications to HRT, or if there is uncertainty about the most suitable option.

For people with type 2 diabetes, we can consider HRT after taking comorbidities into account and specialist advice can be sought if needed.

For people at increased risk of venous thromboembolism, we should consider transdermal rather than oral HRT, and this includes people with a BMI over 30.

For people at high risk of venous thromboembolism, for example those with a strong family history or thrombophilia, we should also refer to a haematologist before starting HRT.

For people with a personal history of coronary heart disease or stroke, HRT should only be offered by a menopause specialist.

For people with a personal history of breast cancer, or a high risk of breast cancer, NICE says we should also refer to a menopause specialist.

There is separate specific guidance for people at high familial risk of ovarian cancer, so we will not cover it here.

For people who are likely to experience menopause because of medical or surgical treatment, NICE says they should be able to discuss fertility with a fertility specialist.

Trans men and those who have taken gender-affirming hormone therapy in the past, should also be referred to a menopause specialist.

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/hx1KVBpBbB4

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 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 May 2026 can be found here:

·       https://www.nice.org.uk/guidance/published?from=2026-05-01&to=2026-05-31&ndt=Guidance&ndt=Quality+standard

The new Technology appraisal guidance [TA1152] Semaglutide for reducing the risk of major adverse cardiovascular events in people with cardiovascular disease and overweight or obesity can be found here:

·       https://www.nice.org.uk/guidance/ta1152

Transcript

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 May 2026, focusing on what is relevant in Primary Care only.

This month, we only have one technology appraisal that is relevant to primary care, which is semaglutide for reducing the risk of major adverse cardiovascular events in people with cardiovascular disease and overweight or obesity.

Right, let’s jump into it.

This particular technology appraisal recommends semaglutide for reducing the risk of major adverse cardiovascular events in adults with established cardiovascular disease and overweight or obesity.

The difference is that this is not a general obesity recommendation.

This is about secondary prevention in people who already have established cardiovascular disease and a BMI of at least 27.

NICE defines established cardiovascular disease in this guidance as having at least one of the following: a previous MI, previous ischaemic or haemorrhagic stroke, or symptomatic peripheral arterial disease.

For peripheral arterial disease, NICE specifies intermittent claudication with an ankle brachial index below 0.85 at rest, or previous peripheral arterial revascularisation, or amputation because of atherosclerotic disease.

The recommendation is that semaglutide, up to a maintenance dose of 2.4 mg once weekly, can be used alongside standard routine management in order to reduce the risk of a major adverse cardiovascular event.

In this guidance, a major adverse cardiovascular event means cardiovascular death, non-fatal MI, or non-fatal stroke.

The guidance does not specify which setting semaglutide should be used in and it does not say that it needs to be provided in Primary Care but it does say that, once recommended by NICE, it must be funded in the NHS in England within 90 days of final publication.

NHS England has said semaglutide is expected to become available to eligible people over the next few years, but there is not yet a single national primary care prescribing pathway.

Some local formularies still restrict semaglutide in primary care, although many of these restrictions relate to weight management services rather than this new cardiovascular indication, so we will have to watch the space.

In the rationale, NICE states that lifestyle changes and standard medicines are used to reduce cardiovascular risk. These measures include diet, exercise, reducing alcohol, stopping smoking, and managing weight.

Medicines may include antihypertensives, lipid lowering drugs, antiplatelets, and anticoagulants.

Semaglutide is positioned as another option alongside standard care for secondary prevention given that trial evidence shows that it reduces the risk of a first major adverse cardiovascular event compared with placebo.

We know that people from South Asian, Chinese, other Asian, Middle Eastern, Black African, or African Caribbean ethnic backgrounds may have a higher cardiovascular risk at lower BMI thresholds.

However, NICE did not recommend semaglutide below a BMI of 27 because of licensing reasons and because evidence in that lower BMI group is not available.

In summary, for us primary care, the main message is that semaglutide is a cardiovascular secondary prevention option for people with established cardiovascular disease and a BMI of at least 27.

And semaglutide should be used alongside standard cardiovascular prevention, not instead of it. So, we should still give lifestyle advice and optimise blood pressure and lipids and prescribe antiplatelet or anticoagulant treatment where appropriate.

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/JktVjws4xQ4

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 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 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

Transcript

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. 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 patient information, diagnosis, and treatment choices.

In future episodes we will cover the other sections of the guideline.

Right, let’s jump into it.

Let’s start by saying that the NICE menopause guideline applies to women, trans men, and non-binary people registered female at birth who have menopause-associated symptoms now, or who may experience them in the future.

It does not apply to people having gender-affirming hormone therapy.

Let’s now look at what information should be given to patients. When we assess and manage menopause, we should use shared decision making when discussing symptom management, including the benefits and risks of different options.

We should explain that menopause usually happens in mid-life, but that it can also happen earlier because of surgery, medical treatment, an inherited condition, or an unknown cause.

Menopause symptoms may be mild or severe, and they may last for a short time or a long time. Symptoms may include changes in the menstrual cycle, hot flushes, vaginal dryness, mood symptoms, joint or muscle pain, and sexual difficulties, such as low sexual desire.

NICE says we should discuss contraception with people who have menopause-associated symptoms because menopause symptoms do not necessarily mean that ovulation has stopped. Although fertility declines with age, contraception may still be needed if pregnancy is not wanted.

For people using non-hormonal contraception, the Faculty of Sexual and Reproductive Healthcare advises that contraception can usually be stopped after 2 years of amenorrhoea between the ages of 40 and 50, or after 1 year of amenorrhoea after the age of 50.

However, most women using hormonal contraception during the perimenopause will have altered bleeding patterns or amenorrhoea. As a result, it can be difficult to give accurate advice, so we should check the specific recommendations for each type of hormonal contraceptive in the Faculty of Sexual and Reproductive Healthcare guidance. In general, it advises that contraception can be stopped at age 55, because spontaneous pregnancy after this age is exceptionally rare.

Bone health should be discussed too, explaining the importance of maintaining muscle mass and strength through physical activity.

For people experiencing early menopause, between the ages of 40 and 44, we should offer psychological support if they are distressed by it.

Let’s now look at the diagnosis. In otherwise healthy people aged 45 or over, with menopause-associated symptoms, NICE says we can usually identify perimenopause and menopause without laboratory tests.

Perimenopause can be identified if vasomotor symptoms have recently started, and there are changes in the menstrual cycle.

Menopause can be identified if the person has not had a period for at least 12 months, and they are not using hormonal contraception.

In people who have had a hysterectomy, menopause is identified based on the type and combination of symptoms, for example vasomotor symptoms.

NICE also says that menopause can be harder to identify in people taking hormonal treatments, because, as we mentioned earlier, hormonal contraception can alter bleeding patterns, making it difficult to know the underlying menopausal status.

NICE says we should not use FSH to identify menopause in people using combined oestrogen and progestogen contraception, or high-dose progestogen and The Faculty of Sexual and Reproductive Healthcare explains why: combined hormonal contraception suppresses oestradiol, FSH, and LH, and depot medroxyprogesterone acetate can suppress FSH to some extent, meaning someone could be menopausal but not show the expected rise in FSH.

NICE also says that people from some ethnic minority backgrounds, and people with some lifelong conditions, may experience menopause at a younger age.

NICE does not give a list of specific ethnicities, but in its rationale, it gives Down’s syndrome as an example of a lifelong condition. So, the practical point is to think about menopause earlier in these groups.

NICE says that FSH should only be considered in specific situations.

This includes people aged 40 to 45 with menopause-associated symptoms, including a change in their menstrual cycle.

It also includes people under 40 in whom menopause is suspected, where we also need to think about premature ovarian insufficiency.

When discussing management options with people aged 40 or over, we should discuss the benefits and risks of the various treatment options.

Additionally, when discussing HRT, we should discuss combined HRT compared with oestrogen-only HRT, and explain which type the person would be offered and why.

We should also discuss transdermal HRT compared with oral HRT, the different types of oestrogen and progestogen, and when to give sequential versus continuous combined HRT, and why.

If the person chooses to take HRT, we should discuss the possible duration of treatment from the start and revisit, at every review, the benefits and risks of continuing it.

We should also explain that symptoms may return when HRT is stopped, and discuss the option of restarting treatment if needed.

Cognitive behavioural therapy can also be discussed as a possible management option, including menopause-specific CBT, which may include face-to-face or remote sessions, individual or group sessions, and self-help options, depending on the person’s preferences.

For complementary therapies, we should explain that the safety, quality, and purity of unregulated preparations may be unknown.

There is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms, but NICE says we should also explain that their safety is uncertain, preparations may vary, and interactions with other medicines have been reported.

For people with a personal history of breast cancer, or at high risk of breast cancer, we should explain that, although St John’s wort may help relieve vasomotor symptoms, there is uncertainty about the correct dose, how long the effect lasts, and the variation in strength and content between preparations.

We should also warn about potential serious interactions with other medicines, including tamoxifen, anticoagulants, and anticonvulsants.

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/9vJt7FMA0to

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 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 Hypertension in adults: diagnosis and management [NG136] can be found here:

·      https://www.nice.org.uk/guidance/NG136

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’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only.

In previous episodes we covered the diagnosis, criteria for urgent referral, when to start drug treatment and blood pressure targets.

Today we will focus on antihypertensive drug treatment.

Right, let’s jump into it.

Let’s start with what antihypertensive treatment to choose.

The recommendations in this guideline apply to people with hypertension, with or without type 2 diabetes, but for people with type 1 diabetes or CKD, we should refer to the relevant NICE guideline.

We should also remember that ACE inhibitors and angiotensin receptor blockers should not be used in pregnancy, breastfeeding, or when planning pregnancy, unless absolutely necessary. If used, we must discuss risks and benefits and follow safety guidance.

In general, and if possible, we should choose once daily treatments.

For isolated systolic hypertension, defined as a systolic blood pressure of 160 or higher, we should treat in the same way as people with both raised systolic and diastolic blood pressure. 

We should offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension, in line with the general guideline on hypertension.

For women planning pregnancy, who are pregnant, or breastfeeding, we should manage hypertension in line with the specific NICE guideline on hypertension in pregnancy, including guidance during breastfeeding.

When choosing antihypertensive treatment for adults of Black African or African Caribbean family origin, we should consider an angiotensin receptor blocker in preference to an ACE inhibitor. This is because ACE inhibitors may be less effective in this group, partly because low renin hypertension is more common, and they also carry a higher risk of angioedema.

For people with cardiovascular disease, we should first follow the disease specific recommendations in the relevant NICE guideline for their condition. These include:

·      acute coronary syndromes,

·      acute and chronic heart failure,

·      stable angina, and

·      type 1 diabetes.

If blood pressure remains uncontrolled despite following these disease specific recommendations, we should then offer the general stepwise approach outlined in the hypertension guideline. Let’s have a look at it.

As step 1 treatment, we should offer an ACE inhibitor or an ARB as step 1 treatment if they have type 2 diabetes, regardless of age or family origin.

We should also offer an ACE inhibitor or an ARB to adults under the age of 55, provided they are not of Black African or African Caribbean family origin.

If an ACE inhibitor is not tolerated, for example because of cough, we should offer an ARB instead. We should not combine an ACE inhibitor with an ARB.

We should offer a calcium channel blocker as step 1 treatment if they are aged 55 or over and do not have type 2 diabetes.

We should also offer a calcium channel blocker to adults of Black African or African Caribbean family origin who do not have type 2 diabetes, regardless of age.

If a calcium channel blocker is not tolerated, for example because of oedema, we should offer a thiazide like diuretic.

Equally, if there is evidence of heart failure, we should offer a thiazide like diuretic and follow the NICE guideline on chronic heart failure.

If starting or changing diuretic treatment, we should prefer a thiazide like diuretic, such as indapamide, over conventional thiazides such as bendroflumethiazide or hydrochlorothiazide.

If blood pressure is stable and well controlled on bendroflumethiazide or hydrochlorothiazide, we should continue the current treatment.

Now let’s move on to step 2 treatment.

Before considering the next step, we should discuss with the person whether they are taking their medication as prescribed.

If blood pressure is not controlled on step 1 treatment with an ACE inhibitor or an ARB, we should offer one of the following in addition:

a calcium channel blocker, or

a thiazide like diuretic.

If blood pressure is not controlled in adults taking step 1 treatment with a calcium channel blocker, we should offer one of the following in addition:

an ACE inhibitor,

an ARB, or

a thiazide like diuretic.

For adults of Black African or African Caribbean family origin without type 2 diabetes, not controlled on step 1 treatment, we should consider an ARB in preference to an ACE inhibitor as the add on treatment.

Now let’s move on to step 3 treatment.

Before considering the next step, we should make sure that optimal tolerated doses are being taken, and we should discuss adherence.

If blood pressure is not controlled on step 2 treatment, we should offer a combination of three drugs, that is:

an ACE inhibitor or an ARB,

plus a calcium channel blocker,

plus a thiazide like diuretic.

And finally, let’s now move on to step 4 treatment.

If blood pressure is not controlled despite optimal tolerated doses of an ACE inhibitor or an angiotensin receptor blocker, plus a calcium channel blocker, plus a thiazide like diuretic, we should regard this as resistant hypertension.

Before considering further treatment, we should confirm the elevated clinic readings using ambulatory or home blood pressure monitoring.

We should assess for postural hypotension.

And we should discuss adherence.

If resistant hypertension is confirmed, we should consider a fourth antihypertensive drug or seek specialist advice.

If considering a fourth drug. we should consider adding low dose spironolactone if the blood potassium is 4.5 millimoles per litre or less, using caution if kidney function is reduced, because of hyperkalaemia.

When starting further diuretic therapy, we should monitor sodium, potassium, and renal function within one month, and repeat as needed.

If potassium is above 4.5, we should consider an alpha blocker or a beta blocker instead.

If blood pressure remains uncontrolled despite four drugs at optimal tolerated doses, we should seek specialist advice.

So that is it, a review of a section of the NICE guideline on hypertension.

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/ab9q6W0B1OU

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 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 Hypertension in adults: diagnosis and management [NG136] can be found here:

·      https://www.nice.org.uk/guidance/NG136

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’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only.

In the last two episodes we covered the diagnosis and the criteria for urgent referral.

Today we will focus on initial management, when to start drug treatment and how to monitor hypertension.

Right, let’s jump into it.

And let’s remember that the recommendations in the hypertension guideline apply to all adults, including those with type 2 diabetes. However, in some situations, management differs, and NICE recommends referring to other relevant guidelines, including those on chronic kidney disease, type 1 diabetes, and hypertension in pregnancy.

Now let’s look at lifestyle interventions.

We should offer lifestyle advice and continue to reinforce this periodically.

We should ask about diet and exercise patterns, because a healthy diet and regular exercise can help reduce blood pressure.

We should ask about alcohol consumption, and encourage a reduced intake if the person drinks excessively, as this can lower blood pressure and has broader health benefits.

We should discourage excessive consumption of coffee and other caffeine rich products.

We should encourage people to keep their dietary sodium intake low, either by reducing salt or using substitutes, as this can also reduce blood pressure.

However, salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease, or those taking certain antihypertensive drugs, such as ACE inhibitors or angiotensin receptor blockers.

In these groups, we should focus on reducing salt intake rather than using substitutes.

Finally, we should offer advice and support to help people stop smoking.

Now let’s look at when we should start antihypertensive drug treatment.

We should offer antihypertensive drug treatment to adults of any age with persistent stage 2 hypertension. That is, a clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent daytime average on ambulatory monitoring, or average on home monitoring of 150/95 mmHg or higher.

We should use clinical judgement for people with frailty or multimorbidity in order to minimise overtreatment and the risk of side effects.

What about those with stage 1 hypertension, that is, a clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent daytime average on ambulatory monitoring, or average on home monitoring ranging from 135/85 mmHg to 149/94 mmHg? Well, treatment here will depend on risk factors.

For adults under 80 with persistent stage 1 hypertension, we should definitely start treatment if they have signs of target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk of 10 percent or more, again, we should use clinical judgement in people with frailty or multimorbidity.

In other situations, NICE is less prescriptive and advises us to “consider” treatment, which means using our clinical judgement more flexibly.

For example, in adults under 60 with stage 1 hypertension and a 10-year cardiovascular risk below 10 percent, we should still consider treatment, bearing in mind that a 10-year risk score may underestimate lifetime cardiovascular risk.

Similarly, in adults over 80 with stage 1 hypertension, we should consider treatment if clinic blood pressure is above 150 over 90.

And this distinction between “offer” and “consider” is important. It reflects the level of certainty in the evidence and reminds us that clinical judgement is crucial.

Finally, for adults under 40, we should consider specialist referral for secondary causes and assessment of long-term risks and benefits of treatment.

Now let’s go through clinic blood pressure targets.

For adults under 80, the general target is a clinic blood pressure below 140 over 90.

This applies to people with hypertension, with or without type 2 diabetes, and also to those with type 1 diabetes or CKD if the albumin to creatinine ratio is below 70.

However, if the albumin to creatinine ratio is 70 or higher, the target is lower, below 130 over 80.

For adults aged 80 and over, the general clinic blood pressure target is below 150 over 90.

And although this may feel counterintuitive, this target also applies to people with type 1 or type 2 diabetes, regardless of albumin to creatinine ratio. In this age group, albumin to creatinine ratio only changes the target for people with CKD.

NICE does not set lower blood pressure targets in people over 80 just because they have diabetes, as the evidence for lower blood pressure in this age group is limited.

So, if they have CKD with an albumin to creatinine ratio below 70, the target is below 140 over 90, and if it is 70 or higher, the target is below 130 over 80.

Now let’s look at monitoring in practice.

We should use clinic blood pressure measurements to monitor response to treatment.

We should check for postural hypotension in people with type 2 diabetes, symptoms of postural hypotension, or who are aged 80 and over.

If there is a significant postural drop, or symptoms, we should base treatment targets on standing blood pressure.

We should also consider ambulatory or home monitoring in addition to clinic readings if there is a white coat effect or masked hypertension.

For people who self-monitor, we should use home blood pressure monitoring and we should remember that out of clinic readings are about 5 mm of mercury lower.

So, in adults without relevant comorbidities, under 80, the target is below 140 over 90 in clinic, or below 135 over 85 at home.

Over 80, the target is below 150 over 90 in clinic, or below 145 over 85 at home.

We should use the same blood pressure targets regardless of whether the person has established cardiovascular disease. When type 2 diabetes is diagnosed, we should review blood pressure control and the medications used and make changes if the current treatment is not appropriate because of microvascular complications or metabolic problems.

Finally, we should provide an annual review for all adults with hypertension.

So that is it, a review of a section of the NICE guideline on hypertension.

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/35Yog27dOoA

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 April 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 April 2026 can be found here:

·       https://www.nice.org.uk/guidance/published?from=2026-04-01&to=2026-04-30&ndt=Guidance&ndt=Quality+standard

The updated guideline on acne vulgaris: management [NG198] can be found here:

·       https://www.nice.org.uk/guidance/ng198

The updated guideline on suspected cancer: recognition and referral can be found here:

·       https://www.nice.org.uk/guidance/ng12/

The updated guideline on Menopause: identification and management

[NG23] can be found here:

·       https://www.nice.org.uk/guidance/ng23

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/

The updated quality standard on ovarian cancer [QS18] can be found here:

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

The updated guideline on Ovarian cancer: recognition and initial management [CG122] can be found here:

·       https://www.nice.org.uk/guidance/cg122

Transcript

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 April 2026, focusing on what is relevant in Primary Care only.

This month, we have a lot to cover and the areas are wide ranging: acne, the menopause and cancer, in particular endometrial and ovarian cancer and weight loss as a symptom of concern.

Right, let’s jump into it.

And let’s start with acne. The update does not change how we manage it. It’s still structured, stepwise, and based on severity.

We should explain that there is no strong evidence for specific diets for acne.

For mild to moderate acne, we should give a 12 week course of a first line option, which for most patients includes a fixed combination topical such as adapalene with benzoyl peroxide, or alternatives such as tretinoin with clindamycin, or benzoyl peroxide with clindamycin.

For moderate to severe acne, we should combine the first line topical treatment with an oral antibiotic such as lymecycline or doxycycline.

Topical or oral antibiotics should not be used as monotherapy, and courses for more than 6 months should be in exceptional circumstances. We should review at 3‑monthly intervals and stop the antibiotic as soon as possible. Additionally, we should not use a combination of a topical antibiotic and an oral antibiotic.

If there is a poor response, we should consider switching options, and referral.

Hormonal treatment like combined oral contraception, can be considered in women if first-line treatment is not effective. For people with polycystic ovary syndrome we can consider adding co-cyprindiol also known as dianette, or an alternative combined oral contraceptive pill.

Now, the update itself relates to isotretinoin safety. Although it is initiated in secondary care, we should still be aware of the issues.

There is no longer a requirement for two independent prescribers to approve its use in people under 18. Instead, updated MHRA safety measures must be followed.

There is strengthened emphasis on mental health, requiring assessment and monitoring of mental health problems. Patients should be advised about the potential for psychiatric adverse effects of isotretinoin, including low mood, depression, and suicidal thoughts, and told to seek medical advice if these occur.

In addition, as isotretinoin is teratogenic, patients must follow the MHRA pregnancy prevention programme, which includes effective contraception and formal acknowledgement of risk before treatment begins.

Let’s now move to the update on menopause management. The main change here is about unscheduled vaginal bleeding in people taking systemic HRT.

NICE now says that people should be told 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 told to seek medical help promptly if they have unscheduled vaginal bleeding beyond those timeframes.

NICE has added that there is limited evidence for unscheduled bleeding while on HRT, and signposts the British Menopause Society guidance. The link is in the episode description. Let’s see what they recommend.

We should first assess the patient fully, including, amongst other things, assessing 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 persists 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 the bleeding pattern or timing.

In terms of reducing bleeding, we should check adherence, prescribe adequate progestogen and consider a levonorgestrel intrauterine system. We should also consider vaginal oestrogens if the examination suggests atrophic changes.

And now let’s move on to the area of cancer.

The first updated area is endometrial cancer.

Previously, NICE recommended suspected cancer referral with unexplained postmenopausal bleeding, particularly if they were aged 55 or over.

The updated wording is more specific. NICE now recommends a cancer referral if they have unexplained postmenopausal bleeding that cannot be attributed to HRT, again, particularly if they are aged 55 or over, although we should consider it for younger patients too.

So this update links the suspected cancer guideline with the menopause guidance and makes it clearer that bleeding on HRT needs context, rather than automatically leading to a cancer referral.

Next is ovarian cancer.

Examples of ovarian cancer symptoms are, for example, abdominal distension or pain, loss of appetite, and unexplained urinary symptoms, amongst many others.

Previously, NICE used a single CA125 threshold of 35 IU per ml or greater to trigger ultrasound. Now, the updated guidance is more age specific. For people aged 39 or under with symptoms, we should not use CA125 in isolation and consider an urgent direct access ultrasound scan. This is because CA125 is not an accurate indicator of ovarian cancer risk in this age group.

For people aged 40 or over, we should still check CA125, but there are now age specific thresholds for urgent ultrasound. These are 35 IU per ml or greater from 40 to 49, 31 from 50 to 59, 24 from 60 to 69, 25 from 70 to 79, and 31 from 80 onwards.

The third updated area is unexplained weight loss.

Previously, NICE recommended urgent investigation or suspected cancer pathway referral for people with unexplained weight loss without an age threshold.

The new recommendation is narrower and now applies to people aged 60 and over. Unexplained weight loss is defined as more than 5 percent weight loss within 6 months, which can be a symptom of several cancers.

In this situation we will assess further to clarify which cancer is most likely, and then offer urgent investigations, a suspected cancer pathway referral, or a non specific symptoms pathway referral.

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/Ybf2fuw880Y

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 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 Hypertension in adults: diagnosis and management [NG136] can be found here:

·      https://www.nice.org.uk/guidance/NG136

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’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only.

In the last episode we covered the diagnosis and initial assessment and then, we said that we would cover the investigations for target organ damage and the criteria for urgent referral in this episode.

So let’s go through that now.

Right, let’s jump into it.

For all people with hypertension, we should offer the following investigations for target organ damage.

We should test for protein in the urine by sending a urine sample for albumin to creatinine ratio, and test for haematuria using a reagent strip.

We should take a blood sample to measure glycated haemoglobin, electrolytes, creatinine, eGFR, total cholesterol, and HDL cholesterol.

We should examine the fundi for hypertensive retinopathy.

And we should arrange a 12-lead ECG.

Examples of target organ damage include left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy, or an increased urine albumin to creatinine ratio.

Now let’s move on to identifying who to refer for same day specialist review.

We should consider this when a person has severe hypertension, defined as a clinic blood pressure of 180 over 120 or higher. However, referral depends on more than just the blood pressure reading.

So, we should refer people for same day specialist assessment if they have a clinic blood pressure of 180 over 120 or higher together with specific high-risk features.

These include signs of retinal haemorrhage or papilloedema, which indicate accelerated hypertension. Accelerated hypertension refers to a severe increase in blood pressure to 180 over 120 or higher, often above 220 over 120, with signs of retinal haemorrhage or papilloedema. It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.

We should also refer if there are life threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.

We should also refer people for same day specialist assessment if phaeochromocytoma is suspected. This may present with features such as labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or sweating.

So, as we can see, not all patients with a  blood pressure of 180 over 120 or higher will need urgent specialist referral.

So, what do we do with patients who have severe hypertension, that is, who have a blood pressure of 180 over 120 or higher but do not meet the urgent specialist referral criteria?

Let’s look at this group now.

If a person has severe hypertension but no symptoms or signs indicating same day referral, we should carry out investigations for target organ damage as soon as possible.

If target organ damage is identified, we should consider starting antihypertensive drug treatment immediately, without waiting for the results of ambulatory blood pressure monitoring or home blood pressure monitoring.

If no target organ damage is identified, we should confirm the diagnosis by either repeating the clinic blood pressure within 7 days, or considering ambulatory blood pressure monitoring, or home blood pressure monitoring if ambulatory monitoring is not suitable or not tolerated, and ensuring a clinical review within 7 days.

Before we move on to the final definitions, let’s summarise how to approach severe hypertension in practice.

Severe hypertension is defined as a blood pressure of 180 over 120 or higher.

At this level, the key question is whether there are symptoms or signs that indicate the need for same day specialist referral.

Importantly, not all target organ damage means a hypertensive emergency.

NICE recommends urgent same day referral only when severe hypertension is associated with specific high-risk features, such as retinal haemorrhage or papilloedema, or life-threatening symptoms like chest pain, confusion, heart failure, or acute kidney injury, or when phaeochromocytoma is suspected.

So, in practice, we are not simply looking for any target organ damage, but for features of acute or ongoing organ damage that require immediate assessment.

If these features are present, we call this hypertensive emergency andwe should refer the patient urgently for same day specialist care.

If they are not present, this is often referred to as hypertensive urgency, as opposed to hypertensive emergency.

Hypertensive urgency is more common, and the immediate risk of serious complications is generally low.

In these cases, NICE advises that we should carry out investigations for target organ damage as soon as possible, but this does not necessarily mean hospital admission.

Most patients can be managed safely in Primary Care with prompt investigations, close follow up, and appropriate initiation or adjustment of treatment.

We need to remember that, in the absence of acute organ damage, blood pressure should be reduced gradually rather than rapidly to avoid complications such as cerebral or renal hypoperfusion.

So overall, the main message is to identify red flag features that require urgent referral, and to use our clinical judgement.

Now, before ending this short episode, let’s briefly clarify some definitions used in the guideline.

Stage 1 hypertension is defined as clinic blood pressure between 140 over 90 and 159 over 99, with corresponding ambulatory or home averages between 135 over 85 and 149 over 94.

Stage 2 hypertension is defined as clinic blood pressure of 160 over 100 or higher but below 180 over 120, with ambulatory or home averages of 150 over 95 or higher.

Stage 3, or severe hypertension, is defined as clinic systolic blood pressure of 180 or higher, or diastolic blood pressure of 120 or higher.

White coat effect is when the clinic blood pressure is higher by more than 20 over 10 millimetres of mercury compared with readings taken outside the clinic.

Finally, at the opposite end of the spectrum, masked hypertension occurs when clinic blood pressure is normal, that is, below 140 over 90, but is higher outside the clinic on ambulatory or home monitoring.

So that is it, a review of a section of the NICE guideline on hypertension.

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/8QEsYYKKGu0

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 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 Hypertension in adults: diagnosis and management [NG136] can be found here:

·      https://www.nice.org.uk/guidance/NG136

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’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only.

Today, we are focusing on the diagnosis and initial assessment.

In subsequent episodes, we will cover the other sections.

Right, let’s jump into it.

And let’s start about the measurement of blood pressure.

Because automated devices may not measure blood pressure accurately if there is pulse irregularity, for example due to atrial fibrillation, we should palpate the radial or brachial pulse before measuring blood pressure.

If pulse irregularity is present, we should measure blood pressure manually using direct auscultation over the brachial artery.

When measuring blood pressure in the clinic or in the home, we should standardise the environment and provide a relaxed and temperate setting, with the person quiet and seated, and their arm outstretched and supported.

Furthermore, we should make sure that we use an appropriate cuff size for the person’s arm.

Now, let’s look at postural hypotension.

In people with symptoms of postural hypotension, including falls or postural dizziness, we should measure blood pressure with the person lying on their back, although we can consider a seated position if it is inconvenient to measure blood pressure with the person lying down.

We should then measure blood pressure again after the person has been standing for at least one minute.

If the person’s systolic blood pressure falls by 20 millimetres of mercury or more, or their diastolic blood pressure falls by 10 millimetres of mercury or more after standing for at least one minute, we should consider likely causes, including reviewing their current medication.

We should also manage appropriately, for example giving advice on preventing falls, and we should measure subsequent blood pressures with the person standing.

Additionally, we should consider referral to specialist care if symptoms of postural hypotension persist despite addressing the likely causes.

If the drop in blood pressure is smaller than the diagnostic thresholds, and the person still has suggestive symptoms, we should repeat the test. This is especially important if the initial reading was taken from a seated position.

This is because the drop in blood pressure from sitting to standing may be smaller than from lying down to standing, which can lead to false negatives.

So, this time, we should start with the person lying flat, and then measure their blood pressure again after they stand up.

We should then consider specialist referral if blood pressure measurements do not confirm postural hypotension despite suggestive symptoms.

Let’s look at how we make the diagnosis of hypertension.

When considering the diagnosis, we should measure blood pressure in both arms.

If the difference between arms is more than 15 millimetres of mercury, we should repeat the measurements and if the difference remains more than 15, we should use the arm with the higher reading for future measurements.

Now, if clinic blood pressure is 140 over 90 or higher, we should take a second measurement during the same consultation.

If the second reading is substantially different from the first, we should take a third measurement.

We then record the lower of the last two readings as the clinic blood pressure.

If the clinic blood pressure is between 140 over 90 and 180 over 120, we should offer ambulatory blood pressure monitoring to confirm the diagnosis.

If ambulatory blood pressure monitoring is not suitable or not tolerated, we should offer home blood pressure monitoring instead.

While waiting to confirm the diagnosis, we should check their cardiovascular risk assessment using a validated tool and we should also carry out investigations for target organ damage.

If the clinic blood pressure is 180 over 120 or higher, we should consider whether they need urgent referral.

We will cover both the urgent referral criteria and the investigations for target organ damage in the next episode.

When using ambulatory blood pressure monitoring, we should ensure that at least two measurements are taken per hour during the person’s usual waking hours, for example between 8am and 10pm.

We should use the average of at least 14 measurements during waking hours to confirm the diagnosis.

When using home blood pressure monitoring, we should ensure that two consecutive readings are taken for each recording, at least one minute apart, with the person seated and that blood pressure should be recorded twice daily, ideally in the morning and evening and that monitoring should continue for at least four days, but ideally for seven days.

In home blood pressure monitoring we should discard the first day’s readings, and use the average of the remaining measurements to confirm the diagnosis.

We will confirm hypertension if the clinic blood pressure is 140 over 90 or higher, and the ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average is 135 over 85 or higher.

If hypertension is not diagnosed but there is evidence of target organ damage, we should consider investigating for alternative causes.

If hypertension is not diagnosed, we should recheck clinic blood pressure at least every five years, more frequently if readings are close to 140 over 90.

However, we should measure blood pressure at least once a year in adults with type 2 diabetes who do not have previously diagnosed hypertension or renal disease.

Additionally, we should consider the need for specialist investigations in people who have signs and symptoms suggesting a secondary cause of hypertension.

So that is it, a review of a section of the NICE guideline on hypertension.

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/URcxCjFEFRM

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 review the NICE guideline on Type 2 diabetes in adults: management, 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 Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections.

Today, we are focusing on insulin-based treatment and the management of complications.

In recent episodes, we covered the earlier sections.

Right, let’s jump into it.

First, let’s look at insulin-based treatments.

When we start insulin in adults with type 2 diabetes, we should provide structured education. This education should cover aspects like injection technique, self-monitoring, dose titration, fitness to drive advice, managing hypoglycaemia, and managing acute changes in glucose.

When initiating insulin, we should continue metformin in people already taking it.

We should stop any other medicines used solely to manage hyperglycaemia.

And we should discuss the risks and benefits of continuing medicines that have other benefits, for example cardiovascular protection or weight management.

As initial insulin therapy, we should offer a basal insulin intended for once or twice daily use.

If HbA1c is very high, especially 75 mmol per mol or higher, we should consider starting with basal insulin plus a short or rapid acting insulin. This can be given as separate injections, or as a premixed, biphasic insulin preparation.

When choosing the insulin preparation, we should take into account whether the person needs help with injections, whether there is concern about nocturnal hypoglycaemia, and whether once daily injections would be preferred.

If more than one basal insulin type is equally suitable, we should choose the least expensive option.

We should consider premixed preparations that include insulin analogues rather than human insulin if the person wants to inject immediately before meals, if hypoglycaemia is a problem, or if glucose rises significantly after meals.

At each review, we should check whether someone on basal insulin also needs bolus insulin before meals, or a move to a premixed biphasic regimen.

At each review, if someone is on premixed biphasic insulin and their targets are not met, we should check whether they need to switch to a different premix or move to a basal bolus regimen.

Now let’s move to complications.

At annual review, we should advise adults with type 2 diabetes that they are at higher risk of periodontitis.

We should explain that treating periodontitis can improve blood glucose control and can reduce the risk of hyperglycaemia.

We should advise regular oral health reviews, and if periodontitis is diagnosed, we should offer dental appointments at a frequency based on their needs.

We should think about gastroparesis in adults with erratic blood glucose control or unexplained bloating or vomiting, while considering alternative diagnoses.

If vomiting is caused by gastroparesis, we should explain that there is no strong evidence that antiemetic treatments are effective. Some people may benefit from domperidone, erythromycin, or metoclopramide.

We should be clear that domperidone has specific safety risks, particularly cardiac risk and drug interactions, so we need to prescribe cautiously.

For treatment, we should consider alternating erythromycin and metoclopramide.

We should only consider domperidone in exceptional circumstances, when it is the only effective option, and in line with safety guidance.

If gastroparesis is suspected, we should consider referral to specialist services if the diagnosis is uncertain or vomiting is persistent or severe.

For painful diabetic peripheral neuropathy, we should follow the relevant guideline.

If someone loses their warning signs of hypoglycaemia, we should think about autonomic dysfunction.

We should also consider autonomic involvement of the gut in unexplained nocturnal diarrhoea.

If someone has autonomic neuropathy, we should be aware that orthostatic hypotension is more likely when taking antihypertensive medication.

If someone has unexplained bladder emptying problems, we should investigate possible autonomic neuropathy affecting the bladder.

Management should focus on the symptoms present, for example interventions for abnormal sweating or nocturnal diarrhoea.

For prevention and management of diabetic foot problems, we should follow the diabetic foot problems guideline.

As part of the annual review, we should offer to discuss erectile dysfunction when relevant, including addressing contributory factors such as cardiovascular disease and discussing treatment options.

We should consider a phosphodiesterase 5 inhibitor and initially choose the option with the lowest acquisition cost, taking contraindications into account.

If treatment is unsuccessful, we should refer to services that can offer other medical, surgical, or psychological options.

In terms of eye disease, at diagnosis, we should refer adults immediately to the local eye screening service and encourage regular attendance.

We should arrange emergency ophthalmology review for sudden loss of vision, rubeosis iridis, pre retinal or vitreous haemorrhage, or retinal detachment.

We should refer to ophthalmology in line with diabetic eye screening pathway standards, and follow the diabetic retinopathy guideline.

In this guideline, the recommendations on diagnosing and managing hypertension have been removed. For hypertension in people with type 2 diabetes, we should follow the hypertension in adults guideline, because management is broadly the same as for other people unless specified otherwise.

Finally, we should not offer antiplatelet therapy, such as aspirin or clopidogrel, for people with type 2 diabetes who do not have cardiovascular disease.

For primary and secondary prevention of cardiovascular disease, we should follow the relevant cardiovascular disease and acute coronary syndromes guidelines.

So that is it, a review of a section of the NICE guideline on type 2 diabetes.

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/dp6d3yH7AJs

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 review the NICE guideline on Type 2 diabetes in adults: management, 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 Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections.

Today, we are focusing on how to introduce medicines, how to review them, and what to do when further treatment is needed after the initial regimen.

In recent episodes, we covered the earlier sections of the guideline. In future episodes, we will move on to insulin-based treatment in more detail and the management of complications.

Right, let’s jump into it.

First, let’s look at introducing medicines.

We should introduce medicines one at a time and check tolerability and effectiveness before moving on.

When starting initial therapy with modified release metformin and other medicines, we should begin with metformin and confirm it is tolerated.

If we are using an SGLT 2 inhibitor, we should start it once metformin is at the maximum tolerated dose.

If we are also planning to use a GLP 1 receptor agonist or tirzepatide, we should introduce this once the SGLT 2 inhibitor is at the maximum tolerated dose.

So even though the initial plan may involve more than one medicine, we still introduce them sequentially one at a time and monitor carefully.

Now, let’s look at preventing diabetic ketoacidosis with SGLT 2 inhibitors.

Before starting an SGLT 2 inhibitor, we should assess the risk of DKA.

Risk factors include a previous episode of DKA, acute illness, dehydration, or following a very low carbohydrate or ketogenic diet.

We should address modifiable risks before starting treatment. For example, if someone is on a ketogenic diet, we may need to delay the SGLT 2 inhibitor until their diet changes.

We should also advise people that a very low carbohydrate diet increases the risk of DKA while on an SGLT 2 inhibitor. They should speak to a healthcare professional before starting such a diet, and treatment may need to be temporarily suspended.

Next, let’s look at general principles when reviewing treatment.

Before switching or adding medicines, we should optimise the current regimen. That means checking doses, adherence, side effects, and revisiting lifestyle advice.

Now, let’s look at reviewing metformin.

If someone is already taking standard release metformin, we can continue it.

If it is not tolerated, or if the person prefers, we should switch to modified release metformin.

Now, let’s look at reviewing other medicines.

If a person has reached their target, we should consider continuing the medicines that contributed to that success.

We should consider continuing SGLT 2 inhibitors for their cardiovascular or renal benefits, even if HbA1c targets are not fully achieved.

We should stop GLP 1 receptor agonists or tirzepatide if the person becomes underweight, with a BMI below 18.5.

We should also stop them if they are not helping the person reach glycaemic targets and they are not being used for cardiovascular benefit.

We must take into account adverse effects from combinations, such as hypoglycaemia and we should not combine a GLP 1 receptor agonist or tirzepatide with a DPP 4 inhibitor.

Now let’s move on to further medication, group by group.

For people with no relevant comorbidity who need further treatment, we should add a DPP 4 inhibitor.

If this is contraindicated, not tolerated, or not effective, we should add a sulfonylurea, pioglitazone, or insulin-based treatment.

For people with heart failure who need further treatment, we should also add a DPP 4 inhibitor.

If that is not suitable or not effective, we should add a sulfonylurea or insulin-based treatment.

For people with atherosclerotic cardiovascular disease who develop this after initial treatment, we should add subcutaneous semaglutide, up to 1 mg once weekly, for cardiovascular and renal benefit.

If further glycaemic control is needed, we should add a sulfonylurea, pioglitazone, or insulin-based treatment.

For people with early onset type 2 diabetes who need further treatment, we should consider adding a GLP 1 receptor agonist or tirzepatide.

If these are not suitable, we should add a DPP 4 inhibitor.

If that is also not suitable or not effective, we should add a sulfonylurea, pioglitazone, or insulin-based treatment.

If they are already taking a GLP 1 receptor agonist or tirzepatide and still need further control, we should add a sulfonylurea, pioglitazone, or insulin.

For people living with obesity, if weight management is a key issue, we should follow the obesity guidance.

If after at least 3 months of initial therapy further glycaemic control is needed, and they are not already on a GLP 1 receptor agonist or tirzepatide, we should consider adding one.

If these are contraindicated, not tolerated, or ineffective, we should add a DPP 4 inhibitor.

If that is not suitable, we should add a sulfonylurea, pioglitazone, or insulin.

If they are already on a GLP 1 receptor agonist or tirzepatide and still need further control, we should add a sulfonylurea, pioglitazone, or insulin.

For people with chronic kidney disease who need further treatment, we should consider adding a DPP 4 inhibitor.

If they are already on one, or it is not suitable, we should consider adding pioglitazone, or a sulfonylurea if eGFR is above 30, or insulin.

Finally, for people with frailty who need further treatment to control symptoms and reach targets, we should consider adding a DPP 4 inhibitor.

If they are already on one or it is not suitable, we should consider adding pioglitazone, a sulfonylurea, or insulin.

When choosing in frailty, we must remember that sulfonylureas and insulin increase the risk of hypoglycaemia and falls.

So that is it, a review of a section of the NICE guideline on type 2 diabetes.

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/-kla7F8yibM

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 March 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 February 2026 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2026-03-01&to=2026-03-31&ndt=Guidance&ndt=Quality+standard

The new guideline on Kidney cancer: diagnosis and management [NG256] can be found here:

·      https://www.nice.org.uk/guidance/ng256

The guideline on suspected cancer: recognition and referral can be found here:

·      https://www.nice.org.uk/guidance/ng12/

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’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in March 2026, focusing on what is relevant in Primary Care only.

This month, none of the updated guidelines were relevant to primary care. Only one new guideline had some relevance: kidney cancer: diagnosis and management.

We will cover this briefly, focusing mainly on diagnosis and referring to the relevant section of the NICE guideline on suspected cancer, recognition and referral.

Right, let’s jump into it.

Before we go into kidney cancer itself, let’s briefly set the scene by looking at the NICE suspected cancer guideline. It is designed to help us recognise when symptoms may represent cancer and when to refer patients urgently.

In urological cancers, we need to be aware that many cancers, including kidney and bladder cancer, may present with relatively non-specific symptoms.

However, one symptom stands out as particularly important: that is, haematuria.

Visible haematuria is the single most important red flag symptom for urological cancers.

NICE recommends that we should make an urgent suspected cancer referral for bladder or renal cancer in adults aged 45 and over with unexplained visible haematuria, either without a urinary tract infection, or if it persists or recurs after treatment of a urinary tract infection.

So, this is an important point. Visible haematuria, especially when unexplained, should always be taken seriously.

At the same time, we should remember that haematuria can also be associated with prostate cancer. NICE advises that we should consider a PSA test and a digital rectal examination in patients with visible haematuria as well as those with lower urinary tract symptoms or erectile dysfunction.

However, prostate cancer assessment follows a separate pathway, so today we will just focus on renal cancer.

Now, what about non-visible haematuria?

This is less specific, but still important in certain groups.

NICE recommends that we should consider an urgent suspected cancer referral in people aged 60 and over with unexplained non visible haematuria if this is associated with symptoms such as dysuria, or abnormal blood results such as a raised white cell count.

So the threshold is higher, but it is still clinically relevant.

However we should note that this relates to suspected bladder cancer rather than kidney cancer, as the urgent criteria for renal cancer are based on visible haematuria.

And while we are here, NICE also advises that we should consider a non urgent referral for bladder cancer, I repeat, a non urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection.

Additionally, the suspected cancer guideline also emphasises safety netting.

If a patient does not meet the referral criteria but symptoms persist or evolve, we should reassess and reconsider referral, always using our clinical judgement alongside the guideline.

Now, with that context in mind, let’s move on to the new kidney cancer guideline itself.

Diagnosing kidney cancer in Primary Care can be challenging. In fact, patients with kidney cancer may present late or with non-specific symptoms which may overlap with other conditions.

So in practice, the diagnosis pathway for kidney cancer in Primary Care relies heavily on the features that trigger referral under the guideline on suspected cancer.

This means that visible haematuria remains central.

In addition, we also need to be aware that kidney cancer may present with more general symptoms, like flank or abdominal pain, weight loss, or fatigue.

However, these are non-specific, and on their own may not meet referral thresholds.

So again, clinical judgement and safety netting are really important.

Another important point is the role of incidental findings.

Some kidney cancers are detected incidentally on imaging performed for other reasons, although, in these cases, the pathway is usually driven by secondary care.

In Primary Care, our role is mainly in recognising the features and making the referral and after that, most of the diagnostic pathway takes place in secondary care. There, once kidney cancer is suspected, the main test used is a CT scan of the abdomen and pelvis, or, if necessary, an MRI scan. On occasions, a contrast-enhanced ultrasound scan can be considered.

So to summarise this section.

Kidney cancer diagnosis in Primary Care is largely based on recognising features that trigger referral under the suspected cancer guideline.

Visible haematuria remains the most important red flag symptom.

Non-visible haematuria can also be relevant for bladder cancer in higher risk groups.

And because symptoms can be vague, safety netting and clinical judgement are essential.

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/7LiKkriN9tc

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 review the NICE guideline on Type 2 diabetes in adults: management, 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 Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections.

Today, we are focusing on medicines management, including sick day rules and choosing initial medicines.

In recent episodes, we covered the initial sections of the guideline and in future episodes, we will move on to further drug treatment and the management of complications.

Right, let’s jump into it.

When discussing medicines, we should go through the benefits and risks of each option. This includes:

·      The effect on HbA1c and weight.

·      The effect on cardiovascular and renal outcomes.

·      Whether there are contraindications, such as pioglitazone in heart failure or metformin when eGFR is below 30.

·      Practical issues that might affect adherence.

·      And cost. If two medicines from the same class are equally suitable, we should use the least expensive option.

If a person has more than one comorbidity, for example atherosclerotic cardiovascular disease and obesity, we should make a shared decision about which condition to prioritise.

When discussing GLP 1 receptor agonists or tirzepatide we should explain the guidance on use in pregnancy and breastfeeding. We should explain that weight loss may improve fertility and that effective contraception must be used while taking these medicines. And if pregnancy is planned, contraception should continue for a period after stopping treatment.

Now let’s move on to sick day rules.

We should include clear sick day guidance in each person’s individual treatment plan.

Depending on the medicines they are taking, this should cover:

·      Whether medicines need to be adjusted during illness or surgery.

·      Whether medicines such as metformin or SGLT 2 inhibitors should be temporarily stopped if there is a risk of dehydration, vomiting, or diarrhoea.

·      How to adjust insulin doses.

·      And how to restart treatment after recovery.

Before initiating treatment, we should assess cardiovascular and renal status, and the person’s future cardiovascular risk.

If frailty is a concern, we should assess this before starting medicines. Frailty can change the balance between benefits and harms.

Let’s now move on to initial medicines.

This section sets out what we should start at diagnosis, before insulin is needed. The recommendations are grouped by clinical profile.

Let’s go through them one by one.

First, people with no relevant comorbidities.

For them, we should offer dual therapy with modified release metformin and an SGLT 2 inhibitor from the outset.

If metformin is contraindicated or not tolerated, we should offer an SGLT 2 inhibitor alone.

So the default starting point is dual therapy, not metformin alone.

Next, people with heart failure.

For adults with type 2 diabetes and heart failure, regardless of ejection fraction unless otherwise specified, we should again offer modified release metformin and an SGLT 2 inhibitor.

If metformin cannot be used, we should offer an SGLT 2 inhibitor alone.

Now let’s look at people with atherosclerotic cardiovascular disease.

Here, we should offer modified release metformin, an SGLT 2 inhibitor, and subcutaneous semaglutide, up to 1 mg once weekly, for its cardiovascular, renal, and glycaemic benefits.

If metformin is contraindicated or not tolerated, we should offer an SGLT 2 inhibitor plus subcutaneous semaglutide.

So in this group, initial therapy is triple therapy, reflecting the very high cardiovascular risk.

Next, people with early onset type 2 diabetes.

Early onset means diagnosis under the age of 40.

For these adults, we should offer modified release metformin and an SGLT 2 inhibitor, and we should consider adding either a GLP 1 receptor agonist for its cardiovascular, renal, and glycaemic benefits, or tirzepatide for its glycaemic benefits.

If metformin is not suitable, we should offer an SGLT 2 inhibitor and consider adding a GLP 1 receptor agonist or tirzepatide.

This reflects the higher lifetime risk in early onset disease and the need for more intensive early management.

Now, let’s look at people living with obesity.

For adults with type 2 diabetes who are living with obesity, we should offer modified release metformin and an SGLT 2 inhibitor.

If metformin is contraindicated or not tolerated, we should offer an SGLT 2 inhibitor alone.

Obesity itself does not automatically change the initial dual therapy recommendation, but it will influence later choices.

Next, people with chronic kidney disease.

We need to tailor treatment according to eGFR.

If eGFR is above 30, we should offer modified release metformin and an SGLT 2 inhibitor.

If metformin is not suitable, we should offer an SGLT 2 inhibitor alone.

If eGFR is between 20 and 30, we should offer either dapagliflozin or empagliflozin, together with a DPP 4 inhibitor.

If eGFR is below 20, we should consider a DPP 4 inhibitor.

If a DPP 4 inhibitor is contraindicated, not tolerated, or not effective, we should consider pioglitazone or an insulin-based treatment.

So in advanced kidney disease, the pathway shifts away from metformin and SGLT 2 inhibitors, depending on renal function.

Finally, people with frailty.

For adults with type 2 diabetes and frailty, we should offer modified release metformin.

We should only offer an SGLT 2 inhibitor if the person’s level of frailty does not place them at risk of adverse effects, such as volume depletion or hypotension.

If metformin is contraindicated or not tolerated, we should assess frailty carefully.

If frailty does not increase the risk of adverse events, we should consider an SGLT 2 inhibitor alone.

If frailty does increase risk, we should consider a DPP 4 inhibitor instead.

So that is it, a review of a section of the NICE guideline on type 2 diabetes.

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/LsB8J96adC0

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 review the NICE guideline on Type 2 diabetes in adults: management, 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 Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The diabetes guideline is a comprehensive document, so I am breaking it down into clear and practical sections.

Today, we are focusing on blood glucose management, including HbA1c targets and glucose monitoring.

In the last episode, we covered patient education, dietary advice, and bariatric surgery. In future episodes, we will move on to further drug treatment and the management of complications.

Right, let’s jump into it.

Let’s start with HbA1c measurement and targets.

We should measure HbA1c every 3 to 6 months, tailored to the person, until levels are stable on unchanging therapy. Once HbA1c and treatment are stable, we should measure it every 6 months.

If HbA1c is unreliable, for example because of abnormal haemoglobin or altered red cell turnover, we should use alternative methods. These include quality-controlled plasma glucose profiles, total glycated haemoglobin if abnormal haemoglobins are present, or fructosamine.

If there is a mismatch between HbA1c and other glucose readings, we should investigate and seek specialist advice if needed.

Now let’s talk about targets.

We should agree an individual HbA1c target with each person. This should be a shared decision. We should encourage people to reach and maintain their target, unless doing so causes adverse effects, including hypoglycaemia, or reduces their quality of life.

For people managed with lifestyle alone, or with medicines that do not cause hypoglycaemia, we should support them to aim for an HbA1c of 48 mmol per mol, or 6.5 percent.

For people taking medicines associated with hypoglycaemia, we should support them to aim for 53 mmol per mol, or 7 percent.

If HbA1c rises to 58 mmol per mol, or 7.5 percent or higher, we should reinforce advice about diet, lifestyle and adherence, and intensify treatment, aiming again for 53 mmol per mol or 7 per cent.

We should consider relaxing HbA1c targets on a case-by-case basis. This is particularly important for older or frail adults, people with reduced life expectancy, those at high risk of hypoglycaemia, or those with significant comorbidities.

If someone achieves an HbA1c lower than their agreed target and is not having hypoglycaemia, we should encourage them to maintain it. However, we should remember that a low HbA1c may sometimes be a sign of other issues, such as weight loss or deteriorating kidney function.

Now let’s move to self-monitoring of capillary blood glucose.

We should not routinely offer self-monitoring to everyone with type 2 diabetes.

We should offer it if the person is on insulin, has hypoglycaemic episodes, is taking medicines that increase the risk of hypoglycaemia while driving or operating machinery, or is pregnant or planning pregnancy.

Additionally, we should consider short term self-monitoring when starting corticosteroids, or to confirm suspected hypoglycaemia.

During acute illness, we should review treatment because blood glucose levels can worsen.

If someone is self-monitoring, we should carry out a structured review at least once a year. This should include checking their technique, how often they test, whether they understand the results, the impact on their quality of life, whether it is still beneficial, and the equipment they are using.

Now let’s look at continuous glucose monitoring.

NICE says that we should offer intermittently scanned continuous glucose monitoring, often called flash monitoring, to adults on multiple daily insulin injections if they have recurrent or severe hypoglycaemia, impaired hypoglycaemia awareness, a disability that prevents finger prick testing, or if they would otherwise need to test at least eight times a day.

We should also offer flash monitoring to adults on insulin who would otherwise need help from a care worker or healthcare professional to monitor their glucose.

We should consider real time continuous glucose monitoring instead of flash if it is available at the same or lower cost.

Continuous glucose monitoring should be provided by a team with expertise, and it must be part of a wider self-management plan.

People using continuous glucose monitoring still need to check capillary blood glucose at times. This is to confirm accuracy and as a back up if the device fails or glucose levels are changing quickly. They should be given enough test strips to do this safely.

If someone cannot or does not want to use continuous monitoring, we should offer capillary blood glucose monitoring instead.

We should review the use of continuous monitoring regularly as part of the diabetes care plan. If there are concerns about how it is being used, we should explore any problems and offer further education or support.

Finally, a word on hyperglycaemia.

If an adult with type 2 diabetes develops symptoms of hyperglycaemia, we should consider insulin or a sulfonylurea, and then review treatment once blood glucose returns to target.

So that is it, a review of the first section of the NICE guideline on type 2 diabetes.

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/y-hTBUYkInk

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 review the NICE guideline on Type 2 diabetes in adults: management, 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 Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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’m Fernando, a GP in the UK. Today we are looking at the new updated NICE guideline on type 2 diabetes in adults, always focusing on what is relevant in Primary Care only.

The link to the NICE guideline is the episode description.

Right, let’s jump into it.

The diabetes guideline is a comprehensive document, so I am going to break it down into manageable sections.

Today, we will focus on the first part of the NICE guideline, covering tailoring care, structured education, dietary advice, and bariatric surgery.

In future episodes, we will move on to drug treatment and the management of complications.

First, let’s start with tailoring care to the person.

NICE recommends an individualised approach for adults with type 2 diabetes. Care should be tailored to the person’s needs and circumstances. This includes their personal preferences, their other medical conditions, the risks from polypharmacy, and their likelihood of benefiting from long term treatments.

This is especially important for people with multimorbidity. At each review, we should reassess the person’s situation and think about whether any medicines are no longer effective and could be stopped.

When planning care, we should take into account any disabilities, including visual impairment.

For discussions about overweight and obesity, NICE directs us to the guideline on overweight and obesity management, including how to classify overweight and obesity and how to address the drivers behind it. There is also a specific section in the guideline on eating disorders for those who have both type 2 diabetes and an eating disorder, covering advice on collaborative care, blood glucose management, and insulin use.

Next is structured education.

NICE says we should offer structured education to all adults with type 2 diabetes at diagnosis. Family members or carers should also be involved where appropriate. Education should be reinforced and reviewed every year and it should be explained clearly that structured education is a core part of diabetes care.

Education programmes should be evidence based and suitable for the person. They should have clear aims and learning objectives, and support people to develop the knowledge and skills to self-manage their diabetes.

Programmes should follow a structured curriculum, be delivered by trained educators, and outcomes should be regularly monitored.

Group education is the preferred option, but there must be an alternative of equal standard for people who cannot attend or prefer not to take part in group sessions.

Education programmes should meet local cultural, language, cognitive and literacy needs. All members of the diabetes team should know what programmes are available locally, and these programmes should be integrated into the overall care pathway.

Now let’s move on to dietary advice.

Adults with type 2 diabetes should receive individualised and ongoing nutritional advice from a healthcare professional with expertise in nutrition.

Dietary advice should be sensitive to the person’s culture, beliefs, willingness to change, and the impact on quality of life.

In general, people with type 2 diabetes should follow the same healthy eating advice as the general population. This includes choosing high fibre, low glycaemic index carbohydrates such as fruit, vegetables, wholegrains and pulses, choosing low fat dairy products, eating oily fish, and limiting saturated and trans fats.

For low energy or very low energy diets aimed at remission, the guideline directs us to the specific guidance on the NHS Type 2 Diabetes Path to Remission Programme and the overweight and obesity management guideline.

Dietary advice should be integrated into a personalised diabetes management plan, including physical activity and weight management.

Carbohydrate intake, alcohol intake, and meal patterns should be individualised. Reducing the risk of hypoglycaemia is particularly important for people using insulin or insulin secretagogues.

People can substitute a limited amount of sucrose containing foods for other carbohydrates in their meal plan, but they should avoid excess calorie intake.

NICE advises against using foods marketed specifically for people with diabetes.

For people admitted to hospital or another care setting, there should be a meal planning system that provides consistency in carbohydrate content.

Finally, let’s talk about bariatric surgery.

For people with recent onset type 2 diabetes, we should follow the recommendations on surgical interventions in the overweight and obesity management guideline.

This guideline is separate to the diabetes guideline but we will cover it briefly here. It says that we should offer adults a referral for a comprehensive assessment by a specialist multidisciplinary overweight and obesity management service to see whether bariatric surgery is suitable if they have a BMI of 40 or more, or a BMI between 35 and 39.9 with a significant health condition that could improve with weight loss. These conditions include cardiovascular disease, hypertension, fatty liver disease, obstructive sleep apnoea, and type 2 diabetes. The person must also agree to long term follow up after surgery, including lifelong annual reviews.

For people of South Asian, Chinese, other Asian, Middle Eastern, Black African, or African Caribbean background, we should use a BMI threshold that is 2.5 lower than these values, because cardiometabolic risk occurs at lower BMI in these groups.

We should refer for expedited assessment for bariatric surgery to people with a BMI of 30 or more who have recent onset type 2 diabetes, defined as diagnosed within the past 10 years, provided they are also being assessed within a specialist overweight and obesity management service.

For people from South Asian, Chinese, other Asian, Middle Eastern, Black African, or African Caribbean backgrounds, we should use BMI thresholds that are 2.5 lower when deciding on expedited assessment.

So that is it, a review of the first section of the NICE guideline on type 2 diabetes.

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/YX_YmP-yRfM

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 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.

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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 2026 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2026-02-01&to=2026-02-28&ndt=Guidance&ndt=Quality+standard

The updated guideline on Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

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’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in February 2026, focusing on what is relevant in Primary Care only.

This month there is just one updated guideline relevant to us, but it’s a major one: type 2 diabetes.

A few months ago we reviewed the draft version of the guideline. Now that the final version has been published, over the next few weeks I’ll be creating separate episodes covering the different sections in more depth.

So today, I’ll just give you an overview, highlighting the differences between the draft recommendations and the final version.

Right, let’s jump into it.

Firstly, let’s have a look at the first line treatment in people with no relevant comorbidities.

In the draft guideline, NICE recommended starting metformin plus an SGLT2 inhibitor from the outset, with SGLT2 monotherapy if metformin was not tolerated.

The final guideline confirms this, but now specifies that patients should be started on modified release metformin rather than just metformin.

This change applies throughout the guideline. Wherever standard release metformin was previously recommended, it now says modified release metformin.

Is this the death of the standard release preparation? Possibly in the long term. Anyone starting treatment should be on the modified release version, so numbers on standard release metformin will gradually fall. However, NICE also states that patients already on standard release can continue, or switch if necessary.

Now let’s look at first line treatment in specific clinical groups, starting with heart failure.

In the draft guideline, the recommendation was metformin plus an SGLT2 inhibitor, and it suggested that semaglutide could be added for weight management in selected people with preserved ejection fraction and no frailty.

In the final guideline, it’s still modified release metformin plus an SGLT2 inhibitor, with SGLT2 monotherapy if metformin is not tolerated.

However, for people with heart failure who need further treatment, the guideline moves straight to adding a DPP4 inhibitor first, then a sulfonylurea or insulin if needed. There is no recommendation in this section to add a GLP1 receptor agonist specifically for heart failure.

Next, people with atherosclerotic cardiovascular disease.

The draft guideline recommended early triple therapy with metformin plus an SGLT2 inhibitor plus semaglutide, continuing for cardiorenal benefit even if glycaemic targets were not met.

In the final guideline, this is confirmed but made more specific. Here, we should offer modified release metformin plus an SGLT2 inhibitor plus subcutaneous semaglutide up to 1 milligram once a week for cardiovascular, renal and glycaemic benefits. If metformin is not tolerated, we will use an SGLT2 inhibitor plus semaglutide. It also explicitly recommends starting semaglutide if atherosclerotic cardiovascular disease develops at any stage after initial therapy.

Next is the obesity group.

In the draft guideline, semaglutide was recommended after three months, with additional filters such as preserved ejection fraction and no frailty.

In the final guideline, NICE broadens this. It recommends either a GLP1 receptor agonist or tirzepatide after at least three months of initial therapy if further treatment is needed.

Now let’s look at chronic kidney disease.

There are three eGFR bands here: above 30, 20 to 30, and below 20.

For eGFR above 30, we will use modified release metformin. SGLT2 inhibitors are still prioritised early for kidney and cardiovascular protection, and dapagliflozin and empagliflozin are specifically named because of licensing reasons.

The 20 to 30 eGFR band is where we see a change.

In the draft guideline, if eGFR was between 20 and 30, NICE advised offering dapagliflozin or empagliflozin alone.

In the final guideline, it now says that if eGFR is 20 to 30, we should offer dapagliflozin or empagliflozin plus a DPP4 inhibitor. So, this is now explicit dual therapy rather than SGLT2 monotherapy. The rationale explains why. If the eGFR is below 30, cardiorenal protection of SGLT2 inhibitors remains, but the glucose lowering effect is reduced, so a DPP4 inhibitor is recommended for HbA1c control.

For eGFR below 20, the draft guideline advised using a DPP4 inhibitor first, then considering pioglitazone or insulin, and it stated that sulfonylureas should not be used if eGFR was below 30.

In the final guideline it remains the same, a DPP4 inhibitor first and then pioglitazone or insulin. However, there is no blanket rule about sulfonylureas in the CKD section although we need to know that hypoglycaemia risk increases as renal function falls. .

The draft also recommended not using empagliflozin or dapagliflozin if eGFR was less than 20. The final guideline does not phrase it that way. It simply directs us to DPP4 inhibitors rather than a blanket ban of SGLT2 inhibitors when eGFR is below 20.

And now, the final group is frailty.

The draft guideline recommended metformin alone, effectively deprioritising SGLT2 inhibitors as frailty increases SGLT2 risks.

In the final version, modified release metformin remains first line, but there is no automatic ban of SGLT2 inhibitors at baseline. Instead, the escalation sequence is first a DPP4 inhibitor and then consider pioglitazone, a sulfonylurea or insulin, taking into account hypoglycaemia and falls risk.

Regarding GLP1 receptor agonists and tirzepatide, the draft implied they were generally inappropriate in frailty due to weight loss and gastrointestinal effects.

However, the final guideline is more neutral. It does not specifically recommend them for frailty, but it states there is no inherent safety risk. If another indication exists, they can still be used even in frailty.

Now, let’s look at some other sections of the guideline.

Looking at GLP1 receptor agonists, the draft recommended stopping them if glycaemic or weight goals were not achieved, unless the person had atherosclerotic cardiovascular disease or early onset diabetes.

In the final guideline, NICE recommends stopping GLP1 receptor agonists or tirzepatide if BMI falls below 18.5 or if they do not help with the glycaemic targets as long as they are not being taken for cardiovascular benefit. So, the emphasis shifts from weight thresholds towards glycaemic targets and cardiovascular benefit.

Regarding combining GLP1 receptor agonists and DPP4 inhibitors, both the draft and the final guideline advise against it. The final guideline also extends this to tirzepatide.

In the insulin section, the draft stated that GLP1 receptor agonists could be combined with insulin in Primary Care without specialist approval.

The final guideline does not explicitly restate the specialist approval point. It simply states that when initiating insulin, we should continue metformin, stop other medicines used solely for glycaemic control, and discuss continuing medicines used for cardiovascular protection or weight management.

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.