Recommendations 2018

Recommendation 1

Not all patients with simple respiratory tract infection infections will need antibiotics.

Evidence/guidance

English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2017

Antibiotic prescription strategies and adverse outcome for uncomplicated lower respiratory tract infections: prospective cough complication cohort (3C) study. BMJ. 2017 May 22;357:j2148. doi: 10.1136/bmj.j2148.

Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev. 2013 Jun 4;(6):CD000247. doi: 10.1002/14651858.CD000247.pub3.

Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2017 Jun 19;6:CD000245. doi: 10.1002/14651858.CD000245.pub4.

Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis. 2013 Feb;13(2):123-9. doi: 10.1016/S1473-3099(12)70300-6. Epub 2012 Dec 19.

Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis of potential high-risk groups. Br J Gen Pract. 2014 Feb;64(619):e75-80. doi: 10.3399/bjgp14X677121.

Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 12;12:CD010257. doi: 10.1002/14651858.CD010257.

Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev. 2017 Sep 7;9:CD004417. doi: 10.1002/14651858.CD004417.pub5.

Influenza vaccine effectiveness among high-risk groups: A systematic literature review and meta-analysis of case-control and cohort studies. Hum Vaccin Immunother. 2017 May 8:1-12. doi: 10.1080/21645515.2017.1321722. [Epub ahead of print]

Effectiveness of the 23-Valent Pneumococcal Polysaccharide Vaccine (PPV23) against Pneumococcal Disease in the Elderly: Systematic Review and Meta-Analysis. PLoS One. 2017 Jan 6;12(1):e0169368. doi: 10.1371/journal.pone.0169368. eCollection 2017.

Trends in antibiotic resistance of Streptococcus pneumoniae and Haemophilus influenzae isolated from nasopharyngeal flora in children with acute otitis media in France before and after 13 valent pneumococcal conjugate vaccine introduction. BMC Infect Dis. 2015 Jun 21;15:236. doi: 10.1186/s12879-015-0978-9.

US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016 Nov 22;316(20):2115-2125. doi: 10.1001/jama.2016.16201.

Antibiotics, gut microbiome and obesity. Clin Endocrinol (Oxf). 2018 Feb;88(2):185-200. doi: 10.1111/cen.13495. Epub 2017 Nov 20.

The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda and management guidelines:

Start smart and then focus

Public Health England. Managing common infections: guidance for primary care

NICE. Self-limiting respiratory tract infections – antibiotic prescribing overview

NICE. Managing exacerbations of COPD

National guidelines recommend influenza and pneumococcal vaccination for patients at risk:

Public Health England. National flu immunisation programme for 2017-18

Pneumococcal: the green book, chapter 25

Patient information/decision aids

Adults and children:

NHS Choices. Antibiotics.

Public Health England. Treating your infection leaflets.

NHS Choices. Vaccinations.

Children:

Caring for children with coughs

When should I worry?

 

Recommendation 2

Clinician

Review use of antibiotics for patients with bacteria in their urine who have no, minimal, non-specific, or long-standing urinary symptoms

Evidence\guidance

Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis2005;40:643-54.

Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents? Ann Intern Med1995;122:749-54

Health Protection Agency. English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011

Urinary tract infection in old age: over-diagnosed and over-treated. Age Ageing. 2000 Jul;29(4):297-8

Testing for urinary infection using urinary reagent test strips in unselected acute medical patients. Clin Med (Lond). 2007 Dec;7(6):645-6.

Benefits and Harms of Treatment of Asymptomatic Bacteriuria: A Systematic Review and Meta-analysis by the European Association of Urology Urological Infection Guidelines Panel. Eur Urol. 2017 Dec;72(6):865-868. doi: 10.1016/j.eururo.2017.07.014. Epub 2017 Jul 25.

Benefits and harms of screening for and treatment of asymptomatic bacteriuria in pregnancy: a systematic review. BMC Pregnancy Childbirth. 2016 Nov 2;16(1):336.

Maternal and neonatal consequences of treated and untreated asymptomatic bacteriuria in pregnancy: a prospective cohort study with an embedded randomised controlled trial. Lancet Infect Dis. 2015 Nov;15(11):1324-33. doi: 10.1016/S1473-3099(15)00070-5. Epub 2015 Aug 5.

The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: to treat or not to treat? Clin Infect Dis2012;55:771-7

Prior trimethoprim use and trimethoprim-resistant urinary tract infection: a nested case-control study with multivariate analysis for other risk factors. J Antimicrob Chemother. 2001 Jun;47(6):781-7.

Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care. J Antimicrob Chemother. 2006 Nov;58(5):1000-8. Epub 2006 Sep 23.

US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016 Nov 22;316(20):2115-2125. doi: 10.1001/jama.2016.16201

Antibiotics, gut microbiome and obesity. Clin Endocrinol (Oxf). 2018 Feb;88(2):185-200. doi: 10.1111/cen.13495. Epub 2017 Nov 20.

The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda: Start smart and then focus

Patient information/decision aids

NHS Choices. Antibiotics.

 

Recommendation 3

Consider stopping antibiotics after 4 days for patients with abdominal infection under control after operation or drain

Evidence/Guidance

English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2017

Health Protection Agency. English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011

CABI: A multicentre study of the management and outcomes of complicated intra-abdominal infection.

Association of excessive duration of antibiotic therapy for intra-abdominal infection with subsequent extra-abdominal infection and death: a study of 2,552 consecutive infections. Surg Infect (Larchmt) 2014;15:417–424.

Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015 May 21;372(21):1996-2005.

Patients with Complicated Intra-Abdominal Infection Presenting with Sepsis Do Not Require Longer Duration of Antimicrobial Therapy. J Am Coll Surg. 2016 Apr;222(4):440-6.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017 Jan;18(1):1-76.

Low dosage and long treatment duration of beta-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA. 1998 Feb 4;279(5):365-70.

The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda:

Start smart and then focus

Patient information/decision aids

NHS Choices. Antibiotics.

 

Recommendation 4

Discuss the use of antibiotics with patients who are close to the end of life

Evidence/guidance

English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2017

Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care 2016; 28(4): 456–69.

A nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manage 2013; 46(4): 483–90.

Antibiotic use during the last days of life in cancer patients. Eur J Cancer Care 2006; 15(1): 74–9.

Antimicrobial use at the end of life among hospitalized patients with advanced cancer. Am J Hosp Palliat Care 2012; 29(8): 599–603.

Treatment of the dying in the acute care hospital. Advanced dementia and metastatic cancer. Arch Intern Med 1996; 156(18): 2094–100.

Patterns of antimicrobial use among nursing home residents with advanced dementia. Arch Intern Med 2008; 168(4): 357–62.

Interventions in the last year of life: do they prevent death in hospital in England? In: 8th World Research Congress of the European Association for Palliative Care (EAPC). Spain: Palliat Med 2014:538–913.

Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manage 2003;25(5): 438–43.

Can anti-infective drugs improve the infection-related symptoms of patients with cancer during the terminal stages of their lives? J Palliat Med 2010;13(5):535–40.

Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med 2010;170(13):1102–7.

Infection management and multidrugresistant organisms in nursing home residents with advanced dementia. JAMA. Intern Med 2014;174(10):1660–7.

Bacterial infections in terminally ill hospice patients. J Pain Symptom Manage 2000;20(5):326–34.

US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016 Nov 22;316(20):2115-2125. doi: 10.1001/jama.2016.16201.

End-of-life treatment and bacterial antibiotic resistance: a potential association. Chest 2010;138(3):588–94.

General Medical Council. Guidance: Treatment and care towards the end of life: decision making

NICE Quality Standard 13. End of life care for adults

NICE Quality Standard 144. Care of dying adults in the last days of life

The GMC and NICE provide guidance and quality standards on end of life care (ref. 16 to 18).

The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda:

Start smart and then focus

Patient information/decision aids

NHS Choices. Antibiotics.

Public Health England. Treating your infection leaflets.

 

Recommendation 5

Review the use of antibiotics for conditions that are not infections

Evidence/guidance

Use of antibiotics for noninfectious dermatologic disorders. Dermatol Clin. 2009 Jan;27(1):85-9.

Systematic review and meta-analysis of the role of metronidazole in post-haemorrhoidectomy pain relief. Colorectal Dis. 2017 Sep;19(9):803-811. doi: 10.1111/codi.13755. Review.

Do prokinetics influence the completion rate in small-bowel capsule endoscopy? A systematic review and meta-analysis.Curr Med Res Opin. 2013 Sep;29(9):1171-85. doi: 10.1185/03007995.2013.818532. Epub 2013 Jul 11.

Low dosage and long treatment duration of beta-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA. 1998 Feb 4;279(5):365-70.

Evidence-based management of rosacea. Br J Dermatol. 2017 Feb;176(2):300-301. doi: 10.1111/bjd.15277.

Interventions for rosacea. Cochrane Database Syst Rev. 2015 Apr 28;(4):CD003262. doi: 10.1002/14651858.CD003262.pub5.

Systemic Metronidazole May Not Reduce Posthemorrhoidectomy Pain: A Meta-Analysis of Randomized Controlled Trials. Dis Colon Rectum. 2017 Apr;60(4):446-455. doi: 10.1097/DCR.0000000000000792

Prokinetics in acute upper GI bleeding: a meta-analysis. Gastrointest Endosc. 2010 Dec;72(6):1138-45. doi: 10.1016/j.gie.2010.08.011.

US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016 Nov 22;316(20):2115-2125. doi: 10.1001/jama.2016.16201.

Antibiotics, gut microbiome and obesity. Clin Endocrinol (Oxf). 2018 Feb;88(2):185-200. doi: 10.1111/cen.13495. Epub 2017 Nov 20.

The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda: Start smart and then focus

Patient information/decision aids

NHS Choices. Antibiotics.

Recommendation 1

Consider restricting coagulation screens on patients presenting to emergency departments to only those taking anticoagulant drugs, massive haemorrhage or suspected of having a bleeding disorder.

Evidence\guidance

 There is no specific recommendation from NICE about this patient groups. Related guidance from NICE about preoperative testing before surgery advocates a similar targeted approach

 

Recommendation 2

A clinician should discuss the need for a lumbar puncture for a patient suspected of having a sub-arachnoid haemorrhage if a CT is performed within 6 hours of the start of the headache.

Standard investigations for patients suspected of having suffered a sub-arachnoid haemorrhage involve a CT scan and then, if the CT is normal, a lumbar puncture. Lumbar punctures are painful procedures, usually require hospital admission and some people develop worse headaches afterwards.

CT Scanners have become better at detecting blood in the brain. A normal scan performed with 6 hours of onset of a severe headache means that the risk of having a sub-arachnoid haemorrhage is extremely low.

Evidence\guidance

There is a systematic review of five observational studies, showing that the missed rate of sub-arachnoid haemorrhage was 1.46 per 1,000 patients in CT scans performed within 6 hours of onset.

Dubosh NM Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Stroke 2016

 

Recommendation 3

Review the routine use of urine toxicology tests in patients who are poisoned.

Urine toxicology tests are commonly performed on patients who are suspected of having taken a drug overdose. The results of these tests very rarely change management. There are also several newer recreational drugs which are not picked up by these tests.

 

Recommendation 4

People who have suffered a first seizure, who have fully recovered, have no headache and have a normal neurological examination do not usually need a CT scan while in the emergency department. They should be offered an MRI as an outpatient instead.

Evidence\guidance

NICE CG 137 ‘Epilepsies: diagnosis and management’

 

Recommendation 5

Discuss the need for antibiotics for asymptomatic bacteriuria in older people

Many older people have bacteria in their urine normally. A bedside urine dip test will frequently show cells (leucocytes) and many patients are then treated with antibiotics, despite having no signs or symptoms of a urinary tract infection. This means many older people are treated unnecessarily with antibiotics and some people will develop complications of the antibiotic treatment, such as diarhoea.

We advocate that patients with a urine dip that shows leucocytes should be evaluated by a clinician before antibiotics are offered

Evidence\guidance

 NICE Quality Standard ‘Urinary Tract Infections in Adults’ CG90

The Silver Book, published by the British Geriatrics Society

Recommendation 1 

Avoid use of antibiotics for group B Streptococcus carriage until labour starts

Antibiotics should not be given before labour starts or waters break when group B Streptococcus (GBS) is identified simply from a vaginal or rectal swab during pregnancy. Women with GBS urinary tract infection (growth of greater than 10cfu/ml) during pregnancy should receive appropriate treatment at the time of diagnosis as well as in labour. Information on GBS in pregnancy should be provided to all pregnant women, and any questions answered.

Evidence\guidance

Royal College of Obstetricians & Gynaecologists Guideline: Group B Streptococcal Disease, Early onset

NICE Antibiotics for the prevention and treatment of early-onset neonatal infection (2012)

Patient information\decision aids

The Royal College of Obstetricians and Gynaecologists provides detailed information on Group B Streptococcal infection in pregnancy:

Additional information from charity Group B Strep Support www.gbss.org.uk

 

Recommendation 2

Endometrial hyperplasia can often be managed without surgery

Hysterectomy should not be considered as a first-line treatment for hyperplasia without atypia as progestogen therapy induces histological and symptomatic remission in the majority of women and avoids the morbidity associated with major surgery. Information should be given to the patient, any questions answered, and their individual circumstance and preferences discussed.

Evidence\guidance

Royal College of Obstetricians & Gynaecologists: Endometrial Hyperplasia, Management of.

Patient information\decision aids

The patient info website provides detailed information on endometrial hyperplasia: https://patient.info/doctor/endometrial-hyperplasia-pro 

 

Recommendation 3

Where possible an external cephalic version should be offered for breech presentation before a planned caesarean section is agreed

In the absence of contraindications, a planned caesarean section should not be carried out for breech presentation before ECV has been offered. Information should be given to the patient, any questions answered, and their individual circumstance and preferences discussed.

 Evidence\guidance

Royal College of Obstetricians and Gynaecologists: External cephalic version and reducing the risk of term breech presentation.

Patient information\decision aids

Royal College of Obstetricians and Gynaecologists provide detailed information on this: https://www.rcog.org.uk/en/patients/patient-leaflets/breech-baby-at-the-end-of-pregnancy/

 

Recommendation 4

Parental karyotyping is not routinely indicated in recurrent miscarriage. Information should be given to the patient, any questions answered, and their individual circumstance and preferences discussed.

Evidence\guidance

Royal College of Obstetricians and Gynaecologists: Recurrent Miscarriage, investigation and treatment of couples 

Patient information\decision aids

Royal College of Obstetricians and Gynaecologists provide detailed information on recurrent and late miscarriage

 

Recommendation 5

Nausea and vomiting in pregnancy is very common and most women are able to manage this by eating and drinking frequently

Outpatient management of nausea and vomiting in pregnancy is suitable for many patients for whom primary care measures have be unsuccessful. Information should be given to the patient, any questions answered, and their individual circumstance and preferences discussed.

Evidence\guidance

The Royal College of Obstetricians and Gynaecologists: The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum

Patient information\decision aids

Royal College of Obstetricians and Gynaecologists provide detailed information nausea and vomiting in pregnancy: https://www.rcog.org.uk/en/patients/patient-leaflets/pregnancy-sickness/

Recommendation 1

Referral for cataract surgery should be made based on a shared decision-making process about how it may impact quality of life. It should not be restricted because of visual acuity alone.

The decision to refer a person with a cataract for surgery should be based on a discussion that includes:

  • How the cataract affects the person’s vision and quality of life
  • Whether 1 or both eyes are affected
  • What cataract surgery involves, including possible risks and benefits
  • How the person’s quality of life may be affected if they choose not to have cataract surgery
  • Whether the person wants to have cataract surgery.

Evidence/guidance

NICE guideline NG77

 

Recommendation 2

Patients and doctors should use shared decision making to decide when to initiate treatment and what treatment to use for wet active age related macular degeneration. This should take into consideration evidence for visual outcomes to make a fully informed choice of treatment.

Evidence/guidance

NICE guideline NG82

Cohen D (2018) Doctors are cleared to prescribe cheaper drug for wet AMD. BMJ 360:k344 . doi: 10.1136/BMJ.K344

The GMC’s position on the use of off label bevacizumab for treating age related macular degeneration as opposed to one the licensed alternatives is outline here.

Some background on the EU competition law case looking at “off label” use of bevacizumab can be found here.

 

Recommendation 3

Doctors and patients should discuss the risks and benefits of having cataracts surgery on both eyes on the same day.

Evidence/guidelines

NICE guideline NG77

Patient information/decision aids

Patient information on Cataract surgery can be found at NHS Choices, and there is an NHS Right Care shared decision aid 

 

Recommendation 4

Before referring a patient for chronic open angle glaucoma and related conditions and related conditions ensure you have considered the following tests available in the community including:

  • central visual field assessment using standard automated perimetry (full threshold or supra-threshold)
  • optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy (with pupil dilatation if necessary), and optical coherence tomography (OCT) or optic nerve head image if available
  • intraocular pressure (IOP) measurement using Goldmann-type applanation tonometry
  • peripheral anterior chamber configuration and depth assessments using gonioscopy or, if not available or the patient prefers, the van Herick test or OCT.

Patients should be referred for further investigation and diagnosis of COAG and related conditions, after considering repeat measures if:

  • there is optic nerve head damage on stereoscopic slit lamp biomicroscopy or
  • there is a visual field defect consistent with glaucoma or
  • IOP is 24 mmHg or more using Goldmann-type applanation tonometry

If these criteria are not met, people with IOP below 24 mmHg are advised to continue regular visits to their primary eye

Evidence/guidance

For background about glaucoma referral see NICE guideline CG81

Patient information/decision aids

Patient information on Glaucoma can be found at NHS Choices, and on the International Glaucoma Association website

 

Recommendation 5

When considering whether a patient should have cataracts surgery, you should use a validated risk stratification algorithm.

Evidence/guidance

For background about cataract surgery risk stratification see NICE guideline NG77

Blomquist PH, Sargent JW, Winslow HH (2010) Validation of Najjar-Awwad cataract surgery risk score for resident phacoemulsification surgery Journal of Cataract & Refractive Surgery 36 (10) 1753-1757

Muhtaseb M, Kalhoro A, Ionides A (2004) A system for preoperative stratification of cataract patients according to risk of intraoperative complications: a prospective analysis of 1441 cases British Journal of Ophthalmology 88 (10) 1242-1246

Osborne SA, Adams WE, Bunce C, V et al. (2006) Validation of two scoring systems for the prediction of posterior capsule rupture during phacoemulsification surgery British Journal of Ophthalmology 90 (3) 333-336

Tsinopoulos IT, Lamprogiannis LP, Tsaousis KT et al. (2013) Surgical outcomes in phacoemulsification after application of a risk stratification system Clinical Ophthalmology 7 895-899

Patient information/decision aids

Patient information on Cataract surgery can be found at NHS Choices,  and there is an NHS Right Care shared decision aid

Recommendation 1

Avoid unnecessary duplicate genetic testing for inherited variants

Evidence/guidance

Approximately 0.8% of all genetic test requests received for germline mutations were unnecessary duplicate samples from patients who had already been successfully tested (Miller CE et al. Genetic counsellor review of genetic test orders in a reference laboratory reduces unnecessary testing. Am J Med Genet A 2014;164A:1094–1101).

Adverse effects from venepuncture include vasovagal reactions, pain and bruising, and direct and indirect nerve damage (Stevenson M et al. Appendix 8 Diagnostic venepuncture: systematic review of adverse events. Health Technology Assessment 2012;16:4; Kohn D, Bush A, Kessler I. Risk of venepuncture. Br Med J 1976;2:1133).

Patient information/decision aids

Genetic testing can help identify a disease risk or inherited condition.  The results can help your doctor decide:

  • Which additional tests, if any, are required
  • Help to confirm a suspected diagnosis from previous tests undertaken
  • Choose ways to prevent or treat a condition.

Genetic testing may also tell you which family members are at risk.

However, sometimes a genetic test is not the best way to identify a disease risk or inherited condition. A routine blood test or procedure might be just as good.  Therefore, it is important you discuss and understand the reasons for a genetic test with your doctor before agreeing to have a sample taken for testing.

Repeat testing

Usually you don’t need to repeat a genetic test.

Your genetic information generally doesn’t change over your lifetime. Your doctor should check with you directly to confirm whether you have previously had the test.  There is usually no reason to repeat a genetic test unless:

  • Your doctor thinks an error may have been made in the laboratory performing the test.
  • A new, more accurate test is available

 

Recommendation 2

Don’t give a patient a blood transfusion without informing them about the risks and benefits (although do not delay emergency transfusions)

Evidence/guidance

There is a lack of high-quality research in this field with largely observational data available. The evidence suggests that patients have a limited understanding of many aspects of transfusion, but that they do want to be part of an informed decision-making process. The evidence also indicates that patients are reassured by the provision of written information.

NICE guidelines on blood transfusion in November 2015

2016 NICE Quality Standard

Patient information\decision aids

A number of patient information materials are available through the NHSBT website:

Will I need blood transfusion?

 

Recommendation 3

Don’t transfuse red cells for iron deficiency anaemia without haemodynamic instability

Evidence\guidance

NICE guidelines on blood transfusion in November 2015

Royal College of Surgeons of England. 2007; 89(4):418-421;  Luporsi E, Mahi L, Morre C, Wernli J, de Pouvourville G, Bugat R.

Evaluation of cost savings with ferric carboxymaltose in anemia treatment through its impact on erythropoiesis-stimulating agents and blood transfusion: French healthcare payer perspective. Journal of Medical Economics. 2012; 15(2):225-232)

NICE Quality Standard 2016

Patient information\decision aids

Leaflets are available through the NHSBT website

Anaemia patient Information leaflet October 2016

Iron in your diet

 

Recommendation 4

Use statins in appropriate patients

Evidence\guidance

NICE Clinical Guideline CG181 – Cardiovascular disease: risk assessment and reduction, including lipid modification

SIGN 149: Risk estimation and the prevention of cardiovascular disease.

Collins R et al. Interpretation of the evidence for the efficacy and safety of stain therapy. Lancet 2016;388:2532–2561

Mancini GB et al. Diagnosis, Prevention, and Management of Statin Adverse Effects and Intolerance: Canadian Consensus Working Group Update. Can J Cardiol 2016;32:S35–65.

Patient information\decision aids

NICE CG181 patient decision aid

Recommendation 1

Patients with suspected migraine mostly don’t need brain imaging

When managing patients with migraine only perform neuro-imaging where there are atypical features. It is essential to clarify patient expectations and provide education and explanation about the differential diagnosis of migraine. Patients with new onset headaches should have a neurological examination (including fundoscopy) and assessment of ‘red flags’ as per NICE guidance. Where, based on clinical need and imaging is required, unless in a history of trauma or suspected subarachnoid, MRI rather than CT is the preferred modality.

Evidence\guidance

The NICE guidance on migraine

NICE guidance- headaches in over 12-diagnosis & management

 

Recommendation 2

Patients with low back pain do not routinely need imaging

Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica. Explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging. Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management.

Evidence\guidance

NICE guidance on back pain in adults

Metastatic spinal cord compression in adults

Spinal injury

Spondyloarthritis

Suspected cancer

 

Recommendation 3

When managing patients with transient loss of consciousness (TLoC), investigations should be performed only after an appropriate neurological and cardiological assessment.

If the person with suspected transient loss of consciousness (TLoC) has sustained an injury or they have not made a full recovery of consciousness, use clinical judgement to determine appropriate management and the urgency of treatment. Getting a good witness account is vital. The guidance of NICE is excellent  https://www.nice.org.uk/guidance/cg109/chapter/1-Guidance#further-assessment-and-referral and is not to be replicated, but in essence:

Older people (aged >50 years) with a new onset of epileptic seizures do not need an EEG, unless they are having very frequent or continuous seizures.

Repeated standard EEGs may be helpful when the diagnosis of the epilepsy or the syndrome is unclear.  However, if the diagnosis has been established, repeat EEGs are not likely to be helpful (as per NICE guidance).

Limit use of 24 hour ambulatory ECG recording in TLoC, and use long-term implanted loop ambulatory ECG recording where a cardiac cause is suspected in recurrent TLoC of unclear cause

Evidence\guidance

NICE guidance on Transient Loss of Consciousness

NICE guidance on epilepsies

 

Recommendation 4

 Atraumatic lumbar puncture needles are preferred for lumbar puncture to reduce the risk of post LP headache

Evidence\guidance

Nath et al. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis Lancet 2017

 

Recommendation 5

When managing patients with fleeting sensory symptoms, investigations should not be performed unless clinically indicated

Transient sensory symptoms are extremely common and often have a benign cause. When managing patients with fleeting sensory symptoms, investigations should not be performed unless clinically indicated and are directed by taking a neurological history, examining the patient and having a differential diagnosis. Patients should be referred or investigated where there is clinical uncertainty of the diagnosis. It is essential to clarify patient expectations, and provide education and explanation about the differential diagnosis of fleeting sensory symptoms.

Evidence\guidance

NHS Choices on peripheral neuropathy

https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0800

 

Recommendation 6

When managing patients with suspected carpal tunnel syndrome (CTS) requiring surgery, a neurophysiological assessment should be performed

It is essential to clarify patient expectations and provide education and explanation about the differential diagnosis of carpal tunnel syndrome. It is essential that all patients being considered for surgery have a neurophysiological assessment

Evidence\guidance

The NICE guidance on CTS

 

Recommendation 7

Do not use MRI head imaging in patients with suspected Parkinson’s disease

Do not use structural MRI to diagnose Parkinson’s disease.

Structural MRI may be considered in the differential diagnosis of other parkinsonian syndromes.

Evidence\guidance

NICE guidance on Parkinson’s disease

Recommendation 1

Cognitive testing alone does not diagnose dementia.

In order to establish an accurate diagnosis of dementia it is recommended to obtain a full history, collateral information from key family members and a cognitive assessment.

Evidence\guidance

NICE Guidance

Patient information\decision aids

NICE Guidance

 

Recommendation 2

Aim to use non-drug treatments for the management of behavioural and psychological symptoms of dementia.

If there are significant risks that make treatment with an antipsychotic necessary, this should be discussed with the patient and their family, and the lowest possible dose used.

Evidence\guidance

NICE (CG42) states this is best practice

In March 2004, the Medicines and Healthcare products Regulatory Agency’s Committee on Safety of Medicines issued a safety warning about the atypical antipsychotic drugs risperidone and olanzapine, advising that these drugs should not be used for the treatment of behavioural symptoms of dementia.

Brodaty H, Arasaratnam C. Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry. 2012;169(9):946-53.

“Nonpharmacological interventions were effective in reducing behavioral and psychological symptoms, with an overall effect size of 0.34 (95% CI=0.20-0.48; z=4.87; p<0.01)”

Patient information\decision aids

Treatments for different types of dementia

Drugs to relieve behavioural psychological symptoms

 

Recommendation 3

Do not forget pain as a common cause of agitation in patients with dementia.

50% of people with dementia are estimated to experience regular pain. Despite this, current assessment and treatment of pain in this patient group are inadequate. In addition to the discomfort and distress caused by pain, it is frequently the underlying cause of behavioural symptoms, which can lead to inappropriate. Consider prescribing regular analgesia such as paracetamol if there is clinical suspicion that pain is a relevant trigger.

Evidence\guidance

Achterberg WP, Pieper MJ, van Dalen-Kok AH, De Waal MW, Husebo BS, Lautenbacher S, Kunz M, Scherder EJ, Corbett A. Pain management in patients with dementia. Clinical interventions in aging. 2013;8:1471.

Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial BMJ 2011;343:d4065

More information\ decision support material

Common pain behaviours in cognitively impaired elderly persons according to the AGS Panel on persistent pain in older persons.

 

Recommendation 4

Antipsychotics can cause serious side effects in patients with Lewy Body Dementia. They should only be used under expert guidance.

Severe sensitivity to both typical and atypical antipsychotic medication occurs in approximately 50% of individuals with Lewy Body Dementia.

Evidence\guidance

Nice guideline

McKeith IG, Dickson DW, Lowe J, Emre M, O’brien JT, Feldman H, Cummings J, Duda JE, Lippa C, Perry EK, Aarsland D. Diagnosis and management of dementia with Lewy bodies third report of the DLB consortium. Neurology. 2005 Dec 27;65(12):1863-72.

Patient information\decision aids

LDBA information sheet

 

Recommendation 5

Anticholinergic drugs can be detrimental to cognition in later life and have other serious side effects.

Careful consideration of the risks to patients, including the use of an anticholinergic burden scale, should be undertaken prior to initiation.

Evidence\guidance

It has been estimated that 20–50% of older people have been prescribed at least one medication with anticholinergic activity.  Medications with anticholinergic properties recognized by the anti-cholinergic burden scale have been recently correlated with an additional 0.33 point decline in Mini-Mental State Examination score over 2 years, a 2-fold increase in cognitive impairment with as little as 60–90 days of use, and ∼50–80% increase in the risk of incident cognitive impairment over 6 years.

Fox C, Smith T, Maidment I, Chan WY, Bua N, Myint PK, Boustani M, Kwok CS, Glover M, Koopmans I, Campbell N. Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review. Age and ageing. 2014 Jul 19;43(5):604-15.

Patient information\decision aids

NHS England toolkit

 

Recommendation 6

Do not refuse patients access to a service, investigation or treatment solely on the basis of their age.

Decisions should be based on need

Evidence\guidance

NICE guideline

NHS England information

National Curriculum for CBT

Patient information\decision aids

NICE guidance

Mental health in later life

 

Recommendation 7

Management of older adults with mental problems should be guided by Old Age specialists, who are able to manage the complex needs of this population.

There is a transition towards ‘ageless services’ across many trusts in the UK whereby many patients in later life are being managed on mixed wards and are often neglected in these settings.

Evidence\guidance

Royal College of Psychiatrists

SCIE

Mental Health Foundation

Patient information\decision aids

NICE guideline

Mental Health Foundation

 

Recommendation 8

The care of frail older adults with complex needs who need an inpatient admission, is best managed in an older person’s specialist ward environment.

There is a transition towards ‘ageless services’ across many trusts in the UK whereby many patients in later life are being managed on mixed wards and are often neglected in these settings.

Evidence\guidance

Royal College of Psychiatrists

Royal College of Psychiatrists

National Centre for Biotechnology Information

Patient information\decision aids

Depression in older adults

Mental Health in the Community

 

Recommendation 9

Do not use physical restraints in older adults in hospital settings with delirium except as a last resort.

There is little evidence to support the effectiveness of physical restraints to manage people with delirium who exhibit behaviours that risk injury. Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Restraints should therefore be used as a last resort and should be discontinued at the earliest possible time, particularly given that effective non-pharmacological alternatives are available.

Evidence\guidance

Flaherty JH, Little MO. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. Journal of the American Geriatric Soc 2011;59(S2):S295-300.

Lach HW, Leach KM, Butcher HK. Evidence-based practice guideline: changing the practice of physical restraint use in acute care. Journal of Gerontological Nursing 2016;42(2):17-26.

Mott S, Poole J, Kenrick M. Physical and chemical restraints in acute care: their potential impact on the rehabilitation of older people. Int J Nurs Pract 2005;11(3):95-101

Patient information\decision aids

NICE Guideline

Patient info

 

Recommendation 10

If benzodiazepines or antipsychotics drugs have been initiated during an acute care hospital admission, make sure there is a clear plan to review their use, ideally tapering and discontinuing prior to discharge.

Both benzodiazepines and antipsychotics have serious side effects in the elderly, in particular, addiction, falls, worsening cognition, infections, stroke and death.

Evidence\guidance

Yokoi Y, et al. Benzodiazepine discontinuation and patient outcome in a chronic geriatric medical/psychiatric unit: a retrospective chart review. Geriatr Gerontol Int. 2014 Apr;14(2):388-94. PMID: 24666628.

Gill SS, et al. Atypical antipsychotic drugs and risk of ischaemic stroke: population based retrospective cohort study. BMJ. 2005 Feb 26;330(7489):445. PMID: 15668211.

Patient information\decision aids

Choosing Wisely Canada toolkit

Patient Info

NHS Wales

Royal College of Psychiatrists

Recommendation 1

MRI Is indicated only in specific circumstances. Clinical features will often be sufficient to guide management without the need for imaging.

Evidence\guidance

Nice guideline: Knee pain – assessment (last revised in March 2011)

ACR APPROPRIATENESS CRITERIA: Nontraumatic knee pain (last review date: 2012)

Kemp MA, Lang K, Dahill M et al. Investigating meniscal symptoms in patients with knee osteoarthritis–is MRI an unnecessary investigation? Knee 2011; 18: 252-253. [LEVEL II/III]

Chan KK,Sit RW, Wu RW et al. Clinical Radiological and Ultrasonographic findings related to knee pain in osteoarthritis. PLoS One 2014;9:e92901-[LEVEL II/III]

 

Recommendation 2

Morton’s neuroma is essentially a clinical diagnosis and investigations are generally unnecessary.

If the diagnosis of forefoot pain is uncertain, use XR to assess forefoot bones, joints and alignment. In experienced hands, US with dynamic assessment can confirm a diagnosis of Morton’s neuroma and guide injection treatment if required. It is helpful when clinical suspicion is high and conservative measures have failed

Evidence\guidance

Nice guideline: Morton’s neuroma – Last revised in June 2010

Mahadevan D, Venkatesan M, Bhatt R et al. Diagnostic Accuracy of Clinical Tests for Morton’s Neuroma Compared With Ultrasonography. J Foot Ankle Surg 2015; 54: 549-553. [LEVEL II/III]

Bignotti B, Signori A, Sormani MP et al. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. Eur Radiol 2015; 25: 2254-2262. [LEVEL II/III]

Pastides P, El-Sallakh SCharalambides C. Morton’s neuroma: A clinical versus radiological diagnosis. Foot Ankle Surg 2012; 18: 22-24. [LEVEL II/III]

 

Recommendation 3

US is the investigation of choice in the assessment of rotator cuff and surrounding soft tissues.

It may be used to guide injection. It is reserved for cases with unresponsive to first line treatment and clinically guided injection. It is indicated preoperatively if the surgeon requires assessment if rotator cuff integrity

Evidence\guidance

NICE Guideline Shoulder pain

ACR Appropriateness Criteria: Acute shoulder pain

Lenza M et al. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database Syst Rev 2013; 9: CD009020 [LEVEL II/III]

 

Recommendation 4

Imaging is not normally required for Parkinson’s disease (PD)

MRI is useful for differentiating PD from vascular parkinsonism and atypical parkinsonism syndromes in the differential diagnosis of parkinsonian syndromes (progressive supranuclear palsy, multiple system atrophy and corticobasal degeneration). CT is the alternative when MRI is contraindicated. NM imaging with dopamine transporter is recommended in difficult cases to differentiate true PD and the parkinsonian syndromes from essential tremor and other movement disorders.

Evidence\guidance

NICE Guideline: Parkinson’s Disease: Diagnosis and management in primary and secondary care

SIGN guideline: Diagnosis and pharmacological management of parkinson’s disease

Brigo F, Matinella A, Erro R et al. [(1)(2)(3)I]FP-CIT SPECT (DaTSCAN) may be a useful tool to differentiate between Parkinson’s disease and vascular or drug-induced parkinsonisms: a meta-analysis. Eur J Neurol 2014; 21: 1369-1e90. [LEVEL II/III]

Brigo F, Matinella A, Erro R et al. [(1)(2)(3)I]FP-CIT SPECT (DaTSCAN) may be a useful tool to differentiate between Parkinson’s disease and vascular or drug-induced parkinsonisms: a meta-analysis. Eur J Neurol 2014; 21: 1369-1e90. [LEVEL II/III]

Schwarz ST, Abaei M, Gontu V et al. Diffusion tensor imaging of nigral degeneration in Parkinson’s disease: A region-of-interest and voxel-based study at 3 T and systematic review with meta-analysis. Neuroimage Clin 2013; 3: 481-488. [LEVEL II/III]

Meijer FJ, Aerts MB, Abdo WF et al. Contribution of routine brain MRI to the differential diagnosis of parkinsonism: a 3-year prospective follow-up study. J Neurol 2012; 259: 929-935. [LEVEL II/III]

 

Recommendation 5

Routine follow up imaging is not always appropriate. IREFER guidelines are available, which help you determine what is best for your patients

XR may be required by specialists to assist management decisions; e.g. for instituting and modifying drug treatment and referral for joint replacement. Routine follow up is otherwise not appropriate.

Evidence\guidance

NICE Guideline: Rheumatoid arthritis: The Management of rheumatoid arthritis in adults (CG79) – Published February 2009

SIGN Guideline: Management of early rheumatoid arthritis. 2011

Ven M, Kuijper M, Gerards A et al. Can we use ultrasound to identify rheumatoid arthritis patients in remission who can taper their medication? Annals of the Rheumatic Diseases 2014; 73: [LEVEL II/III]

Baker JF, Ostergaard M, Emery P et al. Early MRI measures independently predict 1-year and 2-year radiographic progression in rheumatoid arthritis: secondary analysis from a large clinical trial. Ann Rheum Dis 2014; 73: 1968-1974. [LEVEL II/III]

Recommendation 1.

Testing ANA and ENAs should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus. Testing ANA and ENAs should be avoided in the investigation of widespread pain or fatigue alone. Repeat testing is not normally indicated unless the clinical picture changes significantly.

Evidence\guidance

Solomon DH, Kavanaugh AJ, Schur PH. Evidence-based guidelines for the use of immunologic tests: Antinuclear antibody testing. Arthritis Rheum 2002;47(4):434-44.

Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med 2000;124(1):71–81.

American College of Rheumatology Ad Hoc Committee on Immunologic Testing. Guidelines for immunologic laboratory testing in the rheumatic diseases: an introduction. Guidelines..Arthritis Rheum. 2002 Aug; 47(4):429-33.

Tozzoli R, Bizzaro N, Tonutti E, Villalta D, Bassetti D, Manoni F, Piazza A, Pradella M, Rizzotti P. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 2002;117(2):316-24.

Yazdany J., Schmajuk G., Robbins M., et al. Choosing wisely: the American College of Rheumatology’s Top 5 list of things physicians and patients should question. Arthritis Care Res. (Hoboken) 2013;65:329–339

Fitch-Rogalsky C, Steber W, Mahler M, Lupton T, Martin L, Barr SG, et al. Clinical and serological features of patients referred through a rheumatology triage system because of positive antinuclear antibodies. PLoS One. 2014;9(4):e93812.

Gundín S, Irure-Ventura J, Asensio E, et al. Measurement of anti-DFS70 antibodies in patients with ANA-associated autoimmune rheumatic diseases suspicion is cost-effective. Auto-Immunity Highlights. 2016;7(1):10.

Lee AY, et al. The concordance of serial ANA tests in an Australian tertiary hospital pathology laboratory. Pathology. 2016;48(6):597-601.

Satoh M., Chan E.K., Ho L.A. Prevalence and sociodemographic correlates of antinuclear antibodies in the United States. Arthritis Rheum. 2012;64:2319–2327.

Sharp, CA, Bruce, IN, Efficiency in follow-up immunology testing for patients with connective tissue disease and vasculitis, Clinical Medicine, 2010;10(3):632-4

Tonutti E, Bizzaro N, Morozzi G, Radice A, Cinquanta L, Villalta D, et al. The ANA-reflex test as a model for improving clinical appropriateness in autoimmune diagnostics. Autoimmunity Highlights. 2016;7(1):9.

Wandstrat AE, Carr-Johnson F, Branch V, Gray H, Fairhurst A-M, Reimold A, et al. Autoantibody profiling to identify individuals at risk for systemic lupus erythematosus. Journal of autoimmunity. 2006;27(3):153-60

Patient information\decision aids

Arthritis Research UK: Lupus (2011)

LUPUS UK: Diagnosis (2015)

 

Recommendation 2

Patients with suspected inflammatory arthritis should be referred to Rheumatology without delay. Rheumatoid factor and CCP/ACPA are important, but should be avoided as screening tests. A negative result does not exclude rheumatoid arthritis, nor does a positive result equate to a diagnosis of rheumatoid arthritis. Repeat testing is not normally indicated.

Evidence\guidance

NICE clinical guideline CG79: rheumatoid arthritis in adults: management (2015)   https://www.nice.org.uk/guidance/cg79

Burr. M. L., Viatte, S., Bukhari, M., Plant, D., Symmons, D. P., Thomson, W., & Barton A. 2012. Long-term stability of anti-cyclic citrullinated peptide antibody state in patients with early inflammatory polyarthritis. Arthritis research & therapy 2012; 14: R109

Sharp, CA, Bruce, IN, Eficiency in follow-up immunology testing for patients with connective tissue disease and vasculitis, Clinical Medicine, 2010, 10 (3): 632-4

Patient information\decision aids

Information for primary care physicians:

Royal College of General Physicians: Inflammatory arthritis toolkit (2017)

Arthritis Research UK: Rheumatoid Arthritis (2014)

National Rheumatoid Arthritis Society (NRAS): Getting an early diagnosis

NRAS: What is RA? (2014)

NRAS: Inflammatory Arthritis Patient Pathway

NRAS: Managing CVD risk in RA – Love your heart

NRAS: Have you got the S factor? (2011)

NRAS: Laboratory tests used in the diagnosis and monitoring of rheumatoid arthritis (2013)

 

Recommendation 3

Everyone should consider Vitamin D supplementation during winter.

People who have restricted access to sunlight (e.g. those living in institutions or who cover their skin), or have dark skin, should consider supplementation all year round.  Vitamin D testing should be reserved for people at high risk from deficiency and avoided as part of routine investigation of widespread pain alone. Repeat testing is not normally indicated in those taking supplements.

Evidence\guidance

NICE: Clinical Knowledge Summary – Vitamin D deficiency in adults – treatment and prevention (2013)

Scientific Advisory Committee on Nutrition – Vitamin D and Health. Scientific Advisory Committee on Nutrition (2016)

National Osteoporosis Society: Vitamin D and bone health – A practical clinical guideline for patient management (2013)

Patient information\decision aids

National Osteoporosis Society patient leaflet – Vitamin D supplements and tests (2016)

Public Health England: Health England: Vitamin D-  All you need to know (2014)

NHS Choices: Vitamin D

 

Recommendation 4

Bisphosphonate therapy should be reviewed with every patient after 3-5 years, and a treatment holiday considered. This should follow a shared-decision making conversation which includes the risks and benefits of continued treatment.

Evidence\guidance

Osteoporosis Guideline Group: Clinical Guideline for the Prevention and Treatment of Osteoporosis(2017)

NICE technology appraisal guidance 464: Bisphosphonates for treating osteoporosis (2017)

Vitamin D and bone health: A practical clinical guideline for patient management (2013)

Patient information\decision aids

National Osteoporosis Society

 

Recommendation 5

The use of intra-articular and soft-tissue steroid injections for non-inflammatory musculoskeletal conditions should be preceded by consideration of non-invasive alternatives such as exercise and physical therapy.  Consent to any invasive procedure such as this must arise from a shared-decision making conversation with every patient, which includes assessment of the risks and benefits.

Evidence\guidance

NICE Guideline CG177 (2014) Osteoarthritis: Care and Management  https://www.nice.org.uk/guidance/cg177

National Safety Standards for Invasive Procedures (NatSSIPS) (2015)

https://improvement.nhs.uk/uploads/documents/natssips-safety-standards.pdf

American College of Rheumatology, Guidelines on use of pharmacologic and non-pharmacologic therapies in osteoarthritis of the hand, knee and hip 2012; Arthritis Care & Research, 2012; 64(4): 465-74

Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. Fleckenstein J, editor. PLoS One 2017;12(6):e0178621

Brennan KL. J Orthop Sports Phys Ther. 2017;47(4):232-239

Jüni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, et al. Intra-articular corticosteroid for knee osteoarthritis. In: da Costa BR, editor. Cochrane Database of Systematic Reviews Chichester, UK: John Wiley & Sons, Ltd; 201

Kim et al. Pain Physician. 2013;16(6):557-68

Manchikanti et al. Pain Physician. 2014;17(4):E489-501

Mandel S, Schilling J, Peterson E, Rao DS, Sanders W. A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections. J Bone Jt Surg 2013;95(11):961–4.

Mardani-Kivi et al. Arch Orthop Trauma Surg.  2013;133(6):757-63

Mohamadi A, et al. Corticosteroid Injections Give Small          and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res. 2017;475(1):232-243

Nguyen C et al.  Intradiscal Glucocorticoid Injection for Patients With Chronic Low Back Pain Associated With Active Discopathy. A Randomized Trial. Ann Intern Med. 2017;18;166(8):547-556

Scott A, Khan KM. Corticosteroids: short-term gain for long-term pain? Lancet. 2010;376(9754):1714–5.

Steuri R, Sattelmayer M, Elsig S, Kolly C, Tal A, Taeymans J, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med. 2017;51(18):1340–7

Wang W, Shi M, Zhou C, Shi Z, Cai X, Lin T, et al. Effectiveness of corticosteroid injections in adhesive capsulitis of shoulder. Medicine. 2017;96(28):e7529

Patient information\decision aids

NHS Right Care – Shared Decision Making: Osteoarthritis of the knee (2017)

 

Recommendation 6

C3, C4 and dsDNA are important tests to help in the diagnosis and assessment of disease activity in lupus. They should be reserved for specialist monitoring of disease activity and should be avoided as screening tests.

Evidence\guidance

Gordon, C., et al for the British Society for Rheumatology Standards, Audit and Guidelines Working Group (2018) The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology. 2018;57(1) e1-e45.

Bertsias G, Ioannidis JP, Boletis J, Bombardieri S, Cervera R, Dostal C, et al. EULAR recommendations for the management of systemic lupus erythematosus: report of a task force of the EULAR Standing Committee for international clinical studies including therapeutics. Ann Rheum Dis 2008;67:195–205

López-Hoyos M, et al. Clinical disease activity and titers of anti-dsDNA antibodies measured by an automated immunofluorescence assay in patients with systemic lupus erythematosus. Lupus. 2005;14(7):505-9.

Nasiri S, Karimifar M, Bonakdar ZS, Salesi M. Correlation of ESR, C3, C4, anti-DNA and lupus activity based on British Isles Lupus Assessment Group Index in patients of rheumatology clinic. Rheumatol Int. 2010;30(12):1605-9

Tozzoli R, Bizzaro N, Tonutti E, Villalta D, Bassetti D, Manoni F, Piazza A, Pradella M, Rizzotti P. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 2002;117(2):316-24.

Patient information\decision aids

Arthritis Research UK: Lupus (2016)

LUPUS UK: Diagnosis (2015)

Recommendation 1

Women can have routine cervical smears taken if they are due at the time that they are attending for other sexual health issues.

Evidence\guidance

Cancer Research UK

Marlow LAV, Chorley AJ, Haddrell J Eur J Cancer. Understanding the heterogeneity of cervical cancer screening non-participants: Data from a national sample of British women. 2017 Jul;80:30-38.

Cancer Research UK

NHS Choices: One in three women don’t attend cervical screening because of ’embarrassment’

NHS Digital. Cervical Screening Programme, England 2016-2017

Patient information\decision aids

NHS Choices. Cervical Screening

 

Recommendation 2

Women without medical problems can be routinely given a repeat 12-month prescription of oral contraception rather than 3 or 6-month supplies.

Evidence\guidance

Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-4):1–66.

Steenland MW, Rodriguez MI, Marchbanks PA, Curtis KM. How does the number of oral contraceptive pill packs dispensed or prescribed affect continuation and other measures of consistent and correct use? A systematic review. Contraception. 2013 May;87(5):605-10.

White KO, Westhoff C. The effect of pack supply on oral contraceptive pill continuation: a randomized controlled trial. Obstet Gynecol. 2011 Sep;118(3):615-22.

Foster DG, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol. 2006 Nov;108(5):1107-14.

Foster DG. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol. 2011 Mar;117(3):566-72

Combined hormonal contraception. Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Healthcare 2011.

 

Recommendation 3

Women requesting intrauterine contraception can attend for a one-stop consultation and insertion appointment provided they have access to high quality local guidance on the procedure and its risks and benefits e.g. online website resources including a check-list.

Evidence\guidance

Gunn C, Gebbie A, Cameron S. ‘One-stop’ visits for insertion of intrauterine contraception using online resources. J Fam Plann Reprod Health Care. 2015 Oct;41(4):300-2.

Stanek AM, Bednarek PH, Nichols MD, et al. Barriers associated with the failure to return for intrauterine device insertion following first-trimester abortion. Contraception. 2009 Mar;79(3):216-20.

Goodman S, Hendlish SK, Benedict C, et al. Increasing intrauterine contraception use by reducing barriers to post-abortal and interval insertion. Contraception. 2008 Aug;78(2):136-42.

Cook L1, Fleming C. What is the actual cost of providing the intrauterine system for contraception in a UK community sexual and reproductive health setting? J Fam Plann Reprod Health Care. 2014 Jan;40(1):46-53.

Recommendations 2016

royal-college-of-anaesthetists-logo
surgeons

1. Day surgery should be considered the default for many elective surgical procedures. Variation in the use of day surgery for these operations should be measured and this information should be available to patients.

Evidence/guidance

2. With the appropriate preoperative assessment and preparation elective surgical patients do not need to be admitted to hospital the day before their operation.

Evidence/guidance

3. Healthy patients having planned minor or intermediate surgery do not need routine preoperative tests. NICE guideline should be used (NG 45) to help determine which tests are appropriate.

Evidence/guidance

4. Patients choosing surgery who are at a high risk of dying after an elective surgical procedure (predicted 30-day mortality of greater than 1%) should be identified by their age, type of surgery and coexisting medical conditions. They should have a shared decision-making consultation to discuss their individual chance of benefit or harm and to identify their personal preference.

Shared decision aids to use with patients

Evidence/guidance

5. Patients should be helped to stop smoking, reduce alcohol consumption, improve fitness and nutrition and modify weight where possible. This should be in addition to active measures to optimise individual medical conditions before surgery.

Shared decision aid to use with patients

Evidence/guidance

royal-college-of-emergency-medicine-logo

1. Connecting an intoxicated (alcohol) patient up to a drip and providing intravenous fluids will not help them feel better or allow discharge from hospital any quicker.

Evidence/Guidance

 

2. Children with small fractures on one side of the wrist, ‘buckle fractures’ do not usually need a plaster cast. They can be treated with a removable splint and written information. There is usually no need to put a plaster cast on, or follow these children up in fracture clinic as they will get better just as quickly without this.

Evidence/Guidance

 

3. Small fractures of the base of the fifth metatarsal, a bone on the outside of the foot, do not usually need to put into a plaster cast as they will heal just as quickly in a removable boot.

Evidence/Guidance

4. Some injuries, such as hip and shoulder dislocations, can be treated with sedation in the emergency department rather than undergoing a general anaesthetic in the operating theatre.

 

5. Tap water is just as effective for cleaning wounds as sterile saline.

Evidence/Guidance

royal-college-of-general-practitioners-_-rcgp

1. When patients are particularly frail or in their last year of life, unless there is a clear preference otherwise by the patient or advocate, discuss with the patient and family/carers the option of decreasing the number of medicines to only those used for control of symptoms.

Evidence/guidance

2. Being alert to the possibility of dementia in patients at risk, with further assessment on an individual basis is good practice, but routinely screening for dementia using structured tools has not been recommended by the UK National Screening Council. It risks false positive diagnoses and has no proven benefit. 

Evidence/guidance

3. When considering risk modifying treatment in primary prevention, for example treatment for blood pressure, cholesterol or bone density, share the option to have treatment or not before prescribing. Decision aids exist to support this process for doctors and patients. 

Shared decision aids to use with patients

4. Treating Stage 1 (mild) hypertension in people without any other cardiovascular risk factors may have only small potential benefit for an individual. Consider total cardiovascular risk before initiating drug treatment.

Shared decision aid to use with patients

Evidence/guidance

5. Ultrasound has very limited value in making a diagnosis of polycystic ovarian syndrome:

Polycystic ovaries do not have to be present to make the diagnosis, and the finding of polycystic ovaries does not alone establish the diagnosis.

Symptoms and a hormonal profile* will usually be enough to establish a diagnosis.
*NICE recommends: Testosterone/SHBG/LH/FSH/Prolactin/TSH

Evidence/guidance

6. Once a patient being treated with a statin has reached their target level of cholesterol, there is no need to keep measuring it.

The only liver function test which needs monitoring on statins is the ALT or AST at 3 months and 1 year. If it is normal at 1 year, it does not require ongoing monitoring.

Shared decision aid to use with patients

Evidence/guidance

the-royal-college-of-obstetricians-and-gynaecologists

1. Medicines like aspirin, heparin or progesterone should not be used in a bid to maintaining a pregnancy in a woman who has had unexplained and recurrent miscarriages.

Evidence/guidance

2. Aspirin is not recommended as a way of reducing the chances of pregnant women developing blood clots (thromboprophylaxis).

 

3. Unless the mother has diabetes, ultrasound scans should not be used to check if a baby is bigger than normal for its gestational age (macrosomia).

Evidence/guidance

4. A simple ovarian cyst less than 5cm in diameter in a woman who has not gone through the menopause does not need to be followed up; nor is there any need for a blood test to check levels of the protein CA-125.

Evidence/guidance

5. Electronic monitoring of a baby’s heart should not be offered routinely during labour unless the mother is at a higher risk of complications than normal.

Evidence/guidance

royal-college-of-ophthalmologists

1. Do not review uncomplicated cataract cases on day one post-op

Shared decision making aid to use with patients

Evidence/guidance


2. If a child is under 12 months old and has a blocked nasolacrimal duct, do not try to unblock.


3. Do not carry out laser retinopexy for asymptomatic lattice degeneration/atrophic retinal holes.

Evidence/guidance


4. If conjunctivitis is thought to be viral, there is no need to send samples to the laboratory or to treat with antibiotics.

Evidence/guidance


5. The initial episode of unilateral anterior uveitis does not usually need further investigation

royal-college-of-pediatrics-and-child-health

1. Helmet therapy is not effective in the treatment of positional plagiocephaly in children, other treatment options should be considered and discussed with your patient.

 

2. Polyethylene Glycol should be used in preference to Lactulose in the treatment of chronic constipation in children. 

Evidence/guidance

3. Buccal midazolam or lorazepam should be in the treatment of prolonged seizures in young people and children, as these are the most effective treatments, in preference to rectal and intravenous diazepam.

Evidence/guidance

4. Bronchodilators should not be used in the treatment of mild or moderate presentations of acute bronchiolitis in children without any underlying conditions.

Evidence/guidance

royal-college-of-pathologists

1. Unless a patient is at increased risk of prostate cancer because of race or family history, PSA testing does not necessarily lead to a longer life.

Shared decision making aid to use with patients

Evidence/guidance

 

2. Calcium testing is used when there are symptoms of kidney stones, bone disease or nerve-related disorders; but it is not necessary to test less than three months after the previous test except in acute conditions, during major surgery or in critically ill patients when tests should not be made more often than every 48 hours.

 

3. Only consider transfusing platelets for patients with chemotherapy-induced thrombocytopenia where the platelet count is < 10 x 109/L except when the patient has clinical significant bleeding or will be undergoing a procedure with a high risk of bleeding.

 

4. Use restrictive thresholds for patients needing red cell transfusions and give only one unit at a time except when the patient has active bleeding.

Evidence/guidance

5. Only transfuse O Rh D negative red cells to O Rh D negative patients and in emergencies for females of childbearing potential with unknown blood group.

royal-college-of-psychiatrists

1. In the treatment of depression, if an antidepressant has been prescribed within the therapeutic range for two months with little or no response, it should be reviewed and changed or another medication added, which will work in parallel with the initial drug that was prescribed.
Shared decision making aid to use with patients

2. When adults with schizophrenia are introduced to treatment with long-term anti-psychotic medication, the benefits and harm of taking oral medication compared to long-acting depot injections should be discussed with all relevant parties.

Evidence/guidance

3. Women who are planning a pregnancy or may be pregnant should not be prescribed valproate for mental disorders except where there is treatment resistance and/or very high risk clinical situations.

Evidence/guidance

4. When a diagnosis of psychosis is made, CT or MRI head scans should only be used for specific indications where there are signs or symptoms suggestive of neurological problems.

Evidence/guidance

rcr

1. In advanced cancer, the use of chemotherapy that is unlikely to be beneficial and may cause harm should be minimised

 

2. In cases of a minor head injury, imaging is not likely to be useful

Evidence/guidance

 

3. Back pain which is uncomplicated, that is not associated with ‘red flags’ or radicolupathy usually does not require imaging

Evidence/guidance

 

4. Where there is suspicion of a pulmonary embolus, imaging should be guided by clinical scoring systems.

Evidence/guidance

 

5. After treatment for cancer, the use of routine scanning should only be used where this is beneficial to the patient.

faculty-of-intensive-care-medicine

1. Life support for patients at high risk of death or severely impaired functional recovery should not be offered. A discussion with patients and their families should focus on the goals of comfort care.

Shared decision aids to use with patients

Evidence/guidance

  • Choosing Wisely US: Critical Care Societies Collaborative – Critical Care

2. Tests and investigations should only be done in response to answering a specific question rather than routinely.

Evidence/guidance

3. Blood transfusions should only be given when the haemoglobin is less than 70 g/L. Blood transfusions may occur above this level where the patient is haemodynamically unstable or actively bleeding.

Evidence/guidance

4. Patients who are mechanically ventilated may not need to be deeply sedated, and where possible daily trials to lighten sedation should be done.

Evidence/guidance

faculty-of-sexual-and-reproductive-health

1. If a woman has abnormal vaginal discharge that is likely to be caused by thrush (also known as candida) or Bacterial vaginosis (BV) and she is at low risk of having a sexually transmitted infection, a vaginal swab is not usually necessary.

Evidence/guidance

2. A woman who is thought to be having recurrent thrush should have an examination of the skin around her vagina to exclude other conditions such as lack of vaginal estrogen, allergies or other skin conditions rather than be given another course of thrush treatment.

Evidence/guidance

3. If a woman over the age of 45 years with typical symptoms of menopause, such as hot flushes and sweats and if her periods have become irregular, much lighter or have stopped, further bloods tests to check hormone levels are not usually necessary.

Evidence/guidance

4. Women who have a copper intrauterine device (IUD) or the hormonal intrauterine system (IUS) fitted only need to seek professional advice when they cannot feel the threads which hang from the device. Women should be taught how to feel for these threads.