GuidelinesinPractice.co.uk
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October 2018 | Volume 21 | Issue 10
Hot topic HIV
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Implementing guidelines Stable angina
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Working smarter Bid writing
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Top tips Community-acquired pneumonia
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View from the ground Being an early career GP
HIV: from fatal condition to chronic disease turn to p.8
25µg/50µg 25µg/125µg
All the strengths*
25µg/250µg
All the indications*
Now that’s ’’s a step in the right direction *Compared to the brand originator Combisal (Salmeterol/Fluticasone) Prescribing Information (please refer to the full SmPC before prescribing) Indications: Regular treatment of asthma where use of combination product (long-acting β2 agonist and inhaled corticosteroid) is appropriate: patients not adequately controlled with inhaled corticosteroids and ‘as needed’ inhaled short-acting β2 agonist or patients already adequately controlled on both inhaled corticosteroid and long-acting β2 agonist Available strengths: 25µg/50µg; 25µg/125µg & 25µg/250µg salmeterol/ fluticasone per metered dose pressurised inhalation, suspension. Dosage and method of use: Inhalation use. Adults and adolescents 12 years and older: two inhalations 25µg/250 µg twice daily. Children 4 years and older: two inhalations 25 µg/50 µg twice daily. Titrate to lowest dose at which effective control of symptoms is maintained and if long-term control maintained at lowest dose, consider testing inhaled corticosteroid alone or combination once daily. Combisal 25 µg /50 µg not appropriate for adults and children with severe asthma. Maximum licensed dose of fluticasone propionate in children is 100 µg twice daily. No data in children under 4 years. AeroChamber Plus® spacer device can be used. This may increase drug delivery to lungs with increase in risk of systemic adverse effects. Advise patients to rinse mouth out with water and spit out, and/or brush teeth after each dose of medicine to minimize risk of oropharyngeal candidiasis and hoarseness. Contraindications: Hyp ersensitivit y to ac tive substance or excipients. Special
warnings and precautions for use: Do not use to treat acute asthma for which fast- and short-acting bronchodilator required or initiate Combisal during an exacerbation, or if asthma is significantly worsening or acutely deteriorating. Use with caution in patients with active or quiescent pulmonary tuberculosis and fungal, viral or other infections of the airway; severe cardiovascular disorders or heart rhythm abnormalities, diabetes mellitus, thyrotoxicosis, uncorrected hypokalaemia or predisposed to low levels of serum potassium. Discontinue if paradoxical bronchospasm occurs. Prolonged use of high doses of ICS may result in adrenal suppression and acute adrenal crisis. Consider additional systemic corticosteroid cover during periods of stress or elective surgery. Monitor patients transferring from oral steroids for impaired adrenal reserve. Safety and efficacy in COPD not established. Patients of black African or Afro-Caribbean ancestry should seek medical advice if asthma uncontrolled or worsens on Combisal. If prolonged treatment in children, monitor height. Interactions: The following combinations should be avoided: Ritonavir or other potent CYP3A inhibitors; ketoconazole or other potent CYP3A4 inhibitors; non- selective and selective β blockers; xanthine derivatives, steroids and diuretics in acute severe asthma. Other β adrenergic containing drugs can have an additive effect. Pregnancy & Lactation: Administer only if expected benefit to mother is greater than any possible risk to fetus. Not to be used during breastfeeding. Side effects: For full list of side effects consult SmPC. ‘Very Common’ ‘Common’ and ‘Serious’ side effects included in prescribing information. Very common (≥1/10) side effects: headache, nasopharyngitis. Common (≥1/100 to <1/10) side
1010422403 v 2.0 September 2018
And valuable savings*
Salmeterol/Fluticasone Meets the ups and downs of cost-effective asthma management effects: candidiasis of mouth and throat, pneumonia, bronchitis, hypokalaemia, throat irritation, hoarseness/dysphonia, sinusitis, contusions, muscle cramps, traumatic fractures, arthralgia, myalgia. Uncommon Serious (≥1/1000 to <1/100) side effects: cutaneous hypersensitivity reactions, dyspnoea, hyperglycaemia, anxiety, sleep disorders, tremor, cataract, palpitations, tachycardia, atrial fibrillation, angina pectoris. Rare serious (≥1/10,000 to <1/1000) side effects: oesophageal candidiasis, facial and oropharyngeal angioedema, bronchospasm, anaphylactic reactions including anaphylactic shock, Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decreased bone mineral density, behavioural changes (psychomotor hyperactivity and irritability predominantly in children), glaucoma, cardiac arrhythmias, paradoxical bronchospasm. Serious side effects (unknown frequency): depression, aggression (predominantly in children). MA number: PL 36532/0001-0003. Cost: £13.50 for 25/50µg, £17.59 for 25/125µg, £29.89 for 25/250µg. MAH: Genetic S.p.A., Via G. Della Monica 26, 84083 Castel San Giorgio (SA), Italy. Distributed in the UK by: Aspire Pharma Ltd, Unit 4, Rotherbrook Court, Bedford Road, Petersfield, Hampshire, GU32 3QG. Legal category: POM. Date reviewed: September 2018. Version number: 1010422348 v 3.0
Adverse events should be reported. Reporting forms and information can be found at www.mhra. gov.uk/yellowcard. Adverse events should also be reported to Aspire Pharma Ltd on 01730 231148.
Editorial 3
HIV: where are we now?
News 7
Guideline on chronic heart failure published by NICE
7
SIGN updates guideline on cardiac arrhythmias
Hot topic 8
HIV: from fatal condition to chronic disease
Dr Toni Hazell presents an overview of HIV prevalence, testing, treatments, and other issues relevant to primary care Test and reflect multiple-choice questions on this article can be found on p.22
Contents
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Working smarter 37
Bid writing in general practice: how to win a losing battle
Dr Satpal Shekhawat explores the business development challenges faced by primary care clinicians, and the steps necessary to overcome them
Top tips 40
Community-acquired pneumonia
Dr Sinan Eccles offers top tips for the assessment and management of adults with community-acquired pneumonia in primary care
View from the ground 44
Being an early career GP by Dr Caroline Begg
Implementing guidelines 25
Stable angina: how does the SIGN guideline compare with NICE?
Dr Alan Begg compares SIGN and NICE recommendations on the diagnosis, assessment, and treatment of stable angina
GuidelinesinPractice.co.uk
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Contents
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Key
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The presence of the Guidelines in Practice independent content (IC) logo indicates that an article has been developed solely between the expert authors and Guidelines in Practice. If an item has been developed in partnership with a third party, the IC logo will be absent and the involvement of the third party will be explained in a disclaimer at the outset.
independent content
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Guidelines published by NICE
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Guidelines published by the Department of Health
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Guidelines published by the Scottish Intercollegiate Guidelines Network
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National guidelines produced by independent professional bodies
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Working party guidelines
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Other content
Front cover image: Colour enhanced transmission electron microscope of HIV particles. The virus infects T-4 white blood cells, making them produce more virus particles. These erupt from the cell and infect other cells. The process kills the white blood cells. © David M. Phillips/Science Photo Library
Guidelines in Practice editorial advisory consultants Cardiovascular and diabetes
Dr Alan Begg: GP, Montrose; GPwSI in cardiovascular disease; trustee of Chest, Heart, and Stroke Scotland (CHSS); and trustee of Scottish Heart and Arterial Risk Prevention Group (SHARP)
Care Quality Commission
Professor Nigel Sparrow OBE: Senior National GP Advisor and Responsible Officer, CQC
Commissioning
Dr Junaid Bajwa: GP, Greenwich; board member for Greenwich CCG; council member for the London Clinical Senate Dr David Jenner: part-time principal GP, Cullompton, Devon
CPD and revalidation
Dr Honor Merriman: GP and Senior Appraiser, Oxfordshire
Diabetes
Dr Kevin Fernando: GP partner, North Berwick; committee member of the Primary Care Diabetes Society; GPwSI in Diabetes and Medical Education
General practice
Dr George Kassianos: GP and CPD tutor, Berkshire Dr Joe McGilligan: GP partner, Surrey; LGA health and wellbeing champion; executive board member of NAPC; former Chair of East Surrey CCG
Information technology
Dr John Lockley: GP, Bedfordshire; Clinical Lead for Informatics, Bedfordshire CCG; LMC member
Medicolegal issues
Dr Maria Dyban: GP, Cardiff; Vice Chair of the RCGP South East Wales Faculty
Mental health
Dr Zoe Neill: portfolio GP and Mental Health Lead at Leeds North CCG
Musculoskeletal and joints Dr Pam Brown: GP, Swansea; member of the authourship group that produced the BOA-BGS Blue Book Oncology
Dr Nicola Harker: GP, North Somerset; Cancer Lead for North Somerset CCG; Macmillan GP Advisor
Paediatrics
Dr Jennifer Parkhouse: GP, Harrogate, GPwSI in Paediatrics
Skin
Dr Rebecca Mawson: GP, Sheffield; NIHR In-Practice Training Fellow, Sheffield University
Urology
Dr Jon Rees: GP, North Somerset; Chair of the Primary Care Urology Society
Value-based prescribing
Omar Ali: member of the NICE Adoption & Impact Reference Panel; visiting lecturer on value-based pricing and innovative contracting, University of Portsmouth
Women’s health
Dr Anne Connolly: GP, Bradford; GPwSI in Gynaecology; Clinical Lead for Maternity, Women’s Health and Sexual Health, Bradford City, Bradford Districts, and AWC CCGs; Chair of the Primary Care Women’s Health Forum; FSRH Vice President, Membership
Editorial Director: Julia Van Danzig. Editor: Gemma Lambert. Digital Editor: Thomas Moore. Editorial Assistant: Alistair Scott. Design: Stuart Cruickshank, Jenna Noah. Production and Print Administration: Vicky Toleman. Subscriptions: Glynis Sutton. Sales team: Sophie Boothe, Jamie Daden, Rob Davey, Matthew Eisenstadt, Carol Hayes, Michael Kirby, Natasha Staines. Publisher: Ivor Eisenstadt. MGP Ltd, MGP House, East Street, Chesham HP5 1DG. Tel: 01442 876100. Email:
[email protected]. Guidelines in Practice is sent monthly free of charge to relevant GPs, board members of primary care organisations, pharmaceutical and medical advisers, public health directors, clinical directors, members of audit groups, and those with an interest in the development and implementation of primary and shared care guidelines who meet the publisher’s criteria. To request regular copies, please write to Vicky Toleman at the above address. Guidelines in Practice is also available to others at an annual UK subscription (12 issues) of £90. Subscriptions to Guidelines in Practice for delivery outside the UK will be subject to an additional charge to cover postage and packing. Order from the above address or online at www.mgp.co.uk/shop. All subscriptions payable to MGP Ltd. Printed and mailed by Warners (Midlands) plc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including photocopying, recording, or any information storage or retrieval system without the express prior written consent of the publisher, unless for the purposes of reference and comment. What information we have about you and why: The law states that we need a legal reason for processing your data. Our legitimate interest is that we send you Guidelines in Practice free of charge to help and assist you with your work and professional development. We hold your name, work address, and job role so that we can send you copies of Guidelines in Practice. We will hold this information until you inform us that you no longer want us to, or you no longer wish to receive copies of Guidelines in Practice. If you have any complaints or need to contact us about your information, please email:
[email protected] You have the following rights over your personal information: Right of access—you have the right to access information that we hold about you. Right to rectification—you have the right to rectify or complete any incorrect or incomplete information that we hold about you. Right to erasure—if we do not have a valid reason to hold or process your information, you can request that we erase information that we hold about you. Right to restrict processing—if you believe that we do not have a valid reason to hold your information, you have the right to restrict the processing of your information until you allow us to, or we can prove that we do have a valid reason. Right to object—you have the right to object to processing based on legitimate interests. We will stop processing the personal data, unless we can demonstrate compelling legitimate grounds for the processing. © MGP Ltd 2018
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ISSN: 1464-64200
HIV: where are we now? Improvements in the treatments offered to people with HIV mean that it is now manageable as a chronic condition. HIV is mostly managed in secondary care but there are some aspects that GPs need to be aware of, which Dr Toni Hazell discusses in the article on pp.8–20. You can also test your updated knowledge using the MCQs on p.22 after reading the article. Early diagnosis of HIV vastly improves prognosis, so it is important that GPs in high-prevalence areas take opportunities to offer HIV testing. Tests should be offered to all new patients at registration, to people having blood tests for another reason, and to those who have symptoms consistent with HIV infection. Dr Hazell also highlights the issues surrounding contraception and fertility. HIV is generally not a contraindication to contraception; however, drug interactions reduce the number of available options in women on enzyme-inducing antiretroviral therapy. Discordant couples who are trying to conceive should be informed about conception strategies that reduce the risk of HIV transmission.
Chest pain is a common presentation in primary care and its diagnosis can be difficult. There are certain typical characteristics of angina pain that can help to elucidate the diagnosis. On pp.25–36, Dr Begg describes the clinical characteristics of angina, the risk factors that increase the likelihood of angina, and the investigations that can be used to assess patients if there is diagnostic uncertainty. The article includes useful algorithms showing the management options for patients with suspected or confirmed angina, as well as tables comparing the NICE and SIGN recommendations on medical therapy for symptom relief, and drugs used to prevent new vascular events. This article also includes a new regular feature: implementation actions for clinical pharmacists, which provide advice on how clinical pharmacists can support the implementation of guidance in general practice.
Confidentiality and legal issues are also highlighted because GPs may need to breach confidentiality if they become aware that a patient with HIV has not informed their partner of their HIV-positive status.
Since CCGs came into being, it has become more necessary for GPs to get involved with business development aspects of primary care, such as commissioning, bid writing, and procuring services. General practice is very much patient-centred, so primary care clinicians will have a good understanding of their patients’ needs, and this knowledge is invaluable when designing and developing effective clinical services.
Earlier this year, the Scottish Intercollegiate Guidelines Network (SIGN) updated its guidance on stable angina. In this issue, Dr Alan Begg compares the recommendations made by SIGN with those made in the NICE guideline, which was last updated in 2016.
However, when bidding for contracts, GPs are often competing with private providers (who have dedicated resources for writing bids), and presenting information to non-clinical decision makers (who award contracts based on whether a proposal meets a specific set of criteria).
Editorial
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
On pp.37–39, Dr Satpal Shekhawat discusses why bid writing is challenging for GPs, and provides useful tips for writing a successful bid, including developing a shared vision, defining the workforce strategy, and keeping patients at the centre of any new service design. Also in this month’s issue is a top tips article on the primary care assessment and management of adults with community-acquired pneumonia (see pp.40–43). The challenge lies in identifying which patients with a lower respiratory tract infection have pneumonia, and which of those with pneumonia require admission to hospital. Dr Sinan Eccles provides advice on diagnosing pneumonia based on examination findings and symptoms, differentiating pneumonia from other respiratory infections, and using CRB-65 to determine the need for hospital assessment. The article includes a useful algorithm, which summarises when point-of-care CRP testing should be used and when to prescribe antibiotics. Dr Eccles explains which antibiotics should be used to treat pneumonia, and the expected timeframe for resolution of pneumonia symptoms. This month, our View from the ground is from Dr Caroline Begg, who describes her journey through GP training, how it influenced her career decisions, and how she feels about being an early career GP at the start of a lifelong journey—see p.44. Gemma Lambert, Editor
[email protected] @Gemma_GinP
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AVEENO One thing they’ll wear for life.
References: 1. Data on File, 2017. Health economic study comparing primary care costs associated with prescribing Aveeno first line vs switching in eczema patients.
®
Prescribing AVEENO® first for eczema patients is proven to reduce overall costs of care through fewer medical visits and reduced prescriptions for antimicrobials and potent corticosteroids.1 Set them up for life with AVEENO®
Date of preparation: August 2018
Job code: UK/AV/18-12164
Fostair® NEXThaler lets your patients know they’ve taken their medication1,2 • The audible ‘click’ reassures patients that the dose has been taken1,2 • The dose counter only counts successful individual inhalations, so each dose registered equals a dose taken1,2 Fostair® NEXThaler is indicated for maintenance therapy in adult asthma patients ≥18 years. Full indication can be found within the Prescribing Information.
FOSTAIR® NEXThaler IT’S GOOD TO KNOW
Visit www.ChiesiRespiratory.co.uk/goodtoknow to find out more Fostair 100/6 and 200/6 Prescribing Information Please refer to the full Summary of Product Characteristics before prescribing. Presentation: Each Fostair pressurised metered dose inhaler (pMDI) 100/6 dose contains 100 micrograms (mcg) of beclometasone dipropionate (BDP) and 6mcg of formoterol fumarate dihydrate (formoterol). Each Fostair pMDI 200/6 dose contains 200mcg of BDP and 6mcg of formoterol. Each Fostair NEXThaler 100/6 dry powder inhaler (DPI) dose contains 100mcg of BDP anhydrous and 6mcg of formoterol. Each Fostair NEXThaler 200/6 DPI dose contains 200mcg of BDP anhydrous and 6mcg of formoterol. Indications: Asthma: Regular treatment of asthma where use of an inhaled corticosteroid/ long-acting beta2-agonist (ICS/LABA) combination is appropriate: patients not adequately controlled on ICS and as needed short-acting beta2-agonist, or patients already adequately controlled on both ICS and LABA. COPD (Fostair 100/6 only): Symptomatic treatment of patients with severe COPD (FEV1 <50% predicted normal) and a history of repeated exacerbations, who have significant symptoms despite regular therapy with long-acting bronchodilators. Dosage and administration: For inhalation in adult patients (≥18 years). Asthma: Maintenance And Reliever Therapy (Fostair pMDI 100/6 only) taken as a regular maintenance treatment and as needed in response to asthma symptoms: 1 inhalation twice daily plus 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation is recommended. The maximum daily dose is 8 inhalations. Fostair pMDI 100/6 may also be used as maintenance therapy (with a separate short-acting bronchodilator as needed). Fostair pMDI 200/6 and NEXThaler (100/6 and 200/6) should be used as maintenance therapy only. Maintenance therapy: Fostair pMDI and NEXThaler 100/6: 1–2 inhalations twice daily. Fostair pMDI and NEXThaler 200/6: 2 inhalations twice daily. The maximum daily dose is 4 inhalations. Patients should receive the lowest dose that effectively controls their symptoms. COPD (Fostair 100/6 only): 2 inhalations twice daily. Fostair pMDI can be used with the AeroChamber Plus® spacer device. BDP in Fostair is characterised by an extrafine particle size distribution which results in a more potent effect than formulations of BDP with a non-extrafine particle size distribution (100mcg of BDP extrafine in Fostair are equivalent to 250mcg of BDP in a non-extrafine formulation). When switching patients from previous treatments, it should be considered that the recommended total daily dose of BDP for Fostair is lower than that for non-extrafine BDP containing products and should be adjusted to the needs of the individual patient. However, patients who are transferred between Fostair NEXThaler and Fostair pMDI do not need dose adjustment. Contraindications: Hypersensitivity to the active substances or to any of the excipients. Warnings and precautions: Use with caution in patients with cardiac
arrhythmias, aortic stenosis, hypertrophic obstructive cardiomyopathy, ischaemic heart disease, severe heart failure, congestive heart failure, occlusive vascular diseases, arterial hypertension, severe arterial hypertension, aneurysm, thyrotoxicosis, diabetes mellitus, phaeochromocytoma and untreated hypokalaemia. Caution should also be used when treating patients with known or suspected prolongation of the QTc interval (QTc > 0.44 seconds). Formoterol itself may induce QTc prolongation. Potentially serious hypokalaemia may result from beta2-agonist therapy and may also be potentiated by concomitant treatments (e.g. xanthine derivatives, steroids and diuretics). Formoterol may cause a rise in blood glucose levels. Fostair should not be administered for at least 12 hours before the start of anaesthesia, if halogenated anaesthetics are planned as there is risk of arrhythmias. Use with caution in patients with pulmonary tuberculosis or fungal/viral airway infections. Increase in pneumonia and pneumonia hospitalisation in COPD patients receiving ICS. Clinical features of pneumonia may overlap with symptoms of COPD exacerbations. Fostair treatment should not be stopped abruptly. Treatment should not be initiated during exacerbations or acutely deteriorating asthma. Fostair treatment should be discontinued immediately if the patient experiences a paradoxical bronchospasm. Fostair is not intended for initial management of asthma. Systemic effects of ICS may occur, particularly at high doses for long periods, but are less likely than with oral steroids. These include Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression and aggression. Consider referral of patients reporting blurred vision or visual disturbances to an ophthalmologist as causes may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy. Prolonged treatment with high doses of ICS may result in adrenal suppression and acute adrenal crisis. Lactose contains small amounts of milk proteins, which may cause allergic reactions. Interactions: Possibility of systemic effects with concomitant use of strong CYP3A inhibitors (e.g. ritonavir, cobicistat) cannot be excluded and therefore caution and appropriate monitoring is advised. Beta-blockers should be avoided in asthma patients. Concomitant administration of other beta-adrenergic drugs may have potentially additive effects. Concomitant treatment with quinidine, disopyramide, procainamide, phenothiazines, antihistamines, monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants can prolong the QTc interval and increase the risk of ventricular arrhythmias. L-dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance towards beta2sympathomimetics. Hypertensive reactions may occur following coadministration with MAOIs including agents with similar properties (e.g. furazolidone, procarbazine). Concomitant treatment with xanthine derivatives,
References: 1. Fostair® NEXThaler 100/6 Patient Information Leaflet. Chiesi Limited. 2. Fostair® NEXThaler 200/6 Patient Information Leaflet. Chiesi Limited.
steroids or diuretics may potentiate a possible hypokalaemic effect of beta2agonists. Hypokalaemia may increase the likelihood of arrhythmias in patients receiving digitalis glycosides. Presence of ethanol may cause potential interaction in sensitive patients taking metronidazole or disulfram. Fertility, pregnancy and lactation: Fostair should only be used during pregnancy or lactation if the expected benefits outweigh the potential risks. Effects on driving and operating machinery: Fostair is unlikely to have any effect on the ability to drive and use machines. Side effects: Common: pneumonia (in COPD patients), pharyngitis, oral candidiasis, headache, dysphonia, tremor. Uncommon: influenza, oral fungal infection, oropharyngeal candidiasis, nasopharyngitis, oesophageal candidiasis, vulvovaginal candidiasis, gastroenteritis, sinusitis, rhinitis, granulocytopenia, allergic dermatitis, hypokalaemia, hyperglycaemia, hypertriglyceridaemia, restlessness, dizziness, otosalpingitis, palpitations, prolongation of QTc interval, ECG change, tachycardia, tachyarrhythmia, atrial fibrillation, sinus bradycardia, angina pectoris, myocardial ischaemia, blood pressure increased, hyperaemia, flushing, cough, productive cough, throat irritation, asthmatic crisis, exacerbation of asthma, dyspnoea, pharyngeal erythema, diarrhoea, dry mouth, dyspepsia, dysphagia, burning sensation of the lips, nausea, dysgeusia, pruritus, rash, hyperhidrosis, urticaria, muscle spasms, myalgia, C-reactive protein increased, platelet count increased, free fatty acids increased, blood insulin increased, blood ketone body increased, blood cortisol decrease, oropharyngeal pain, fatigue, irritability, cortisol free urine decreased, blood potassium increased, blood glucose increased, ECG poor r-wave progression. Rare: ventricular extrasystoles, paradoxical bronchospasm, angioedema, nephritis, blood pressure decreased. Very rare: thrombocytopenia, hypersensitivity reactions, including erythema, lips, face, eyes and pharyngeal oedema, adrenal suppression, glaucoma, cataract, peripheral oedema, bone density decreased. Unknown frequency: psychomotor hyperactivity, sleep disorders, anxiety, depression, aggression, behavioural changes, blurred vision. (Refer to SPC for full list of side effects). Legal category: POM Packs and price: £29.32 1x120 actuations Marketing authorisation (MA) No(s): PL 08829/0156, PL 08829/0175, PL 08829/0173, PL 08829/0174 MA holder: Chiesi Ltd, 333 Styal Road, Manchester, M22 5LG. Date of preparation: Apr 2018. AeroChamber Plus® is a registered trademark of Trudell Medical International.
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Chiesi Ltd on 0800 0092329 (GB), 1800 817459 (IE) or
[email protected]. CHNEX20180633. Apr 18.
News
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Guideline on chronic heart failure published by NICE NICE has published NICE Guideline (NG) 106 on Chronic heart failure in adults: diagnosis and management.
improvements in care have contributed towards increased survival rates in ischaemic heart disease.
being offered cardiac rehabilitation would also improve hospitalisation and mortality rates.
Around 920,000 people in the UK have been diagnosed with heart failure, and the prevalence is rising as a result of an ageing population and increasing rates of obesity.
There is still room for improvement in the prescription of angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and aldosterone agonists which can all, with optimal usage, reduce hospitalisations and deaths from heart failure. A higher proportion of patients
The recommendations made by NG106 include advice on: a diagnosis, treatment, and management of heart failure a monitoring treatment a cardiac rehabilitation a palliative care. www.nice.org.uk/ng106
However, treatment for heart failure has become more effective, and
SIGN updates guideline on cardiac arrhythmias The Scottish Intercollegiate Guidelines Network (SIGN) has published SIGN guideline 152 on Cardiac arrhythmias in coronary heart disease.
are also affected by atrial fibrillation (AF) which is also associated with considerable morbidity and an increased risk of stroke and death.
There are many cardiac arrhythmias associated with coronary heart disease (CHD). Acute coronary syndrome (ACS) often accompanies arrhythmia as well, with ventricular tachyarrhythmias being a particularly important cause of cardiac arrest. An increasing number of patients with chronic CHD
The evidence-based recommendations made by SIGN 152 cover: a management of cardiac arrest and arrhythmias associated with ACS, chronic CHD, and cardiac surgery a rhythm management of AF a psychosocial issues. www.sign.ac.uk/assets/sign152.pdf
Guidance on reflective practice published The Academy of Medical Royal Colleges, Conference of Postgraduate Medical Deans, General Medical Council, and Medical Schools Council have published The reflective practitioner—guidance for doctors and medical students. The short guide is intended to support medical students, doctors in training,
and doctors who are engaging in revalidation with advice on how to reflect as part of their practice, covering: a key points on being a reflective practitioner a demonstrating reflection a disclosure of reflective notes a references and further reading. bit.ly/2xWF0SD
News in brief NHS England will provide £10 million to general practice in order to support the delivery of extended hours, out of hours, and unscheduled care sessions over the winter. The funds, provided as part of the Winter Indemnity Scheme, will be used to cover the costs of professional indemnity for extra services to allow GPs to work extra sessions without incurring costs to themselves. The scheme will run from 1 October 2018 to 31 March 2019.
bit.ly/2QlGWux NICE has published NICE Guideline (NG) 108 on Decision-making and mental capacity, covering decision-making for people 16 years of age and older who may lack the capacity to make their own decisions now or in the future. The guideline recommendations are designed to keep patients at the centre of the decision-making process when they lack the mental capacity to make certain decisions.
www.nice.org.uk/ng108
GuidelinesinPractice.co.uk
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Infection Hot topic
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
i
independent content
HIV: from fatal condition to chronic disease Dr Toni Hazell presents an overview of HIV prevalence, testing, treatments, and other issues relevant to primary care
H
uman immunodeficiency virus (HIV) has a fascinating history—the condition used to be a death sentence but is now manageable as a chronic disease. While the prescribing and monitoring of antiretrovirals remains in secondary care, there are some aspects of HIV that GPs need to be aware of, which this article aims to cover. Note: Some of the treatments discussed in this article currently (October 2018) do not have UK marketing authorisation for the indications mentioned. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s guidance on Good practice in prescribing and managing medicines and devices1 for further information.
Prevalence and testing Public Health England (PHE) estimates that there are around 101,200 people living with HIV in the UK, 13% of whom are undiagnosed. 2
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GuidelinesinPractice.co.uk
Read this article to learn more about: a HIV
prevalence, testing, diagnosis, and treatment
a contraception,
fertility treatment, cervical screening, and
breastfeeding a pre-exposure
prophylaxis (PrEP).
Read this article online at: GinP.co.uk/oct18-hiv Test and reflect multiple-choice questions on this article are available on p.22 and online at: GinP.co.uk/mcq-hiv
Those diagnosed late (with a CD4 count of less than 350 cells/mm 3) are 10 times more likely to die within a year of diagnosis than those diagnosed earlier, 3 so one of the most
… GPs in areas with high or extremely high prevalence of HIV [are advised to] offer an HIV test to all new patients
useful things GPs can do in primary care is to increase the number of HIV tests requested. There is no need for lengthy pre-test counselling; the main issues that need be covered are the benefits of an HIV test and how the patient is going to get the result. Patients should also be made aware of the window period, that is, the concept that an HIV test may not be positive for 1–3 months after HIV has been transmitted.4,5 NICE and PHE advise that GPs in areas with high or extremely high prevalence of HIV (more than two per 1000 patients aged 15–59) offer an HIV test to all new patients. In some areas this is funded as a local enhanced service. Tests should also be offered in these areas to people having a blood
test for another reason, who have not had an HIV test in the last year. If the area has an extremely high prevalence (more than five per 1000 patients aged 15–59 years), practitioners should consider offering an HIV test at every consultation, whether bloods are being taken for another reason or not. Prevalence in England is outlined in Figure 1; the whole of London is a high-prevalence area and most of central London is an area of extremely high prevalence. Testing should also be offered to those in the high-risk groups listed in Box 1. Global adult HIV prevalence is illustrated in Figure 2.
Figure 1: Diagnosed HIV prevalence (per 1000 population aged 15–59 years): England, 20152
Hot topic Infection
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Symptoms and incidental findings Practitioners should also test people who have symptoms that are consistent with HIV.4 The British HIV Association (BHIVA) has a list of conditions that should prompt an HIV test; this is shown in Table 1 and includes common presentations to general practice (such as dementia, chronic diarrhoea, and weight loss) as well as incidental findings such as leucopenia and neutropenia.5 Over half of all patients with HIV will have seroconversion symptoms within 2–4 weeks of infection but making the diagnosis at this point is not easy in general practice.7,8 Symptoms include maculopapular rash, fever, sore throat, headache, malaise, lymphadenopathy, joint or muscle pain, mouth ulcers, and diarrhoea—all very common in primary care.8 One small study7 showed that a fever and typical rash was the strongest predictor for HIV seroconversion, so it is worth practitioners being alert to this combination as well as being aware of other symptoms. In a possible seroconversion situation, it is important that patients understand the risk of a false negative test soon after infection. Most modern tests will be positive before the traditional 3-month window period, but it is worth re-testing at 3 months to be certain of not missing a diagnosis.
Kirwan P, Chau C, Brown A et al. Public Health England. HIV in the UK—2016 report. Public Health England, 2016. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/602942/HIV_in_the_UK_report.pdf Reproduced under the terms of the Open Government Licence v3.0 (www.nationalarchives.gov.uk/doc/open-government-licence/version/3/)
Antiretroviral therapy
Contraception
All patients with HIV should be offered antiretroviral therapy (ART) from diagnosis, a change to previous practice where ART was only used below a certain CD4 count.9 Practitioners are therefore likely to see more patients on ART, with the potential for drug interactions.
Regarding contraception, HIV itself is generally not a contraindication to any specific methods. The 2016 UK Medical Eligibility Criteria for contraceptive use11 says only that intrauterine devices and systems are relatively contraindicated, but that the risks are likely to outweigh the benefits only when the CD4 count is less than 200 cells/mm 3. The main problem with prescribing contraception is that many types of ART are enzyme-inducing and will therefore significantly reduce the activity of both oestrogenand progesterone-based hormonal contraceptives. Women taking enzyme-inducing ART can use an
Antiretroviral therapy should always be entered on to the computer record (as a hospital issue) so that the GP is alerted to possible interactions. If in doubt, the University of Liverpool has a useful website for checking interactions (www.hivdruginteractions.org/checker).10
GuidelinesinPractice.co.uk
9
WHICH ICS/LABA
HELPS MORE PATIENTS IMPROVE
ASTHMA
CONTROL?
Prescribing information and details on adverse event reporting can be found on the next page.
RELVAR ELLIPTA (fluticasone furoate/vilanterol)
Relvar Ellipta was superior to other ICS/LABAs (usual care) in helping more patients improve asthma control in everyday clinical practice in the Salford Lung Study.1 The most commonly used ICS/LABAs were: Seretide (fluticasone propionate/salmeterol), Symbicort, Fostair.2 Data presented are from a subset of patients in the PEA population prescribed ICS/LABA at randomisation.1
ead the clinical data at relvarhcp.co.uk P
primar effectiveness anal sis.
References: .
oodcoc
et al. Lancet. . . o
.
Prescribing information Please consult the full ummar of Product haracteristics mP before prescribing. Relvar Ellipta (fluticasone furoate/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms mcg and vilanterol mcg provides a delivered dose of mcg and mcg . ach single inhalation of mcg and mcg provides a delivered dose of mcg of and mcg of . Indications: Asthma: egular treatment of asthma in patients ≥12 years where a long-acting β -agonist (LABA) and inhaled corticosteroid combination is appropriate i.e. patients not ade uatel controlled on and as needed short-acting inhaled β -agonists or patients already adequately controlled on both ICS and LABA. COPD: mptomatic predicted treatment of adults with COPD with a FEV normal (post-bronchodilator) and an exacerbation history despite regular bronchodilator therap . Dosage and administration: nhalation onl . Asthma: Adults and adolescents ≥12 years: one inhalation once daily of Relvar 92/22 mcg for patients who require a low to mid dose of ICS in combination with a LABA. f patients are inade uatel controlled then the dose can be increased to one inhalation once dail elvar mcg. elvar 184/22 mcg can also be considered for patients who require a higher dose of ICS in combination with a LABA. Regularly review patients and reduce dose to lowest that maintains effective symptom control. COPD: one inhalation once daily of Relvar mcg. elvar mcg is not indicated for patients with COPD. Contraindications: persensitivit to the active
substances or to an of the excipients lactose monoh drate magnesium stearate . Precautions: Pulmonar tuberculosis severe cardiovascular disorders or heart rh thm abnormalities th rotoxicosis uncorrected h po alaemia patients predisposed to low levels of serum potassium, chronic or untreated infections, diabetes mellitus, paradoxical bronchospasm. In patients with moderate to severe hepatic impairment mcg dose should be used. cute symptoms: Not for acute symptoms, use shortacting inhaled bronchodilator. arn patients to see medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Asthma-related adverse events and exacerbations ma occur during treatment. Patients should continue treatment but see medical advice if asthma symptoms remain uncontrolled or worsen after initiation of elvar. Systemic effects: stemic effects of s ma occur particularl at high doses for long periods but much less li el than with oral corticosteroids. Possible Systemic effects include: ushing s s ndrome ushingoid features adrenal suppression decrease in bone mineral density, growth retardation in children and adolescents. e s mptoms such as blurred vision ma be due to underl ing serious conditions such as cataract glaucoma or central serous chorioretinopath consider referral to ophthalmologist. ore rarel a range of ps chological or behavioural effects including ps chomotor h peractivit sleep disorders anxiet depression or aggression particularl in children . ncreased incidence of pneumonia has been observed in patients with COPD receiving inhaled corticosteroids. Risk factors for pneumonia include: current smo ers old age patients with a history of prior pneumonia, patients with a body mass index <25 kg/m2 and patients with a FEV predicted. f pneumonia occurs with Relvar treatment should be re-evaluated. Patients with rare hereditary problems of galactose intolerance, the Lapp
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellowcard in the Google Play or Apple App store. Adverse events should also be reported to GlaxoSmithKline on 0800 221 441
lactase deficiency or glucose-galactose malabsorption should not ta e elvar. Interactions with other medicinal products: nteraction studies have onl been performed in adults. void β-blockers. Caution is advised when coadministering with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products). Concomitant administration of other s mpathomimetic medicinal products ma potentiate the adverse reactions of . elvar should not be used in conjunction with other long-acting β adrenergic agonists or medicinal products containing longacting β -adrenergic agonists. Pregnancy and breastfeeding: Experience limited. Balance risks against benefits. Side effects: Very Common (≥1/10): headache, nasopharyngitis. Common (≥1/100 to <1/10): candidiasis of the mouth and throat d sphonia pneumonia bronchitis upper respirator tract infection, influenza, oropharyngeal pain, sinusitis, pharyngitis, rhinitis cough abdominal pain arthralgia bac pain fractures pyrexia, muscle spasms. Other important side effects include: Uncommon (≥1/1,000 to <1/100); blurred vision h pergl caemia. Rare (≥1/10,000 to <1/1,000) paradoxical bronchospasm and h persensitivit reactions including anaph laxis angioedema rash urticaria. ee mP for other adverse reactions. Legal category: POM. Presentation and Basic NHS cost: elvar llipta. inhaler x doses. Relvar Ellipta 92/22 - £22.00. Relvar Ellipta 184/22 - £29.50. Marketing authorisation (MA) nos. 92/22 mcg 1x30 doses [EU/1/13/886/002]; 184/22 mcg 1x30 doses [EU/1/13/886/005]. MA holder: Glaxo Group Ltd, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK. Last date of revision: September 2018. UK/FFT/0227/15(6). Trademarks are owned by or licensed to the GSK group of companies. group of companies or its licensor. Relvar Ellipta was developed in collaboration with Innoviva Inc. © 2018 GlaxoSmithKline Group of Companies. Zinc code: UK/FFT/0054/18a Date of preparation: September 2018
Infection Hot topic
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Box 1: Groups at high risk of contracting HIV4 a Men
who have sex with men and their female partners
a Sexual
partners of those who are HIV positive
a Intravenous
drug users
from a country with a high prevalence of HIV infection (see Figure 2) and their sexual partners
who are taking enzyme-inducing drugs and need emergency contraception should have a double dose of levonorgestrel (3 mg)—this is also unlicensed. They should not use ulipristal.13
a Those
women who have sex with men and have not had an HIV test in the last year
Fertility treatment
a Trans
a Those
who disclose high-risk sexual practices, such as ‘chemsex’ (the use of drugs to facilitate sex)
a Anyone
who requests a test for a sexually transmitted infection or has one diagnosed.
Key points a GPs
in areas with high or extremely high prevalence of HIV are advised to offer HIV testing to all new patients and to those who are having blood tests for another reason and have not had an HIV test in the last year
a An
HIV test should be arranged for those presenting with indicator conditions, including dementia and unexplained weight loss. There is no need for extensive pre-test counselling before HIV testing— the only point to cover is the risk of a false negative test during the window period
a A
maculopapular rash and a fever should prompt consideration of HIV seroconversion
a HIV
itself is generally not a contraindication to contraceptive methods, but drug interactions may limit the woman’s choices of contraception
a Antiretroviral
therapy has significant drug interactions and should be entered on the computer record as a hospital issue
a Patients
with HIV should not be refused fertility treatment solely on the basis of their HIV-positive status
a Some
women with HIV can be supported to breastfeed, but those who breastfeed with a detectable viral load or without undergoing regular testing for themselves and/or their child should be considered for a child protection referral
a Women
with HIV need colposcopy at diagnosis, and lifelong annual
smears a GPs
may need to breach confidentiality if they become aware that a patient with HIV has not told their partner.
intrauterine device or system, or the depot injection. They can of course also use condoms as a sole method of contraception, but this carries a high failure rate. For those who refuse all these methods, there are oral contraceptive regimens (usually
12
GuidelinesinPractice.co.uk
involving an oestrogen dose of 50–70 mcg with a shortened pill-free interval) that have been designed for women taking enzyme-inducers. This type of use is unlicensed and has a high failure rate so should always be combined with condoms.12 Women
People with HIV may also approach their GP for help with subfertility. It would be inappropriate to deny fertility treatment to a patient with HIV based solely on their HIV status, assuming that they fit other local criteria. Discordant couples (those where only one of the couple has HIV) may need help to try and conceive while avoiding unprotected sex. If the man has HIV then sperm washing14 can be used. This separates the sperm (which does not carry HIV) from the surrounding fluids (which do carry HIV) and then the sperm is used in assisted conception. If the woman is HIV positive then the couple can have intrauterine insemination, either done themselves at home or in a clinic. Funding for these procedures is likely to vary from area to area. Some discordant couples, particularly those for whom sperm washing or intrauterine insemination is not available on the NHS, may try to conceive naturally by having targeted unprotected sex around the time of ovulation. BHIVA’s comment on this is that, where the HIV positive partner has an undetectable viral load for the last 6 months, ‘the risk to the uninfected partner is difficult to quantify but can certainly not be quoted as zero. Mathematical models cite a risk of 1 in 100,000 per act of intercourse.’ Various studies of several hundred patients have shown no transmission of HIV using this method of conception, however data is limited and sample sizes are small so caution should always be advised. These discussions should really be had with the patient’s HIV physician rather than in primary care.15
&
D
Si
m iff p er le en t!
Added Extra Added Confidence Adex Gel Adex Gel does not contain topical corticosteroids
Adex Gel offers an effective, simple and different approach to the treatment and management of mild to moderate eczema, contact dermatitis and psoriasis. Adex Gel emollient can help reduce inflammation and redness because Adex Gel provides Added Extra anti-inflammatory action.
Prescribe Adex Gel and see the results
Essential Information: Adex™ Gel Presentation: White opaque gel. Uses: Highly moisturising and protective emollient with an ancillary anti-inflammatory medicinal substance for the treatment and routine management of dry and/or inflamed skin conditions such as mild to moderate atopic dermatitis, various forms of eczema, contact dermatitis and psoriasis. Directions: Adults, the elderly and children from 1 year of age. For generalised all-over application to the skin. Apply three times daily or as often as needed. Adex Gel can be used for as long as necessary either occasionally, such as during flares, or continuously if the added anti-inflammatory action is beneficial. Seek medical advice if there is no improvement within 2-4 weeks. Contra-indications, warnings, side effects etc: Do not use if sensitive to any of the ingredients. Keep away from the eyes, inside
AdexGel.com for further information
the nostrils and mouth. Temporary tingling, itching or stinging may occur with emollients when applied to damaged skin. Such symptoms usually subside after a few days of treatment, however, if they are troublesome or persist, stop using and seek medical advice. Rarely skin irritation (mild rashes) or allergic skin reactions can occur on extremely sensitive skin, these tend to occur during or soon after the first few uses and if this occurs stop treatment. As safety trials have not been conducted during pregnancy and breast-feeding, seek medical advice before using this product. Care should be taken as emollients which soak into clothing, pyjamas, bedlinen etc. can increase the flammability of these items. Patients should avoid these materials coming into contact with naked flames or lit cigarettes etc. As a precaution, dressings and clothing, etc., should be changed frequently and laundered thoroughly. Ingredients: Carbomer, glycerol, isopropyl myristate, liquid paraffin, nicotinamide, phenoxyethanol, sorbitan laurate, trolamine, purified water.
Pack sizes and NHS prices: 100g tube £2.69, 500g pump pack £5.99. Legal category: Class III medical device with an ancillary medicinal substance. Further information is available from the manufacturer: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. Date of preparation: August 2017. ‘Adex’ is a trademark. Adverse events should be reported to Dermal.
www.dermal.co.uk
ADXPR101/JUL18
Visit
Infection Hot topic
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Figure 2: Adult HIV prevalence (15–49 years), 2017 by World Health Organization region6
v
Reproduced with permission. Information Evidence and Research, World Health Organization. Prevalence of HIV among adults aged 15 to 49, 2017—by WHO region. WHO, 2018. Available at: www.who.int/gho/hiv/hiv_013.png?ua=1
Pregnancy, birth, and breastfeeding Pregnant women with HIV will always have shared consultant-led care; previous practice has been to offer a caesarean although in women with an undetectable viral load and in the absence of obstetric complications it is now considered safe to attempt a vaginal delivery. Current advice is still that women with HIV should not breastfeed, although BHIVA says that if women insist on breastfeeding, they should be supported to make it as safe as possible. This involves making sure the woman has an undetectable viral load, good adherence to ART, and agrees to monthly viral load checks for themselves and testing for their
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infant throughout breastfeeding and for 2 months afterwards. Any woman who continues to breastfeed while their viral load is detectable, or who does not attend for these checks, should be referred to social services as a child protection concern. BHIVA
Women with HIV should all have a smear and colposcopy at the time of their diagnosis with HIV
also advises that those who choose to breastfeed should do so exclusively and should finish breastfeeding by the time the infant is 6 months old.16
Cervical smear tests Another potential challenge for primary care is managing the cervical smear test requirements of women with HIV. These women have a higher prevalence of cervical cancer and of oncogenic forms of human papillomavirus (HPV) than the general population. Women with HIV should all have a smear and colposcopy at the time of their diagnosis with HIV, and thereafter should have lifelong annual smears,17,18 with repeat colposcopy only if recommended on the smear report.
A logical choice
of maintenance treatment to help prevent exacerbations of COPD
beclometasone/formoterol/ glycopyrronium (87/5/9 mcg) Trimbow is indicated for maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a lon actin 2 a onist for e ects on s mptoms control and prevention of exacerbations see section 5.1 of the SPC) Prescribing information can be found overleaf
a combination of 3 established compounds in an extrafine formulation
Inspired logic CHTRI20170962f(1) Oct 2017
Infection Hot topic
Prescribing Information Trimbow 87/5/9 Pressurised Metered Dose Inhaler (pMDI) Prescribing Information Please refer to the full Summary of Product Characteristics (SPC) before prescribing. Presentation: Each Trimbow 87/5/9 pMDI delivered dose contains 87micrograms (mcg) of beclometasone dipropionate (BDP), 5mcg of formoterol fumarate dihydrate (formoterol) and 9mcg of glycopyrronium. This is equivalent to a metered dose of 100mcg BDP, 6mcg formoterol and 10mcg glycopyrronium. Indications: Maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) not adequately treated by a combination of an inhaled corticosteroid (ICS) and a long-acting beta2-agonist (for effects on symptoms control and prevention of exacerbations see section 5.1 of SPC). Dosage and administration: For inhalation in adult patients (≥18 years). 2 inhalations twice daily (bd). Can be used with the AeroChamber Plus® spacer device. BDP in Trimbow is characterised by an extrafine particle size distribution which results in a more potent effect than formulations of BDP with a non-extrafine particle size distribution (100mcg of BDP extrafine in Trimbow are equivalent to 250mcg of BDP in a non-extrafine formulation). Contraindications: Hypersensitivity to the active substances or to any of the excipients. Warnings and precautions: Not for acute use in treatment of acute episodes of bronchospasm or to treat COPD exacerbation. Discontinue immediately if hypersensitivity or paradoxical bronchospasm. Deterioration of disease: Trimbow should not be stopped abruptly. Cardiovascular effects: Use with caution in patients with cardiac arrhythmias, aortic stenosis, hypertrophic obstructive cardiomyopathy, severe heart disease, occlusive vascular diseases, arterial hypertension and aneurysm. Caution should also be used when treating patients with known or suspected prolongation of the QTc interval (QTc > 450 milliseconds for males, or > 470 milliseconds for females) either congenital or induced by medicinal products. Trimbow should not be administered for at least 12 hours before the start of anaesthesia as there is a risk of cardiac arrhythmias. Caution in patients with thyrotoxicosis, diabetes mellitus, phaeochromocytoma and untreated hypokalaemia. Increase in pneumonia and pneumonia hospitalisation in COPD patients receiving ICS observed. Clinical features of pneumonia may overlap with symptoms of COPD exacerbations. Systemic effects of ICS may occur, particularly at high doses for long periods, but are less likely than with oral steroids. These include Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation, decrease in bone mineral density, cataract, glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression and aggression. Use with caution in patients with pulmonary tuberculosis or fungal/viral airway infections. Potentially serious hypokalaemia may result from beta2-agonist therapy. Formoterol may cause a rise in blood glucose levels. Glycopyrronium should be used with caution in patients with narrow-angle glaucoma, prostatic hyperplasia or urinary retention. Use in patients with severe hepatic or renal impairment should only be considered if benefit outweighs the risk. Interactions: Since glycopyrronium is eliminated via renal route, potential drug interactions could occur with medicinal products affecting renal excretion mechanisms e.g. with cimetidine (an inhibitor of OCT2 and MATE1 transporters in the kidney) co-administration, glycopyrronium showed a slight decrease in renal excretion (20%) and a limited increase in total systemic exposure (16%). Possibility of systemic effects with concomitant use of strong CYP3A inhibitors (e.g. ritonavir, cobicistat) cannot be excluded and therefore caution and appropriate monitoring is advised. Related to formoterol: Non-cardioselective beta-blockers (including eye drops) should be avoided. Concomitant administration of other beta-adrenergic drugs may have potentially additive effects. Concomitant treatment with quinidine, disopyramide, procainamide, antihistamines, monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants and phenothiazines can prolong the QTc interval and increase the risk of ventricular arrhythmias. L-dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance towards beta2sympathomimetics. Hypertensive reactions may occur following co-administration with MAOIs including drugs with similar properties (e.g. furazolidone, procarbazine). Risk of arrhythmias in patients receiving concomitant anaesthesia with halogenated hydrocarbons. Concomitant treatment with xanthine derivatives, steroids or diuretics may potentiate a possible hypokalaemic effect of beta2-agonists. Hypokalaemia may increase the likelihood of arrhythmias in patients receiving digitalis glycosides. Related to glycopyrronium: Co-administration with other anticholinergic-containing medicinal products is not recommended. Excipients: Presence of ethanol may cause potential interaction in sensitive patients taking metronidazole or disulfram. Fertility, pregnancy and lactation: Should only be used during pregnancy if the expected benefits outweigh the potential risks. Children born to mothers receiving substantial doses should be observed for adrenal suppression. Glucocorticoids and metabolites are excreted in human milk. It is unknown whether formoterol or glycopyrronium (including their metabolites) pass into human breast-milk but they have been detected in the milk of lactating animals. Anticholinergic agents like glycopyrronium could suppress lactation. A risk/benefit decision should be taken to discontinue therapy in the mother or discontinue breastfeeding. A decision must be made whether to discontinue breastfeeding or to discontinue/abstain from therapy. Effects on driving and operating machinery: None or negligible. Side effects: Common: pneumonia (in COPD patients), pharyngitis, oral candidiasis, urinary tract infection, nasopharyngitis, headache, dysphonia. Uncommon: influenza, oral fungal infection, oropharyngeal candidiasis, oesophageal candidiasis, sinusitis, rhinitis, gastroenteritis, vulvovaginal candidiasis, granulocytopenia, dermatitis allergic, hypokalaemia, hyperglycaemia, restlessness, tremor, dizziness, dysgeusia, hypoaesthesia, otosalpingitis, atrial fibrillation, electrocardiogram QT prolonged, tachycardia, tachyarrhythmia, palpitations, hyperaemia, flushing, cough, productive cough, throat irritation, epistaxis, diarrhoea, dry mouth, dysphagia, nausea, dyspepsia, burning sensation of the lips, dental caries, rash, urticaria, pruritus, hyperhidrosis, muscle spasms, myalgia, pain in extremity, musculoskeletal chest pain, dysuria, urinary retention, fatigue, asthenia, C-reactive protein increased, platelet count increased, free fatty acids increased, blood insulin increased, blood ketone body increased, blood cortisol decreased. Rare: Lower respiratory tract infection (fungal), hypersensitivity reactions, including erythema, lips, face, eyes and pharyngeal oedema, decreased appetite, insomnia, hypersomnia, angina pectoris (stable and unstable), ventricular extrasystoles, nodal rhythm, sinus bradycardia, blood extravasation, hypertension, paradoxical bronchospasm, oropharyngeal pain, angioedema, nephritis, blood pressure increased, blood pressure decreased. Very rare: thrombocytopenia, adrenal suppression, glaucoma, cataract, dyspnoea, growth retardation, peripheral oedema, bone density decreased. Unknown frequency: psychomotor hyperactivity, sleep disorders, anxiety, depression, aggression, behavioural changes (Refer to SPC for full list of side effects). Legal category: POM Packs and price: £44.50 1x120 actuations. Marketing authorisation No: EU/1/17/1208/002 UK Distributor: Chiesi Limited, 333 Styal Road, Manchester, M22 5LG. Date of preparation: Jun 2017. AeroChamber Plus® is a registered trademark of Trudell Medical International.
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Chiesi Limited on 0800 0092329 (GB), 1800 817459 (IE).
beclometasone/formoterol/ glycopyrronium (87/5/9 mcg)
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Guidelines in Practice | October 2018 | Volume 21 | Issue 10
GPs should check whether the HIV clinic is arranging annual smears and the initial colposcopy—if not, the GP could consider asking their local cytology lab whether they will adjust the screening interval to yearly if informed that a woman has HIV. If this is not possible then the practice will need to have an internal system to ensure that these women are recalled annually rather than every 3 years as standard.
Pre-exposure prophylaxis (PrEP) A relatively new concept in the world of HIV is that of pre-exposure prophylaxis (PrEP)—the idea that a person who is confirmed to be HIV negative but at high risk of transmission takes a single daily dose of ART, in combination with safer sex practices, to prevent this transmission. PrEP reduces the relative risk of transmission by 44 –86%, giving a number needed to treat (in 1 year) in order to prevent one transmission, of 13–68.19 PrEP may be appropriate for discordant couples, where the negative partner does not want to have to take post-exposure prophylaxis every time they have a condom accident, or for those with multiple partners who do not use condoms, particularly men who have sex with men.
Pre-exposure prophylaxis reduces the relative risk of [HIV] transmission by 44 –86%
In 2016, an AIDS charity took NHS England (NHSE) to court after NHSE argued that PrEP funding should come from public health not from NHSE. The charity won 20 and at the time of writing (September 2018), NHSE is funding PrEP for some patients as part of a large-scale trial. 21,22 The court case was particularly interesting due to NHSE’s contention that funding PrEP would mean that other treatments may not be funded. 23 This was the first time that NHSE had publicly stated that the funding of one drug may affect the availability of another, something that may become more apparent in years to come. The relevance of this to GPs is that some patients may now be taking PrEP as part of a trial and others may be buying it privately—GPs should be made aware of this and the drugs should be entered in the computer notes to pick up interactions. 22,24
The only licensed treatment for the reduction in recurrence of overt hepatic encephalopathy (OHE)1
At home they are still at risk; …TARGAXAN® rifaximin-α reduces the risk of recurrence of overt hepatic encephalopathy.2
Long-term secondary prophylaxis in hepatic encephalopathy (HE)3 Targaxan 550 mg film-coated tablets (rifaximin-α). REFER TO FULL SUMMARY OF PRODUCT CHARACTERISTICS (SmPC) BEFORE PRESCRIBING Presentation: Film-coated tablet containing rifaximin 550 mg. Uses: Targaxan is indicated for the reduction in recurrence of episodes of overt hepatic encephalopathy in patients ≥ 18 years of age. Dosage and administration: Adults 18 years of age and over: 550 mg twice daily, with a glass of water, with or without food for up to 6 months. Treatment beyond 6 months should be based on risk benefit balance including those associated with the progression of the patients hepatic dysfunction. No dosage changes are necessary in the elderly or those with hepatic insufficiency. Use with caution in patients with renal impairment. Contraindications: Contraindicated in hypersensitivity to rifaximin, rifamycin-derivatives or to any of the excipients and in cases of intestinal obstruction. Warnings and precautions for use: The potential association of rifaximin treatment with Clostridium difficile associated diarrhoea and pseudomembranous colitis cannot be ruled out. The administration of rifaximin with other rifamycins is not recommended. Rifaximin may cause a reddish discolouration of the urine. Use with caution in patients with severe (Child-Pugh C) hepatic impairment and in patients with MELD (Model for End-Stage Liver Disease) score > 25. In hepatic impaired patients, rifaximin may decrease the exposure of concomitantly administered CYP3A4 substrates (e.g. warfarin, antiepileptics, antiarrhythmics, oral contraceptives). Both decreases and increases in international normalized ratio (in some cases with bleeding events) have been reported in patients maintained on warfarin and prescribed rifaximin. If co-administration is necessary, the international normalized ratio should be carefully monitored with the addition or withdrawal of treatment with rifaximin. Adjustments in the dose of oral anticoagulants may be necessary to maintain the desired level of anticoagulation. Ciclosporin may increase the rifaximin Cmax Pregnancy and lactation: Rifaximin is not recommended during pregnancy. The benefits of rifaximin treatment should be assessed against the need to continue breastfeeding.
Side effects: Common effects reported in clinical trials are dizziness, headache, depression, dyspnoea, upper abdominal pain, abdominal distension, diarrhoea, nausea, vomiting, ascites, rashes, pruritus, muscle spasms, arthralgia and peripheral oedema. Other effects that have been reported include: Clostridial infections, urinary tract infections, candidiasis, pneumonia cellulitis, upper respiratory tract infection and rhinitis. Blood disorders (e.g. anaemia, thrombocytopenia). Anaphylactic reactions, angioedemas, hypersensitivity. Anorexia, hyperkalaemia and dehydration. Confusion, sleep disorders, balance disorders, convulsions, hypoesthesia, memory impairment and attention disorders. Hypotension, hypertension and fainting. Hot flushes. Breathing difficulty, pleural effusion, COPD. Gastrointestinal disorders and skin reactions. Liver function test abnormalities. Dysuria, pollakiuria and proteinuria. Oedema. Pyrexia. INR abnormalities. Legal category: UK - POM, Ireland - Prescription only. Cost: UK - Basic NHS price £259.23 for 56 tablets. Ireland - €262.41 for 56 tablets Marketing Authorisation number: UK - PL 20011/0020. Ireland - PA 102/29/1 For further information contact: Norgine Pharmaceuticals Limited, Norgine House, Moorhall Road, Harefield, Middlesex, United Kingdom UB9 6NS Telephone: +44(0)1895 826606 E-mail:
[email protected] Ref: UK/XIF5/0318/0386 Date of preparation: March 2018
United Kingdom - Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Medical Information at Norgine Pharmaceuticals Ltd on 01895 826606.
Ireland - Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail:
[email protected]. Adverse events should also be reported to Medical Information at Norgine Pharmaceuticals on +44 1895 826606. References: 1. National Institute for Health and Care Excellence. Rifaximin for preventing episodes of overt hepatic encephalopathy: appraisal guidance TA337 for rifaximin. Available from: http://www.nice.org.uk/guidance/ta337 2. TARGAXAN® 550 Summary of Product Characteristics. Available for the UK from: https://www.medicines.org.uk/ emc/medicine/27427. Available for Ireland from: http://www. medicines.ie/medicine/15936/SPC/TARGAXAN+550mg+filmcoated+tablets/. 3. Mullen KD, et al. Clin Gastroenterol Hepatol 2014;12(8):1390-97. Product under licence from Alfasigma S.p.A. TARGAXAN is a registered trademark of the Alfasigma group of companies, licensed to the Norgine group of companies. NORGINE and the sail logo are registered trademarks of the Norgine group of companies. UK/XIF5/0718/0414 Date of preparation: August 2018.
Infection Hot topic
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Table 1: Clinical indicator diseases for adult HIV infection5
Respiratory Neurology
Dermatology
AIDS-defining conditions
Other conditions where HIV testing should be offered
a Tuberculosis
a Bacterial
a Pneumocystis
a Aspergillosis
a Cerebral
toxoplasmosis cerebral lymphoma a Cryptococcal meningitis a Progressive multifocal leucoencephalopathy
a Aseptic
a Primary
a Cerebral
a Kaposi’s
a Severe
sarcoma
pneumonia
meningitis/encephalitis abscess a Space occupying lesion of unknown cause a Guillain–Barré syndrome a Transverse myelitis a Peripheral neuropathy a Dementia a Leucoencephalopathy or recalcitrant seborrhoeic dermatitis or recalcitrant psoriasis a Multidermatomal or recurrent herpes zoster a Severe
Gastroenterology aPersistent cryptosporidiosis
a Oral
candidiasis hairy leukoplakia a Chronic diarrhoea of unknown cause a Weight loss of unknown cause a Salmonella, shigella, or campylobacter a Hepatitis B infection a Hepatitis C infection a Oral
Oncology
a Non-Hodgkin’s
lymphoma
a Anal
cancer or anal intraepithelial dysplasia cancer a Seminoma a Head and neck cancer a Hodgkin’s lymphoma a Castleman’s disease a Lung
Gynaecology
a Cervical
cancer
a Vaginal
intraepithelial neoplasia a Cervical intraepithelial neoplasia Grade 2 or above
Haematology
Ophthalmology
a Any
unexplained blood dyscrasia including: b thrombocytopenia b neutropenia b lymphopenia
a Cytomegalovirus
Ear, nose, throat
retinitis
a Infective
retinal diseases including herpes viruses and toxoplasma a Any unexplained retinopathy a Lymphadenopathy
of unknown cause parotitis a Lymphoepithelial parotid cysts a Chronic
Other
a Mononucleosis-like
syndrome (primary HIV infection) of unknown origin a Any lymphadenopathy of unknown cause a Any sexually transmitted infection a Pyrexia
British HIV Association, British Association for Sexual Health and HIV, British Infection Society. UK national guidelines for HIV Testing 2008. BHIVA, 2008. Available at: www.bhiva.org/file/RHNUJgIseDaML/GlinesHIVTest08.pdf Reproduced with permission
18
GuidelinesinPractice.co.uk
The only COPD Triple Therapy delivered in a single daily inhalation.1 Improvement in quality of life vs. ICS/LABA. 2
Prescribing information can be found overleaf
Zinc code: UK/TLY/0062/17 Date of preparation: December 2017
A combination of ICS/LAMA/LABA (FF/UMEC/VI) administered through a single daily inhalation from the Ellipta inhaler, which is easy to use1–4
The only COPD Triple Therapy delivered in a single daily inhalation.1 Improvement in quality of life vs. ICS/LABA. 2
A combination of ICS/LAMA/LABA (FF/UMEC/VI) administered through a single daily inhalation from the Ellipta inhaler, which is easy to use1–4
Trelegy Ellipta FF/UMEC/VI 92/55/22 mcg is indicated for maintenance treatment in adult patients with moderate-to-severe COPD who are not adequately treated by a combination of an ICS and a LABA.1 COPD, chronic obstructive pulmonary disease; FF, fluticasone furoate; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; OD, once-daily; UMEC, umeclidinium, VI, vilanterol. References: 1. Trelegy Ellipta SmPC. 2. Lipson DA et al. Am J Respir Crit Care Med 2017; 196:438–446. 3. Svedsater H et al. BMC Pulm Med 2013; 13:72–86. 4. van der Palen J et al. NPJ Prim Care Respir Med 2016; 26:16079. Ellipta (fluticasone furoate/umeclidinium/vilanterol [as Trelegy trifenatate]) Prescribing information Please consult the full Summary of Product Characteristics (SmPC) before prescribing. Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms (mcg), umeclidinium (UMEC) 62.5 micrograms and vilanterol (VI) 25 mcg provides a delivered dose of 92 mcg FF, 55 mcg UMEC and 22 mcg VI. Indications: Maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid (ICS) and a long-acting β2-agonist (LABA). Dosage and administration: One inhalation once daily. Contraindications:
Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Precautions: Paradoxical bronchospasm, unstable or life-threatening cardiovascular disease or heart rhythm abnormalities, convulsive disorders or thyrotoxicosis, pulmonary tuberculosis or patients with chronic or untreated infections, narrow-angle glaucoma, urinary retention, hypokalaemia, patients predisposed to low levels of serum potassium, diabetes mellitus. In patients with moderate to severe hepatic impairment patients should be monitored for systemic corticosteroid-related adverse reactions. Eye symptoms such as blurred vision may be due to underlying serious conditions such as cataract, glaucoma or central serous chorioretinopathy (CSCR); consider referral to ophthalmologist. Increased incidence of pneumonia has been observed in patients with COPD receiving inhaled corticosteroids. Risk factors for pneumonia include: current smokers, older age, patients with a low body mass index and severe COPD. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Trelegy. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Systemic effects: Systemic effects of ICSs may occur, particularly at high doses for long periods, but much less likely
than with oral corticosteroids. Interactions with other medicinal products: Caution should be exercised during concurrent use of non-selective and selective beta-blockers and when co-administering with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products), hypokalaemic treatments or non-potassium-sparing diuretics. Coadministration with other long-acting muscarinic antagonists or long acting β2-adrenergic agonists has not been studied and is not recommended. Pregnancy and breast-feeding: Experience limited. Balance risks against benefits. Side effects: Common (≥1/100 to <1/10): pneumonia, upper respiratory tract infection, pharyngitis, rhinitis, influenza, nasopharyngitis, headache, cough, arthralgia, back pain. Other important side effects include: Uncommon (≥1/1,000 to <1/100) supraventricular tachyarrhythmia, tachycardia, atrial fibrillation; Not known (cannot be estimated from the available data) vision blurred; See SmPC for other adverse reactions. Legal category: POM. Presentation and Basic NHS cost: Trelegy Ellipta 92/55/22 mcg - £44.50. 1 inhaler x 30 doses. Marketing authorisation (MA) nos. 92/55/22 mcg 1x30 doses [EU/1/17/1236/02]; MA holder: GSK Trading Services Ltd., Currabinny, Co. Cork Ireland. Last date of revision: November 2017. UK/TLY/0031/17. Trademarks are owned by or licensed to the GSK group of companies. 2017 GSK group of companies or its licensor Trelegy Ellipta was developed in collaboration with Innoviva Inc.
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellowcard in the Google Play or Apple App Store. Adverse events should also be reported to GlaxoSmithKline on 0800 221 441.
Discover more at www.trelegy.co.uk A full list of adverse reactions for Trelegy Ellipta can be found in the Summary of Product Characteristics.
Trelegy Ellipta was developed in collaboration with Trelegy and Ellipta are registered trademarks of the GlaxoSmithKline Group of Companies. ©2017 GlaxoSmithKline Group of Companies. All rights reserved. Zinc code: UK/TLY/0062/17 Date of preparation: December 2017
Confidentiality and legal issues GPs are often uniquely placed in that they know a patient’s family and home situation—this can cause uncertainty if they discover that a patient with HIV has not told their partner about their diagnosis. The General Medical Council is clear, stating that:25 ‘You may disclose information to a person who has close contact with a patient who has a serious communicable disease if you have reason to think that: a. the person is at risk of infection that is likely to result in serious harm b. the patient has not informed them and cannot be persuaded to do so.’ As in any case of breaching confidentiality, the patient must be informed in advance if it is practical and safe to do so (and it may be worth letting them know that they are at risk of criminal prosecution for knowingly passing on HIV26); also, it would be sensible to discuss the matter with a medical defence organisation.
Future initiatives What of the future? An effective vaccine is badly needed but sadly it will be a while before there is one available for routine use. However, phase II trials are underway, looking at patients from the general population as well as those who are at high risk of acquisition of HIV27,28 and there must surely be a Nobel prize or two waiting for the scientists who crack this particular conundrum.
Summary The treatment of HIV has come a long way in the last few decades and what used to be a universally fatal condition is now a chronic disease.
Implementation actions for STPs and ICSs written by Dr David Jenner, GP, Cullompton, Devon The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.
Hot topic Infection
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
a Establish
a local STP group led by public health officers to identify any areas with high or very high prevalence of HIV in the local area
a Define
all actions required to address the risk of HIV in the local health improvement plan, including education, prevention, screening, and access to diagnosis and treatment services
a Agree
a care pathway for people diagnosed with HIV to include maternity services
a Ensure
the pathway clearly defines who is responsible for providing each part of the service
a Commission
services required to implement this pathway from various providers and agree what is funded by public health and NHS budgets (or pool budgets)
a Provide
diagnostic prompts to primary care clinicians to stimulate more appropriate HIV testing and explore whether these can be built into GP computing systems.
STP=sustainability and transformation partnership; ICS=integrated care system
References
… what used to be a universally fatal condition is now a chronic disease Provision of antiretroviral therapy will always come from secondary care but there are many issues that GPs need to be aware of for their patients with HIV, including drug interactions, contraception, and issues of confidentiality. Key points are located on p.12 and implementation actions are above.
Dr Toni Hazell Part-time GP, Greater London Diploma in genitourinary medicine
1. General Medical Council. Good practice in prescribing and managing medicines and devices. GMC, 2013. Available at: www.gmcuk.org/Prescribing_guidance.pdf_59055247. pdf 2. Kirwan P, Chau C, Brown A et al. HIV in the UK—2016 report. Public Health England, 2016. Available at: assets.publishing.service. gov.uk/government/uploads/system/uploads/ attachment_data/file/602942/HIV_in_the_ UK_report.pdf 3. Harris J, Khatri R. Late diagnosis of HIV in the United Kingdom: an evidence review. Centre for Public Health, Liverpool John Moores University, December 2015. Available at: www.cph.org.uk/wp-content/ uploads/2015/12/Late-HIV-diagnosis-rapidevidence-review_final_covers.pdf 4. NICE, Public Health England. HIV testing: increasing uptake among people who may have undiagnosed HIV. NICE Guideline 60. NICE, December 2016. Available at: www. nice.org.uk/ng60 5. British HIV Association, British Association for Sexual Health and HIV, British Infection Society. UK national guidelines for HIV testing 2008. BHIVA, 2008. Available at: www.bhiva.
GuidelinesinPractice.co.uk
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Infection Hot topic
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
org/file/RHNUJgIseDaML/GlinesHIVTest08. pdf 6. Information Evidence and Research, World Health Organization. Prevalence of HIV among adults aged 15 to 49, 2017—by WHO region. WHO, 2018. Available at: www.who. int/gho/hiv/hiv_013.png?ua=1 7. Hecht F Busche M, Rawale B et al. Use of laboratory tests and clinical symptoms for identification of primary HIV infection. AIDS 2002; 16 (8): 1119–1129. 8. Chelsea and Westminster Hospital. HIV symptoms. www.chelwest.nhs.uk/services/ hiv-sexual-health/hiv-symptoms (accessed 25 September 2018). 9. British HIV Association. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015 (2016 interim update). BHIVA, 2016. Available at: www.bhiva.org/file/ RVYKzFwyxpgiI/treatment-guidelines2016-interim-update.pdf 10. University of Liverpool. HIV drug interactions. www.hiv-druginteractions.org/ checker (accessed 3 October 2018). 11. Faculty of Sexual and Reproductive Healthcare. UK medical eligibility criteria for contraceptive use. FSRH, 2016. Available at: www.fsrh.org/standards-and-guidance/ external/ukmec-2016-digital-version/ 12. Faculty of Sexual and Reproductive Healthcare. Combined hormonal contraception. FSRH, 2011 updated 2012. Available at: www.fsrh.org/ standards-and-guidance/documents/ combined-hormonal-contraception/ 13. Faculty of Sexual and Reproductive Healthcare. Drug interactions with hormonal contraception. FSRH, 2017. Available at: www.fsrh.org/standards-and-guidance/ documents/ceu-clinical-guidance-druginteractions-with-hormonal/ 14. Chelsea and Westminster Hospital NHS Foundation Trust. Sperm washing. http:// www.chelwest.nhs.uk/services/womenshealth-services/fertility-treatment/
treatment-options/treatment-options-1/ sperm-washing (accessed 3 October 2018). 15. Fakoya A, Lamba H, Mackie N et al. British HIV Association, BASHH and FSRH guidelines for the management of the sexual and reproductive health of people living with HIV infection 2008. HIV Med 2008; 9 (9): 681–720. 16. de Ruiter A, Taylor G, Claydon P et al. British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review). HIV Med 2014; 15 (Suppl 4): 1–77. 17. NICE. Cervical screening. NICE Clinical Knowledge Summary. NICE, 2017. Available at: cks.nice.org.uk/ cervical-screening#!scenario 18. Bower M, Palfreeman A, Alfa-Wali M et al. British HIV Association guidelines for HIV-associated malignancies 2014. HIV Med 2014; 15 (Suppl 2): 1–92. 19. NICE. Pre-exposure prophylaxis of HIV in adults at high risk: Truvada (emtricitabine/ tenofovir disoproxil). Evidence Summary 78. NICE, 2016. Available at: www. nice.org.uk/advice/esnm78/chapter/ key-points-from-the-evidence 20. National AIDS Trust. Final PrEP HIV drug case win for National AIDS Trust at Court of Appeal. www.nat.org.uk/press-release/finalprep-hiv-drug-case-win-national-aids-trustcourt-appeal (accessed 3 October 2018). 21. NHS England. NHS England announces major extension of national HIV prevention programme with Public Health England and funding for ten new specialised treatments. www.england.nhs.uk/2016/12/hivprevention-pregramme/ (accessed 3 October 2018).
Guardian, 2016. www.theguardian.com/ society/2016/aug/03/prep-hiv-drugs-fightfor-limited-nhs-funds-takes-unedifying-turn (accessed 3 October 2018). 24. Gilead Sciences Ltd. Truvada film-coated tablets—summary of product characteristics. Available at: www.medicines.org.uk/emc/ product/3890 25. General Medical Council. Confidentiality: disclosing information about serious communicable diseases. GMC, 2017. Available at: www.gmc-uk.org/ethicalguidance/ethical-guidance-for-doctors/ confidentiality—disclosing-informationabout-serious-communicable-diseases 26. NAM aidsmap. Timeline of developments in the criminalisation of HIV and STI transmission in the UK. www.aidsmap. com/Timeline-of-developments-inthe-criminalisation-of-HIV-and-STItransmission-in-the-UK/page/1504201/ (accessed 3 October 2018). 27. Choi E, Michalski C, Choo S et al. First Phase I human clinical trial of a killed whole-HIV-1 vaccine: demonstration of its safety and enhancement of anti-HIV antibody responses. Retrovirology 2016; 13 (1): 82. 28. US National Library of Medicine— ClinicalTrials.gov. A phase II clinical trial to evaluate the immunogenicity and reactogenicity of the recombinant HIV-1 envelope vaccines SF-2 rgp120 (CHO) [Chiron Vaccines] in MF59 adjuvant and MN rgp120/HIV-1 [VaxGen] in alum adjuvant in healthy adults. clinicaltrials.gov/ct2/show/ NCT00001031 (accessed 3 October 2018). G
22. NHS England. NHS commissioningspecialised services. F03. HIV. www.england. nhs.uk/commissioning/spec-services/ npc-crg/blood-and-infection-group-f/f03/ (accessed 3 October 2018). 23. Boseley S. PrEP HIV drugs: fight for limited NHS funds takes unedifying turn. The
View and comment on this article online at: GinP.co.uk/oct18-hiv
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Start as you mean to go on…
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Continuing professional development
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Test and reflect The following multiple-choice questions written by Dr Toni Hazell relate to her article, HIV: from fatal condition to chronic disease (see pp.8–20 of this issue). To check if you have answered the questions correctly visit: ginp.co.uk/mcq-hiv 1. Which of the following are included in the British HIV Association list of conditions where HIV testing should be offered? (Please select all that apply) bowel cancer lung cancer neutropenia recurrent viral upper respiratory tract infections unexplained weight loss. 2. You are a GP at a practice in outer London and are concerned that you may have patients with undiagnosed HIV. Which of the following correctly reflects current guidelines on testing? GPs in a high-prevalence area should offer a test at registration of new patients GPs in a high-prevalence area should offer to test every patient annually GPs in areas of very high prevalence should offer every patient a test every 6 months patients need pre-test counselling before they have an HIV test. 3. Which of the following is true about cervical cancer screening for women with HIV? (Please select all that apply) all women with HIV should have annual colposcopy all women with HIV should have annual smears all women with HIV should have colposcopy at diagnosis women with HIV can have smear tests based on the standard 3-year cycle. 4. You have a patient with HIV who has always assured you that his partner knows about his diagnosis. His partner comes to see you about her fertility and you realise that she has no idea of his diagnosis and that they have been having regular unprotected sex. Which of the following are correct? (Please select all that apply) he may be at risk of criminal prosecution for transmission of HIV his confidentiality cannot be breached without his consent the General Medical Council (GMC) would support you in breaching his confidentiality as long as you inform him first that you are going to do this (if it is practical and safe to do so) you should immediately tell her about her partner’s diagnosis. 5. Isabel is a 35-year-old woman who is HIV positive and taking enzyme-inducing antiretrovirals. She comes to see you for emergency contraception 18 hours after having unprotected intercourse with her HIV positive partner. Which of the following is true about her options? her only option for emergency contraception is the copper intrauterine contraceptive device (IUCD) she can have levonorgestrel but must take a double dose she can have levonorgestrel but should take it twice a day for 3 days instead of the usual one-off dose she can have ulipristal but must take a double dose you can offer her levonorgestrel or ulipristal at the standard doses.
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GuidelinesinPractice.co.uk
What’s missing in your patients’ cholesterol-lowering diet? Improve your patients’ cholesterol-lowering diet by simply recommending Benecol®. The plant stanols in Benecol are clinically proven to lower LDL cholesterol, and keep it lower with daily use.1,2* For more information please visit: www.benecol.com/hcp
*Plant stanol ester has been shown to lower cholesterol. High cholesterol is a risk factor in the development of coronary heart disease. A daily intake of 1.5–2.4g plant stanols has been shown to lower cholesterol by 7–10% in 2–3 weeks. References: 1. Gylling et al. Plant sterols and plant stanols in the management of dyslipidaemia and prevention of cardiovascular disease. Atherosclerosis 2014; 232(2): 346–360. 2. Párraga-Martínez et al. Long-term effects of plant stanols on the lipid profile of patients with hypercholesterolemia. A randomized clinical trial. Rev esp cardiol (Engl ed) 2015; 68(8): 665–671.
OCTASA 400mg Modified Release Tablets (mesalazine) and OCTASA 800mg Modified Release Tablets (mesalazine) Prescribing Information Presentation: Modified Release tablets containing 400mg mesalazine or 800mg mesalazine. Indications: Ulcerative Colitis Treatment of mild to moderate acute exacerbations. Maintenance of remission. Crohn’s ileocolitis - Maintenance of remission. Dosage and administration: 400mg tablets – Adults: Mild acute disease: 6 tablets (2.4g) once daily or in divided doses, with concomitant steroid therapy where indicated. Moderate acute disease: 6 to 12 tablets (2.4g – 4.8g) daily. 2.4g may be taken once daily or in divided doses, higher doses should be taken in divided doses. Maintenance therapy: 3 to 6 tablets (1.2g – 2.4g) once daily or in divided doses. 800mg tablets - Adults: Mild acute disease: 3 tablets (2.4g) once daily or in divided doses with concomitant steroid therapy where indicated. Moderate acute disease: 3 to 6 tablets (2.4g – 4.8g) daily. 2.4g may be taken once daily, higher doses should be taken in divided doses. Maintenance therapy: 2 to 3 tablets (1.6g - 2.4g) once daily or in divided doses. 400mg and 800mg tablets – No more than 2.4g should be taken at one time. Tablets must be swallowed whole. Elderly: Normal adult dose may be used unless liver or renal function is severely impaired. Children: Limited documentation of efficacy in children >6 years old. Dose to be determined individually. Generally recommended that half the adult dose may be given to children up to a body weight of 40 kg; and the normal adult dose to those above 40 kg. Contra-indications: Hypersensitivity to salicylates, mesalazine or any of the excipients, severe impairment of hepatic or renal function (GFR less than 30 ml/min). Warnings and Precautions: Urinary status (dip sticks) should be determined prior to and during treatment, at discretion of treating physician. Caution in patients with raised serum creatinine or proteinuria. Stop treatment immediately if renal impairment is evident. Haematological investigations are recommended prior to and during treatment, at discretion of treating physician. Stop treatment immediately if blood dyscrasias are suspected or evident. Caution in patients with impaired hepatic function. Liver function should be determined prior to and during treatment, at the discretion of the treating physician. Do not use in patients with previous mesalazine-induced cardiac hypersensitivity and use caution in patients with previous myo- or pericarditis of allergic background. Monitor patients with pulmonary disease, in particular asthma, very carefully. In patients with a history of adverse drug reactions to sulphasalazine, discontinue immediately if acute intolerance reactions occur (e.g. abdominal cramps, acute abdominal pain, fever, severe headache and rash). Use with caution in patients with gastric or duodenal ulcers. Intact tablets in the stool may be largely empty shells. If this occurs repeatedly patients should consult their physician. Use with caution in the elderly subject to patients having normal or non-severely impaired renal and liver function. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption, should not take this medicine. Interactions: No interaction studies have been performed. May decrease the anticoagulant activity of warfarin. May increase the myelosuppressive effects of azathioprine, 6-mercaptopurine or thioguanine. Monitoring of blood cell counts is recommended if these are used concomitantly. Fertility, pregnancy and lactation: Only to be used during pregnancy and lactation when the potential benefit outweighs the possible risk. No effects on fertility have been observed. Adverse reactions: Common: dyspepsia, rash. Uncommon: eosinophilia (as part of an allergic reaction), paraesthesia, urticaria, pruritus, pyrexia, chest pain. Rare: headache, dizziness, myocarditis, pericarditis, abdominal pain, diarrhoea, flatulence, nausea, vomiting, photosensitivity. Very rare: altered blood counts (aplastic anemia, granulocytosis, pancytopenia, neutropenia, leucopenia, thrombocytopenia), hypersensitivity reactions (such as allergic exanthema, drug fever, lupus erythematosus syndrome, pancolitis), peripheral neuropathy, allergic and fibrotic lung reactions (including dyspnoea, cough, bronchospasm, alveolitis, pulmonary eosinophilia, lung infiltration, pneumonitis), interstitial pneumonia, eosinophilic pneumonia, lung disorder, acute pancreatitis, changes in liver function parameters (increase in transaminases and cholestasis parameters), hepatitis, cholestatic hepatitis, alopecia, myalgia, arthralgia, impairment of renal function including acute and chronic interstitial nephritis and renal insufficiency, renal failure which may be reversible on withdrawal, nephrotic syndrome, oligospermia (reversible). Not known: pleurisy, lupus-like syndrome with pericarditis and pleuropericarditis as prominent symptoms as well as rash and arthralgia, intolerance to mesalazine with C-reactive protein increased and/or exacerbation of symptoms of underlying disease, blood creatinine increased, weight decreased, creatinine clearance decreased, amylase increased, red blood cell sedimentation rate increased, lipase increased, BUN increased. Consult the Summary of Product Characteristics in relation to other adverse reactions. Marketing Authorisation Numbers, Package Quantities and basic NHS price: 400mg - PL36633/0002; packs of 90 tablets (£16.58) and 120 tablets (£22.10). 800mg - PL36633/0001; packs of 90 tablets (£40.38) and 180 tablets (£80.75). Legal category: POM. Marketing Authorisation Holder: Tillotts Pharma UK Ltd, The Larbourne Suite, The Stables, Wellingore Hall, Wellingore, Lincolnshire, LN5 0HX, UK. Octasa is a trademark. ©2010 Tillotts Pharma UK Ltd. Further Information is available from the Marketing Authorisation Holder. Date of preparation of API: November 2017
Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk. Adverse events should also be reported to Tillotts Pharma UK Ltd. (address as above) Tel: 01522 813500. Reference: 1. MIMS. Accessed online, December 2017. PU-00105. Date of preparation: December 2017.
You can maintain MORE patients with Octasa® for the same cost as Asacol®* 1 ●
For £50,000, you can maintain 54 more patients at 2.4g/day for a year with Octasa® 400mg than with Asacol® 400mg*†1
123
†
Asacol® 400mg1
Octasa® 400mg1
69
Small changes add up to BIG savings
†
modified release mesalazine
400mg and 800mg For mild to moderate ulcerative colitis
* Using the same daily maintenance dose of 2.4g/day for a year. † Rounded down to the nearest whole patient. There are no clinical comparisons of Octasa® 400mg and 800mg vs Asacol® 400mg and 800mg. SmPCs may differ; consult individual SmPCs before prescribing.
independent content
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Stable angina: how does the SIGN guideline compare with NICE? Dr Alan Begg compares SIGN and NICE recommendations on the diagnosis, assessment, and treatment of stable angina
I
n April 2018, SIGN published Guideline 151 on the Management of stable angina1 replacing Guideline 96, which was published in 2007. 2 The SIGN methodology has changed in the intervening years with the recommendation grading changed from A, B, C levels to two levels of ‘strong’ or ‘conditional’, with recommendations that ‘should’ or ‘should not’ (be implemented) or those that should be ‘considered’ for implementation, respectively. In the 2018 guideline, there are 19 new sections and two new algorithms. A further 21 sections are completely revised, nine are updated, with six sections receiving minor updates. SIGN guidance is the national clinical guidance for use in Scotland but NICE guidance is often quoted, especially if there is an opportunity for cost-saving or reduction of an existing service. The NICE guidance equivalent to SIGN 151 is the part of NICE Clinical Guideline (CG) 95 that relates to people presenting with stable chest pain and also NICE CG126, Stable angina: management. 3,4 The former was published in 2010 and the latter in 2011; both were updated in 2016.
Implementing guidelines Cardiovascular
i
Read this article to learn more about: a the
clinical characteristics of angina and invasive investigations a the role of medication a revascularisation options. Read this article online at: GinP.co.uk/oct18-angina a non-invasive
Clinical characteristics of angina and making a diagnosis Certain characteristics of angina pain will increase the likelihood of making a diagnosis. Those outlined in SIGN 151 are shown in Box 1.1
The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors
cPD credits
NICE describes three features of angina pain that can help determine a diagnosis:3 a constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms a pain precipitated by physical exertion a pain relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes. The presence of all three features represents typical angina, two features signifies atypical angina, and if one or none of the three features are present, the pain is defined as non-anginal.1,3 The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors in individual patients, such as:1,3 a smoking a hypertension a diabetes
GuidelinesinPractice.co.uk
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Cardiovascular Implementing guidelines
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Box 1: Typical characteristics of angina1 a There
are several typical characteristics which should increase the likelihood of making a diagnosis of angina. These include: b type of discomfort—often described as tight, constricting, dull, or heavy b location—often retrosternal or left side of chest and can radiate to left arm, neck, jaw, and back b relation to exertion—angina is often brought on with exertion or emotional stress and eased with rest b duration—typically the symptoms last up to several minutes after exertion or emotional stress has stopped b other factors—angina may be precipitated by cold weather or after a large meal.
Scottish Intercollegiate Guidelines Network (SIGN). Management of stable angina. Edinburgh: SIGN, 2018. (SIGN 151). Available at: www.sign.ac.uk/sign-151-stableangina.html Reproduced with permission
a previous history of coronary artery
disease (CAD) or other vascular disease a family history of CAD a hyperlipidaemia a chronic kidney disease. SIGN defines a positive family history as a history of premature CAD in a male first-degree relative aged less than 55 years or female first-degree relative aged less than 65 years.1 NICE CG95 gives a similar list of cardiovascular risk factors but also states that a diagnosis of stable angina is more likely in men; however, the defining typical and atypical features are the same in men and women and different ethnic groups. 3 NICE CG95 states that a diagnosis of angina is less likely if the chest pain is continuous and/or very prolonged, unrelated to activity, brought on by breathing in, or associated with symptoms such as dizziness, palpitations, tingling, or difficulty swallowing. 3 Both guidelines outline what they individually consider to be the important aspects of clinical examination, with SIGN outlining the necessary baseline laboratory investigations. Conditions that exacerbate angina, such as anaemia, should be identified by appropriate blood tests. 3
26
GuidelinesinPractice.co.uk
SIGN makes it clear that if the diagnosis is uncertain, the clinician should avoid giving the patient the impression that they have angina as it may lead the patient to have false beliefs, which may be difficult to change even after further investigations have ruled out angina as the diagnosis.1 Both guidelines agree that diagnostic tests for myocardial ischaemia should not be offered to those with non-cardiac/ non-angina chest pain unless there are resting electrocardiogram (ECG) ST-T changes or Q waves.1,3
Assessment approach
diagnostic uncertainty from the history, a CT-coronary angiogram should be carried out as an anatomical investigation to determine the presence of obstructive CAD (Figure 1). Those with non-obstructive CAD should receive medical therapy and only invasive coronary angiography if they have ongoing symptoms despite optimal medical therapy (Figure 2). Those with left main-stem or severe three-vessel disease should receive invasive coronary angiography.1 NICE CG95 states that clinical judgment, ECG changes, as well as people’s preferences and co-morbidities should be taken into account when considering diagnostic testing using a 64-slice (or above) CT-coronary angiography. 3 Both guidelines agree that in patients with previously diagnosed CAD, noninvasive functional testing should be considered.1,3 SIGN includes exercise tolerance testing in the list of choices,1 with the NICE options being:3 a myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) a stress echocardiology a first-pass contrast-enhanced magnetic resonance (MR) perfusion a MR imaging for stress-induced wall motion abnormalities.
A 12-lead ECG is an essential part of the assessment and NICE gives guidance on changes that may indicate ischaemia or previous infarction:3 a pathological Q waves a left bundle branch block a ST-segment and T wave abnormalities (such as flattening or inversion).
NICE is clear that exercise ECG or MR coronary angiography should not be used to diagnose stable angina. SIGN states that an exercise tolerance test (exercise ECG) should not be used as a first-line diagnostic test, and only discusses cardiac MR in the context of stratifying risk.
Deciding on diagnostic investigations
Exercise tolerance testing (ETT) as an initial test for patients with angina symptoms and suspected to have CAD should be replaced by computed tomography-coronary angiography
SIGN indicates that in patients with suspected angina, if there is
Exercise tolerance testing (ETT) versus computed tomographycoronary angiography (CT-CA)
EMPOWER SMOKERS TO QUIT FOR GOOD HELP THEM TACKLE THEIR HABIT FROM TWO ANGLES
+ INVISIPATCH™ For sustained relief from withdrawal symptoms 1
Prescribing information can be found on the back cover
QUICKMIST ™ Flexible format for fast craving relief 2
Nicorette Invisi Patch Prescribing Information: Presentation: Transdermal delivery system available in 3 sizes (22.5, 13.5 and 9cm2) releasing 25mg, 15mg and 10mg of nicotine respectively over 16 hours. Uses: Nicorette Invisi Patch relieves and/ or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them. Nicorette Invisi Patch is indicated in pregnant and lactating women making a quit attempt. If possible, Nicorette Invisi Patch should be used in conjunction with a behavioural support programme. Dosage: It is intended that the patch is worn through the waking hours (approximately 16 hours) being applied on waking and removed at bedtime. Smoking Cessation: Adults (over 18 years of age): For best results, most smokers are recommended to start on 25 mg / 16 hours patch (Step 1) and use one patch daily for 8 weeks. Gradual weaning from the patch should then be initiated. One 15 mg/16 hours patch (Step 2) should be used daily for 2 weeks followed by one 10 mg/16 hours patch (Step 3) daily for 2 weeks. Lighter smokers (i.e. those who smoke less than 10 cigarettes per day) are recommended to start at Step 2 (15 mg) for 8 weeks and decrease the dose to 10 mg for the final 4 weeks. Those who experience excessive side effects with the 25 mg patch (Step 1), which do not resolve within a few days, should change to a 15 mg patch (Step 2). This should be continued for the remainder of the 8 week course, before stepping down to the 10 mg patch (Step 3) for 4 weeks. If symptoms persist the advice of a healthcare professional should be sought. Adolescents (12 to 18 years): Dose and method of use are as for adults however, recommended treatment duration is 12 weeks. If longer treatment is required, advice from a healthcare professional should be sought. Smoking Reduction/Pre-Quit: Smokers are recommended to use the patch to prolong smoke-free intervals and with the intention to reduce smoking as much as possible. Starting dose should follow the smoking cessation instructions above i.e. 25mg (Step 1) is suitable for those who smoke 10 or more cigarettes per day and for lighter smokers are recommended to start at Step 2 (15 mg). Smokers starting on 25mg patch should transfer to 15mg patch as soon as cigarette consumption reduces to less than 10 cigarettes per day. A quit attempt should be made as soon as the smoker feels ready. When making a quit attempt smokers who have reduced to less than 10 cigarettes per day are recommended to continue at Step 2 (15 mg) for 8 weeks and decrease the dose to 10 mg (Step 3) for the final 4 weeks. Temporary Abstinence: Use a Nicorette Invisi Patch in those situations when you can’t or do not want to smoke for prolonged periods (greater than 16 hours). For shorter periods then an alternative intermittent dose form would be more suitable (e.g. Nicorette inhalator or gum). Smokers of 10 or more cigarettes per day are recommended to use 25mg patch and lighter smokers are recommended to use 15mg patch. Contraindications: Hypersensitivity. Precautions: Underlying cardiovascular disease, diabetes mellitus, renal or hepatic impairment, phaeochromocytoma or uncontrolled hyperthyroidism, generalised dermatological disorders, gastrointestinal disease. Angioedema and urticaria have been reported. Erythema may occur. If severe or persistent, discontinue treatment. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response, to adenosine. Keep out of reach and sight of children and dispose of with care. Should be removed prior to undergoing MRI procedures. Pregnancy and lactation: Smoking cessation during pregnancy should be achieved without NRT. However, for women unable to quit on their own, NRT may be recommended to assist a quit attempt after consulting a healthcare professional. Side effects: Very common: pruritus. Common: headache, dizziness, nausea, rash, urticaria, vomiting. Uncommon: hypersensitivity, palpitations, paraesthesia, tachycardia, flushing, hypertension, hyperhidrosis, myalgia, application site reactions, asthenia, chest discomfort and pain, malaise, fatigue, dyspnoea. Rare: Anaphylactic reaction, GI discomfort, angioedema, erythema, pain in extremity. Very rare: reversible atrial fibrillation. NHS Cost: 25mg packs of 7: £11.15, 25mg packs of 14: £18.28, 15mg packs of 7: £11.10, 10mg packs of 7: £10.99. Legal category: GSL. PL holder: McNeil Products L.td, Roxborough Way, Maidenhead, Berkshire, SL6 3UG. PL numbers: 15513/0161; 15513/0160; 15513/0159. Date of preparation: May 2016.
Nicorette QuickMist 1mg/spray mouthspray & Nicorette QuickMist Cool Berry 1mg/spray mouthspray Prescribing Information: Presentation: Oromucosal spray. Each 0.07 ml contains 1mg nicotine, corresponding to 1mg nicotine/spray dose. Uses: Relieves and/or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them. It is indicated in pregnant and lactating women making a quit attempt. Dosage: Adults and Children over 12 years of age: The patient should make every effort to stop smoking completely during treatment with Nicorette QuickMist. One or two sprays to be used when cigarettes normally would have been smoked or if cravings emerge. If after the first spray cravings are not controlled within a few minutes, a second spray should be used. If 2 sprays are required, future doses may be delivered as 2 consecutive sprays. Most smokers will require 1-2 sprays every 30 minutes to 1 hour. Up to 4 sprays per hour may be used; not exceeding 2 sprays per dosing episode and 64 sprays in any 24-hour period. Nicorette QuickMist should be used whenever the urge to smoke is felt or to prevent cravings in situations where these are likely to occur. Smokers willing or able to stop smoking immediately should initially replace all their cigarettes with the Nicorette QuickMist and as soon as they are able, reduce the number of sprays used until they have stopped completely. When making a quit attempt behavioural therapy, advice and support will normally improve the success rate. Smokers aiming to reduce cigarettes should use the Mouthspray, as needed, between smoking episodes to prolong smoke-free intervals and with the intention to reduce smoking as much as possible. Contraindications: Children under 12 years of age and hypersensitivity to any of the ingredients. Precautions: Underlying cardiovascular disease, diabetes mellitus, G.I disease, uncontrolled hyperthyroidism, phaeochromocytoma, hepatic or renal impairment. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and both less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response to, adenosine. Keep out of reach and sight of children and dispose of with care. Care should be taken not to spray the eyes whilst administering the spray. Pregnancy & lactation: Smoking cessation during pregnancy should be achieved without NRT. However, if the mother cannot (or is considered unlikely to) quit without pharmacological support, NRT may be used after consulting a healthcare professional. Side effects: Very common: Headache, cough, throat irritation, nausea, hiccups. Common: Toothache, hypersensitivity, burning sensation, dizziness, dysgeusia, paraesthesia, abdominal pain, diarrhoea, dry mouth, flatulence, salivary hypersecretion, stomatitis, vomiting, dyspepsia, fatigue. Uncommon: Abnormal dreams, palpitations, tachycardia, flushing, hypertension, bronchospasm, dysphonia, dyspnoea, nasal congestion, sneezing, throat tightness, eructation, glossitis, oral mucosal blistering and exfoliation, paraesthesia oral, dry skin, urticaria, angioedema, hyperhidrosis, pruritus, rash, erythema, pain in jaw, asthenia, chest discomfort and pain, malaise, oropharyngeal pain, rhinorrhea, gingivitis, musculoskeletal pain, hyperhidrosis. Rare: Dysphagia, hypoaesthesia oral, retching. Not known: Atrial fibrillation, anaphylactic reaction, blurred vision, lacrimation increased, dry throat, GI discomfort, lip pain, muscle tightness, angioedema, erythema. NHS Price: Nicorette QuickMist 1mg/spray mouthspray: 1 dispenser pack £13.03, 2 dispenser pack £20.58, Nicorette QuickMist Cool Berry 1mg/ spray mouthspray: 1 dispenser pack £ 13.03, 2 dispenser pack £20.58. Legal category: GSL PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG PL number: Nicorette QuickMist 1mg/spray mouthspray: 15513/0357, Nicorette QuickMist Cool Berry 1mg/spray mouthspray: 15513/0395 Date of preparation: June 2018.
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to McNeil Products Limited on 01344 864 042. References: 1. Nicorette Invisi 15mg Patch Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/6436. Accessed: August 2018. 2. Nicorette QuickMist 1mg/spray mouthspray Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/medicine/24257. Accessed: August 2018. Date of preparation: September 2018. UK/NI/18-12380
Figure 1: Management options in patients with suspected angina1 Suspected angina (i.e. where there is diagnostic uncertainty from the history)
CT-coronary angiogram (e.g. anatomical investigation) to determine the presence of obstructive CAD
No CAD
Non-obstructive CAD
Discharge
Commence secondary prevention medication
No further cardiac investigations required
Obstructive CAD
Left main-stem or Severe 3-vessel disease
No further cardiac investigations required (See sections 4 and 5.5 of the full guideline)
Implementing guidelines Cardiovascular
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
No Yes
Commence secondary prevention and antianginal medication (see sections 4 and 5.5 of full guideline)
Ongoing symptoms despite optimal medication? No
Yes
Invasive coronary angiography* (*taking into consideration renal function, age, co-morbidities)
Suitable for revascularisation? No Optimise medical therapy
Yes
Ongoing symptoms? No Yes
Continue medical treatment
Consider treatments for refractory angina
PCI or CABG
CT=computerised tomography; CAD=coronary artery disease; PCI=percutaneous coronary intervention; CABG=coronary artery bypass grafting Scottish Intercollegiate Guidelines Network (SIGN). Management of stable angina. SIGN 151. Edinburgh: SIGN, 2018. (SIGN 151). Available at: www.sign.ac.uk/sign-151-stable-angina.html Reproduced with permission
Continued on p.31
GuidelinesinPractice.co.uk
27
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FOR HEALTHCARE PROFESSIONAL USE ONLY
REASSURE
Breastfeeding is best for babies
WITH THE
UK’S MOST PALATABLE EHF1*
Aptamil Pepti HCPs believe palatability increases compliance1
the
step st ep in the effective management of
cows’ milk allergy is extensively hydrolysed formula†
† For the management of mild to moderate cows’ milk allergy, the iMAP guideline2 recommends an Extensively Hydrolysed Formula (EHF) as the first step for formula feeding or mixed feeding (if symptoms only with introduction of top-up feeds) infants.
References: 1. Campden BRI conducted a blind taste test using a home usage design with a sample of 100 Dietitians and General Practitioners from 16.11.2016 to 09.12.16. Participants rank ordered the extensively hydrolysed formula (EHF) milk samples (Danone Aptamil Pepti, Abbott Similac Alimentum, Nestle SMA Althera and Mead Johnson Nutramigen LGG) in term of overall liking and answered a series of attitudinal questions in relation to the impact of EHF’s palatability on infants with CMA and their families. The results from the ranking showed that the Danone Aptamil Pepti sample was liked significantly more than all the other three samples tested. 2. Venter C et al , 2017. Better recognition, diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy. August, vol. 7, no. 26. *A home usage test assessment was carried out between 16/11/16 and 9/12/16 on the 4 products indicated for cows’ milk allergy from birth and included 100 UK healthcare professionals.
IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cows’ milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is suitable for babies over 6 months as part of a mixed diet.
18-044 (Palatability)/Date of Prep: March 2018 © Danone Nutricia Early Life Nutrition 2018
Healthcare Professional Helpline: 0800
996 1234 www.eln.nutricia.co.uk/cma
Figure 2: Management options in patients with a definite diagnosis of stable angina1
Definite diagnosis of stable angina (e.g. known obstructive CAD, clear history)
Introduce or increase antianginal therapy Review secondary prevention (see sections 4 and 5.5 of full guideline)
Suitable for risk stratification with functional assessment? (e.g. exercise tolerance test, myocardial perfusion scintigraphy, stress echocardiogram, perfusion CMR imaging) No
Yes
intermediate or low risk
Implementing guidelines Cardiovascular
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
high risk
Optimise medical therapy
Ongoing symptoms despite optimal medication? Invasive coronary angiography* No
Yes
(*taking into consideration renal function, age, co-morbidities)
Suitable for revascularisation? No
Yes
Optimise medical therapy
Ongoing symptoms? No
Continue medical treatment
Yes Consider treatments for refractory angina
PCI or CABG
CAD=coronary artery disease; CMR=cardiac magnetic resonance imaging; PCI=percutaneous coronary intervention; CABG=coronary artery bypass grafting Scottish Intercollegiate Guidelines Network (SIGN). Management of stable angina. SIGN 151. Edinburgh: SIGN, 2018. (SIGN 151). Available at: www.sign.ac.uk/sign-151-stable-angina.html Reproduced with permission
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31
ONLY ANORO (umeclidinium/vilanterol) HAS POSITIVE HEAD-TO-HEAD EFFICACY DATA VS. ANOTHER ONCE-DAILY LAMA/LABA *1
Anoro Ellipta (55/22mcg) is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with COPD2
*Anoro Ellipta showed superiority on the primary endpoint of trough FEV1 compared to Spiolto in the ITT population (n = 236; p<0.001). Anoro and Spiolto had a similar safety profile. This was an 8-week, randomised, open-label, two-period crossover study.1 Anoro Ellipta (umeclidinium bromide/vilanterol [as trifenatate]) Prescribing information (Please consult the full Summary of Product Characteristics (SmPC) before prescribing) Anoro Ellipta 55/22mcg (umeclidinium bromide /vilanterol [as trifenatate]) inhalation powder. Each single inhalation provides a delivered dose (the dose leaving the mouthpiece) of 55 micrograms umeclidinium (equivalent to 65 micrograms of umeclidinium bromide) and 22 micrograms of vilanterol (as trifenatate). Indications: Anoro is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). Dosage and administration: Inhalation only. One inhalation once daily of Anoro. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate and magnesium stearate). Precautions: Anoro should not be used in patients with asthma. Treatment with Anoro should be discontinued in the event of paradoxical bronchospasm and alternative therapy initiated if necessary. Cardiovascular effects may be seen after the administration of
muscarinic receptor antagonists and sympathomimetics therefore Anoro should be used with caution in patients with severe cardiovascular disease. Anoro should be used with caution in patients with urinary retention, narrow angle glaucoma, convulsive disorders, thyrotoxicosis, hypokalaemia, hyperglycaemia and severe hepatic impairment. No dosage adjustment is required in renal or mild to moderate hepatic impairment. Acute symptoms: Anoro is not indicated for acute episodes of bronchospasm. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases, a re-evaluation of the patient and of the COPD treatment regimen should be undertaken. Interactions with other medicinal products: Avoid β-blockers. Caution is advised when co-administering with strong CYP3A4 inhibitors (e.g. ketoconazole, clarithromycin, itraconazole, ritonavir, telithromycin). Anoro should not be used in conjunction with other long-acting β2-adrenergic agonists or medicinal products containing long-acting muscarinic antagonists. Caution is advised with concomitant use with methylxanthine derivatives, steroids or non-potassium-sparing diuretics as it may potentiate possible hypokalaemic effect of β2-adrenergic agonists. Fertility, pregnancy, and breast-feeding: No available data. Balance
risks against benefits. Side effects: Common (≥1/100 to <1/10): urinary tract infection, sinusitis, nasopharyngitis, pharyngitis, upper respiratory tract infection, headache, cough, oropharyngeal pain, constipation and dry mouth. Other important side effects include: Uncommon (≥1/1,000 to <1/100) atrial fibrillation, supraventricular tachycardia, rhythm idioventricular, tachycardia, supraventricular extrasystoles, palpitations, and hypersensitivity reactions including rash.Rare (≥1/10,000 to <1/1,000) anaphylaxis, angioedema, and urticaria. Glaucoma, vision blurred, intraocular pressure increased and paradoxical bronchospasm. See SmPC for other adverse reactions. Legal category: POM. Presentation and Basic NHS cost: Anoro Ellipta. 1 inhaler x 30 doses. Anoro Ellipta 55/22mcg - £32.50. Marketing authorisation (MA) no. 55/22mcg 1x30 doses [EU/1/14/898/002]; MA holder: Glaxo Group Ltd, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK. Last date of revision: July 2018. UK/UCV/0095/15(2)b. Anoro and Ellipta are registered trademarks of the GlaxoSmithKline group of companies. All rights reserved. Anoro was developed in collaboration with Innoviva Inc. References: 1. Feldman GJ et al. Adv Ther 2017; 34:2518-2533. 2. Anoro Ellipta SmPC.
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellowcard in the Google Play or Apple App store. Adverse events should also be reported to GlaxoSmithKline on 0800 221 441
Read the clinical data at www.anoro.co.uk
© 2018 GlaxoSmithKline Group of Companies. Zinc code: UK/UCV/0010/18(1) I Date of preparation: September 2018
Table 1: Symptomatic management of stable angina1,4 SIGN 1511
NICE CG1264
Immediate relief of symptoms
Sublingual glyceryl trinitrate tablets or spray Offer short-acting nitrate for preventing and treating should be used for the immediate relief of angina episodes angina and before performing activities known Repeat the dose after 5 minutes if pain has not gone to bring on angina Call an emergency ambulance if pain has not gone 5 minutes after taking second dose
First-line therapy for relief of symptoms
Use BBs as first-line therapy Consider rate-limiting CCB when BBs are contraindicated Treat Prinzmetal (vasospastic) angina with a dihydropyridine derivative CCB
Offer a BB or CCB Decide which one to use based on co-morbidities, contraindications, and person’s preference If unable to tolerate BB or CCB or symptoms not satisfactorily controlled, consider switching to the other If BB or CCB or both are contraindicated, monotherapy with: a long-acting nitrate or
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Guidelines in Practice | October 2018 | Volume 21 | Issue 10
a ivabradine or a nicorandil or a ranolazine
Decide which drug to use based on co-morbidities, contraindications, the person’s preference and drug costs* Combination If BB inadequate to control symptoms consider If a BB or a CCB does not adequately control therapy symptoms, consider using a combination of the two† adding a CCB
Rate-limiting CCB should be used with caution when combined with BB Adding IMN to BB or to CCB improves performance on range of clinical end points Adding ivabradine to atenolol relieves symptoms and improves exercise capacity Adding nicorandil to other anti-anginal drugs is effective at reducing combined cardiac events The combination of ivabradine and a BB or rate-limiting CCB is not recommended by the SMC in Scotland Ranolazine improves exercise tests in refractory chronic stable angina. Ranolazine is not recommended by the SMC in Scotland Patients whose symptoms are not controlled on maximum therapeutic doses of two drugs should be considered for referral to a cardiologist
If either BB or CCB monotherapy is contraindicated or ineffective, add in alternative therapy: a long-acting nitrate or a ivabradine or a nicorandil or a ranolazine Decide which drug based on co-morbidities, contraindications, the person’s preferences, and drug costs* Do not offer a third drug if stable angina is controlled with two drugs Consider adding a third drug if: a symptoms not satisfactorily controlled with two drugs and a the person is waiting for revascularisation or revascularisation is not felt to be appropriate or acceptable.
* Since NICE Clinical Guideline 126 was produced, the Medicines and Healthcare products Regulatory Agency (MHRA) has published new advice about safety concerns related to ivabradine (June 2014 and December 2014) and nicorandil (January 2016). †
When combining a calcium channel blocker with a beta blocker, use a dihydropyridine calcium channel blocker, for example, slow release nifedipine, amlodipine, or felodipine.
Developed by Alan Begg (2018) from the following guidelines: Scottish Intercollegiate Guidelines Network (SIGN). Management of stable angina. SIGN 151. Edinburgh: SIGN, 2018. Available at: www. sign.ac.uk/sign-151-stable-angina.html NICE. Stable angina: management. Clinical Guideline 126. NICE, 2011 (updated 2016). Available at: www.nice.org.uk/guidance/cg126 CG=clinical guideline; BB=beta blocker; CCB=calcium channel blocker; IMN=isosorbide mononitrate; SMC=Scottish Medicines Consortium
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Cardiovascular Implementing guidelines
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Table 2: Drugs to prevent new vascular events1,4 SIGN 1511
NICE CG1264
Antiplatelet All patients with angina therapy due to atherosclerotic disease should receive long-term standard aspirin therapy
Consider aspirin 75 mg daily, taking into account the risk of bleeding and co-morbidities
Lipid lowering
All patients should receive long-term statin therapy
Offer statin therapy in line with NICE CG675 [now replaced by NICE CG1816]
ACE-I
All patients should be Consider ACE-I for those with considered for treatment stable angina and diabetes. with ACE-I Offer or continue ACE-I for other conditions in line with relevant NICE guidance
High blood pressure treatment
Offer drug treatment in line with NICE CG1277
SIGN=Scottish Intercollegiate Guidelines Network; ACE-I=angiotensin-converting enzyme inhibitor; CG=clinical guideline
(CT-CA). The latter is noted to have an excellent diagnostic performance with a sensitivity of up to 99%, specificity of up to 92%, and a negative predictive value approaching 100%.1 The diagnostic accuracy of ETT, by contrast, varies depending on many features such as age and gender and the cohort of patients studied. A major drawback to the implementation of this new approach, however, is the lack of CT-CA capacity to implement the guidance; however, cardiologists in the author’s area are hopeful that this will not be too slow to change.
Medical therapy General practice has an important role in the management of angina, which is predominately medical therapy especially if there is a clear history of stable angina (Figure 2). This consists of two separate approaches: relieving symptoms (Table 1) and using therapeutic preventative therapy (Table 2) to prevent secondary vascular events. SIGN and NICE recommendations vary slightly, especially in symptom relief, so practices should consider developing
34
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their own implementation approach based on local prescribing policies and cost-reduction initiatives. Both guidelines show less variation in the therapeutic approach to prevention of cardiovascular events.
[CT-CA] is noted to have an excellent diagnostic performance
patient remains symptomatic on optimal medical therapy a patient high risk on functional assessment. In all other situations, optimal medical treatment is the ideal and if there are still symptoms and the patient is not suitable for revascularisation then treatments for refractory angina should be considered.1 Choice of revascularisation Percutaneous coronary intervention (PCI) involves dilating the artery by inflating a fine balloon and inserting a fine lattice scaffold (stent) to prevent the artery from recoiling. Stents are coated with drugs to prevent or retard endothelialisation.1 Coronary artery bypass grafting (CABG) involves bypassing a section of the coronary artery narrowed by atheroma by a section of healthy saphenous vein or internal mammary artery. SIGN does not come to a conclusion as to whether CABG is superior to PCI in terms of prognostic benefit.1 NICE CG126 says that when either procedure is appropriate, take into account the potential survival advantage of CABG over PCI for people with multi-vessel disease and who:3 a have diabetes or a are over 65 years or a have anatomically complex threevessel disease, with or without involvement of the left main stem.
Revascularisation
NICE 126 also indicates that CABG should be offered if symptoms are not controlled medically, if the anatomy is suitable, and if PCI is felt not to be appropriate; conversely, offer PCI when CABG is not appropriate.
The path to invasive coronary angiography for possible revascularisation is clear in SIGN 151 (Figures 1 and 2): a obstructive left main-stem or severe three-vessel disease on CT-CA a non-obstructive CAD on CT-CA but
Ideally, revascularisation options should be agreed following review by a multidisciplinary ‘heart team’ including cardiac surgeons, cardiac anaesthetists, and interventional cardiologists, and discussion with the patient.
Advice related to surgery The Society of Thoracic Surgeons recommends that aspirin should be stopped for 3–5 days before elective CABG and then restarted early after surgery.1,8 The routine use of perioperative beta-blocker therapy to reduce perioperative myocardial infarction in patients undergoing non-cardiac surgery is now not recommended.1 Similarly, the use of aspirin to reduce perioperative cardiac events in patients undergoing non-cardiac surgery, including those with known stable CAD, is also not recommended.1 Patients undergoing non-cardiac surgery should have their statin therapy continued through the perioperative period.1
Implementation actions for STPs and ICSs written by Dr David Jenner, GP, Cullompton, Devon The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. a Convene
a local STP implementation group to assess the relevant guidance (NICE or SIGN) for your area b ensure
this group includes specialists, radiographers, GPs, and public health professionals alongside commissioners
a Agree
and publish a local care pathway for the diagnosis, management, and ongoing care for people suspected of having angina
a Make
sure sufficient CT angiography is commissioned, as both SIGN and NICE define this as a key first-line diagnostic intervention
Implementing guidelines Cardiovascular
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
a Consider
Managing refractory angina Refractory angina is defined in SIGN 151 as ‘persisting unsatisfactory control of angina symptoms despite maximal tolerated medical therapies and without further revascularisation options’. SIGN does not, however, make any recommendations for invasive interventions for refractory angina. Comprehensive rehabilitation is suggested, with patients following an ‘educational and rehabilitative approach, progressing to a cognitive behaviourally-informed approach where appropriate’.1 The one recommendation made is that patients with angina should be assessed by appropriately trained staff for the impact of angina on mood, quality of life, and function.1 NICE CG126 advises against the use of transcutaneous electrical nerve stimulation (TENS), enhanced external counterpulsation (EECP), or acupuncture to manage stable angina.4 SIGN states that transmyocardial laser revascularisation is not recommended for the treatment of stable angina.1 For patients who have not responded to drug treatment and/ or revascularisation, comprehensive re-evaluation and advice may include:4
local education programmes to help primary care clinicians to understand and implement the new care pathway, ensuring prompt referral and then good medical management of those diagnosed with angina.
STP=sustainability and transformation partnership; ICS=integrated care system; SIGN=Scottish Intercollegiate Guidelines Network; CT=computed tomography. a exploring the patient’s
understanding of their condition a exploring the impact of symptoms on the person’s quality of life a reviewing the diagnosis and considering non-ischaemic causes of pain a reviewing drug treatment and considering future drug treatments and revascularisation options a acknowledging the limitations of future treatment a explaining how the person can manage the pain themselves.
Psychological health in patients with angina Angina can have an adverse effect on the patient’s wellbeing and quality of life. It is important that patients are assessed for this effect and managed appropriately. Interventions such as the Angina plan can help.9 This is a patient-held workbook and relaxation programme delivered in primary care, which has been shown to significantly reduce the mean number of self-reported angina attacks and
physical limitation, with a reduction in anxiety and depression.1
Implementation With the publication of the SIGN 151 angina guideline,1 practitioners now have access to professionally produced guidance that gives an up-to-date overview of the evidence, especially in relation to assessment, medical management, and revascularisation. Primary care has an important role in the first two of these aspects even though there has been an increase in revascularisation in recent years, with more insertion of drug-eluting stents in particular. The use of CT-CA as the main investigation to determine the presence and extent of obstructive CAD does, however, stand out as requiring significant investment before this guideline can be successfully implemented. Implementation actions for STPs and ICSs are above, and those for clinical pharmacists are on p.36
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Cardiovascular Implementing guidelines
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Implementation actions for clinical pharmacists written by Gupinder Syan, Training and Clinical Outcomes Manager, Soar Beyond Ltd The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level. a Agree
the scope of patients to be seen within your competence— most clinical pharmacists should feel competent to review stable angina patients as part of their scope of practice in annual CVD reviews or medication reviews
a Set
up searches to identify patients to see in clinic; coding is essential for evaluating interventions, e.g. search for patients coded with angina who are not on an antiplatelet/statin/ACE-I
a Familiarise
yourself with local guidelines and formularies to ensure cost-effective practice
a Adopt
an MDT approach and involve other HCPs when managing more complex patients
a Know
when and how to refer patients to other local services
a Assess
the following areas in your patient reviews:
b symptom
relief—check if the patient is on a GTN spray and review usage. If the patient is still symptomatic refer them to the GP or secondary care for further investigations, or consider medicines optimisation if it is within your scope of competence
b therapeutic
preventative therapy—ensure the patient is on the correct preventative medications in line with the NICE and SIGN guidelines (including secondary prevention measures e.g. statins, ACE-I, nitrates). Check doses, adherence, interactions, side-effects, and patient understanding, and ask about any upcoming surgery and provide appropriate medication advice
b lifestyle
and mood—reinforce diet and lifestyle advice, establish current QoL and where they would like to be, assess mood, and refer on appropriately
b agree
on a care plan, which aims to improve symptoms, QoL, and prevent deterioration by setting realistic and achievable goals with the patient
a Evaluate
your contribution to patients that you have managed in angina reviews, thinking about the following: b how
many patients with stable angina have you reviewed?
b how
much time have you saved and freed up for additional appointment slots for other HCPs?
b what
local cost-effective switches have you made?
b how
many patients have experienced improvements in angina symptoms, QoL, or mood following your intervention?
b how
many patients have you optimised preventative therapy for by initiating an ACE-I/statin/nitrate?
CVD=cardiovascular disease; ACE-I=angiotensin-converting-enzyme inhibitor; MDT=multidisciplinary team; HCPs=healthcare professionals; GNT=glyceryl trinitrate; QoL=quality of life
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Dr Alan Begg GP, Montrose GPwSI in cardiovascular disease Trustee of Chest, Heart, and Stroke Scotland (CHSS) Trustee of Scottish Heart and Arterial Risk Prevention Group (SHARP) Specialist reviewer of SIGN 151
References 1. Scottish Intercollegiate Guidelines Network. Management of stable angina. SIGN 151. Edinburgh: SIGN, 2018. Available at: www. sign.ac.uk/sign-151-stable-angina.html 2. Scottish Intercollegiate Guidelines Network. Management of stable angina. SIGN 96. Edinburgh: SIGN, 2007. 3. NICE. Chest pain of recent onset: assessment and diagnosis. Clinical Guideline 95. NICE, 2010 (updated 2016). Available at: www.nice. org.uk/guidance/cg95 4. NICE. Stable angina: management. Clinical Guideline 126. NICE, 2011 (updated 2016). Available at: www.nice.org.uk/guidance/ cg126 5. NICE. Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Clinical Guideline 67. NICE, 2008. 6. NICE. Cardiovascular disease: risk assessment and reduction, including lipid modification. Clinical Guideline 181. NICE, 2014 (updated 2016). Available at: www.nice.org.uk/cg181 7. NICE. Hypertension in adults: diagnosis and management. Clinical Guideline 127. NICE, 2011 (updated 2016). Available at: www.nice. org.uk/cg127 8. Ferraris V, Ferraris S, Moliterno D et al; Society of Thoracic Surgeons. The Society of Thoracic Surgeons practice guideline series: aspirin and other antiplatelet agents during operative coronary revascularization (executive summary). Ann Thorac Surg 2005; 79 (4): 1454 –1461. 9. Lewin R, Furze G, Robinson J et al. Randomised controlled trial of a selfmanagement plan for patients with newly diagnosed angina. Br J Gen Pract 2002; 52 (476): 194–196, 199–201. G
independent content
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Bid writing in general practice: how to win a losing battle
Working smarter
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Dr Satpal Shekhawat explores the business development challenges faced by primary care clinicians, and the steps necessary to overcome them
W
hen I qualified as a GP in 2009, Clinical Commissioning Groups (CCGs) were non-existent, and commissioning and the provision of clinical services were not part of the Royal College of General Practitioners (RCGP) training curriculum.1 In 2012, CCGs came into being and became responsible for the provision of healthcare to all residents within their clinical boundaries.1 Clinical services delivered by primary care, secondary care, and the private sector are commissioned by local CCGs, and the contractual agreements between these bodies contain the specifications for the commissioned services (see Figure 1). 2 CCGs are accountable for the care delivered to the residents of their area, and must ensure that the services delivered are in accordance with the specifications and that the outcomes for patients are as agreed. Nationally, CCGs regularly commission new services, renew existing contracts, and monitor the performance of providers against all commissioned contracts. The NHS portal is used by CCGs to advertise new procurement activity, and all providers can register on the portal to track newly advertised services.
Why is it challenging for primary care to win bids? Primary care is currently facing a massive challenge in the form of workforce shortages, which are
Read this article to learn more about: a why
bid writing is challenging for GPs a the importance of shared vision, workforce capacity, and preparing answers in advance a elements of successful bid writing. Read this article at: GinP.co.uk/oct18-bidwriting compounded by the fact that the workload has increased excessively. 3 These challenges are keeping most healthcare professionals in primary care extremely busy: we don’t have the time or capacity to focus on the future growth of the practice as a business, get involved in bid writing, or take on more work. We are all working hard to keep our heads above water and deliver basic general medical services (GMSs) to registered patients. In addition, most of us don’t have the availability or resources needed to deliver these services once contracts are secured. Currently, commissioning, bid writing, and procuring services constitute a small part of the RCGP curriculum;1 most newly qualified GPs have a poor understanding of these processes,
We are clinicians, and our work experience helps us to design effective services …
cPD credits
and it is left up to them to develop the necessary skills in their own time. We are clinicians, and our work experience helps us to design effective services, ensuring that there is robust clinical governance in place, improving the patient journey, and achieving clinical outcomes in line with commissioning intentions. Despite this, the bid-writing process tests us in terms of putting this vision on paper and sharing it with non-clinicians, who award contracts based on whether the proposal covers key areas of clinical governance, its mobilisation plan, its use of existing resources, additional costs to the system, whether it addresses health inequalities, and, most importantly, how it impacts the delivery of other contractual services. Conversely, most private providers have dedicated teams to track new commissioned services, write bids, and secure contracts, that are economically lucrative to their organisations. These organisations use existing contracts to demonstrate effective governance, mobilisation plans, financial security, established referral pathways, and approaches to delivering services within budget to help them in securing NHS contracts.
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Working smarter
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Figure 1: The NHS commissioning cycle2
bid writing and business development and provide them with protected time to fulfil this part of their role. Discuss the 5-year plan for the organisation during practice meetings. This also helps with achieving a shared vision among team members. 4. Be prepared Prepare answers in advance. The clinical governance structure of your organisation should be documented (using illustrations to demonstrate the seven pillars of clinical governance3) and kept up to date so that it is ready to aid bid writing and overcome the challenges posed by short deadlines.
NHS England. Commissioning cycle. www.england.nhs.uk/participation/resources/ commissioning-engagement-cycle/ (accessed 7 September 2018).
How can we turn the tide in our favour? We are primary care clinicians with years of experience in the provision of good clinical care and keeping our patients healthy. We are the frontline, and the wisdom gained from providing care in the community is extremely useful when tendering for NHS contracts. To succeed in winning contracts, bids should include several key features, which are described below. 1. Develop a shared vision Providing good GMSs to registered patients is the main contract for general practice. Practices need to ensure that everyone is committed to the idea of bidding for a new contract and shares the same vision. Primary care is all about teamwork, and it is impossible to move forward unless the entire team works together.
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2. Define the workforce strategy Workforce shortages and increasing workload in primary care present an opportunity to those who have foresight and are willing to engage the entire team to work hard and achieve more. Practices need to ensure that the workforce within the team is sufficient to provide existing services and take on additional work. If this is not done properly, it can impact the work–life balance of the team and lead to problems in the future. One way to enhance the efficiency of the team is to diversify the workforce, i.e. by incorporating paramedics, nurse prescribers, physiotherapists, and pharmacists. 3. Invest in time Most contracts are advertised with an extremely short deadline, usually 1–2 weeks, which puts tremendous pressure on the team to prepare the bid within the given timeframe. Identify team members who have strengths in
Similarly, it is worth preparing answers to questions on areas such as the current contracts, service delivery relative to key performance indicators, policies on data sharing and use of information and technology, and the leadership model of the organisation. This information will already exist in your organisation and keeping it ready can help in formulating a bid in a short time. 5. Use the experts There are many experts in NHS bid writing, and establishing relationships with them is worth every penny. Minimise expenses by doing the initial work and then employing the expert on a contractual basis to amend it to make your bid more successful. This process will also help you learn: in future, you may not need expert help and may be in position to provide consultancy yourself. 6. Keep patients at the centre General practice is patient centred, and this is its unique selling point. When writing any bid, keep patient-centred care at the core and design the service around it. This approach will ensure that the right motives are in place to help deliver better clinical outcomes for the relevant population. 7. Innovate When writing the bid, always include other areas for improvement and
innovation, even if they have not been considered by the commissioners. This demonstrates a depth of understanding of primary care and passion for providing good quality healthcare. Grass-roots GPs are best placed to propose ideas for improving community-based healthcare. 8. Create a mobilisation plan In any bid written for a service, a mobilisation plan is essential. A successful bid must have a detailed mobilisation plan, and it should include the timescales of all activities needed from award of contract to delivery of service. Clinicians will naturally focus on service design, governance, and delivery of service, and usually rely on practice managers for the mobilisation of resources, so this can sometimes get overlooked. Involving the practice management team can strengthen this aspect of your bid. 9. Use illustrations All general practices are contract holders and possess the necessary infrastructure, policies, and skills to deliver healthcare services. Using this knowledge and providing examples in various areas of the bid are essential to demonstrate capability and will help secure the bid. 10. Demonstrate clinical governance The bid should include an explanation of the clinical governance structures in place in the organisation and use examples to demonstrate all seven pillars of clinical governance.4 Newer providers with fewer contracts will need to demonstrate a robust governance process to reassure commissioners— this is the key to securing any contract.
What next? I strongly believe that primary care can deliver safe, effective, outcome-based community services
Key points a Commissioning,
bid writing, and procuring services make up a small part of the current RCGP curriculum, and most newly qualified GPs have a limited understanding of these processes a Workforce shortages and increasing workloads mean that most healthcare professionals in primary care lack the time and capacity to focus on business development a The work experiences of primary care clinicians qualify them to design effective services, ensuring that there is robust clinical governance in place, improving the patient journey, and achieving clinical outcomes in line with commissioning intentions a Successful bids for contracts should include key features such as: b a shared vision among the team b a workforce strategy to deliver existing and new services b a patient-centred approach b a mobilisation plan b an explanation of the clinical governance structures in place b an innovative approach towards delivering service a More information on commissioning and the provision of health services should be included in the GP trainee curriculum so that there is a capable workforce ready to face these challenges in future.
Working smarter
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
RCGP=Royal College of General Practitioners
that will improve the patient journey and help secondary care to focus on acute, unplanned care. For this, we must get actively involved in bidding for upcoming services, propose business plans to our CCGs, and work towards winning bids. We need to share our experiences to help each other and promote good clinical practice in the community. I also feel that the GP trainee curriculum needs to include commissioning and provision of health services so that there is a capable workforce ready to face these challenges in future.
Further reading Information is available on the commissioning cycle and how providers, patients, and clinicians can get involved in the process; one particularly useful resource is a document published by The King’s Fund on What is commissioning and how is it changing?5
Dr Satpal Shekhawat GP partner and trainer, Kirton Lindsey Honorary tutor, Hull York Medical School Associate Medical Director, North Lincolnshire CCG
References 1. Clinical Commissioners. About CCGs. www. nhscc.org/ccgs/ (accessed 26 September 2018). 2. NHS England. Commissioning cycle. www. england.nhs.uk/participation/resources/ commissioning-engagement-cycle/ (accessed 26 September 2018). 3. Buchan J, Charlesworth A, Gershlick B, Seccombe I. Rising pressure: the NHS workforce challenge—workforce profile and trends of the NHS in England. The Health Foundation, 2017. Available at: www.health.org.uk/sites/health/files/ RisingPressureNHSWorkforceChallenge.pdf 4. Gray C. What is clinical governance? BMJ 2005; 330: s254. 5. Wenzel L. What is commissioning and how is it changing? The King’s Fund, 2017. Available at: www.kingsfund.org.uk/publications/ what-commissioning-and-how-it-changing (accessed 26 September 2018). G
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Infection Top tips
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
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independent content
Top tips: communityacquired pneumonia Dr Sinan Eccles offers top tips for the assessment and management of adults with community-acquired pneumonia in primary care
E
ach year, around 1 in 300 of the adult population in the UK will have an episode of communityacquired pneumonia (CAP),1 with the incidence increasing with age. Only a small proportion of patients with symptoms of a lower respiratory tract infection (LRTI) presenting to primary care will have CAP, 2,3 and around one-third of them will require admission to hospital. 3 It is important to identify which patients with an LRTI have pneumonia, and which of these need hospital assessment.
1
Differentiate pneumonia from acute bronchitis
The key feature of pneumonia is the presence of consolidation: the filling of alveoli and adjoining ducts with inflammatory material. In primary care, where a chest X-ray to confirm the presence of consolidation is often not rapidly available, the clinical diagnosis of pneumonia relies on the examination findings of new focal chest signs in combination with symptoms of an LRTI and systemic features such as fever or rigors.4 Around 40% of patients with new focal chest signs treated with antibiotics in the community will have radiological evidence of pneumonia on chest X-ray. 2
2
Reassure patients that antibiotics are not usually indicated for LRTI
Getting the diagnosis right is important, as most patients with
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Read this article to learn more about: a assessing
patients with lower respiratory tract infections for pneumonia and identifying which patients need hospital assessment
a antibiotic
treatment of community-acquired pneumonia in primary
care a what
advice to give patients with pneumonia about self-care measures and likely duration of symptoms.
Read this article at: GinP.co.uk/oct18-pneumonia an LRTI in whom pneumonia is not clinically suspected do not benefit from antibiotics.5,6 Antibiotics should be reserved for those who are systemically unwell, have symptoms or signs suggestive of serious illness and/or complications, or who are at a high risk of complications,6 including patients who: a have significant pre-existing heart, lung, renal, liver, or neuromuscular co-morbidity a are immunosuppressed a are aged over 65 years with acute cough and two or more, or aged over 80 years with acute cough and one or more of the following criteria:
It is important to identify which patients with an LRTI have pneumonia, and which of these need hospital assessment
cPD credits
b hospitalisation in the previous
year b type 1 or 2 diabetes b history of congestive cardiac
failure b current use of oral
glucocorticoids. Point-of-care C-reactive protein (CRP) testing can be helpful in patients with acute bronchitis in whom pneumonia is not clinically suspected. When it is not clear whether antibiotics should be prescribed for a patient after clinical assessment, the use of point-of-care CRP testing can significantly reduce the use of antibiotics without causing harm. An algorithm for suggested use of point of care CRP is shown in Figure 1.
3
Use CRB-65 to help decide who needs hospital assessment
In patients presenting to primary care with a clinical diagnosis of CAP, the CRB-65 score (Table 1) gives an indication of the risk of death.
Figure 1: Algorithm for suggested use of point-of-care CRP6,7 Patient with symptoms of LRTI
Top tips Infection
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Clinical assessment
Clinical diagnosis of pneumonia
LRTI without clinical diagnosis of pneumonia
At high risk of complications*
Antibiotic prescribing decision uncertain
Self-limiting LRTI
Consider a point-of-care CRP test or CRP >100
Antibiotics indicated
CRP 20–100
Consider a delayed antibiotic prescription
CRP <20
Do not routinely offer antibiotics
Consider a delayed antibiotic prescription
* Patients considered ‘at high risk of complications’ are discussed in the text CRP=C-reactive protein; LRTI=lower respiratory tract infection Developed by Dr Sinan Eccles (2018). Adapted from NICE. Respiratory tract infections (self-limiting): prescribing antibiotics. NICE Clinical Guideline (CG) 69. NICE, 2008. Available at: www.nice.org.uk/cg69 and NICE. Pneumonia in adults: diagnosis and management. NICE CG191. NICE, 2014. Available at: www.nice.org.uk/cg191.
Patients with a score of 0 have a low risk of death (<1%) and are usually suitable for treatment in the community. Patients with a score of 1–2 have an intermediate risk of death (1–10% mortality) and those with a score of 3–4 have a high risk of death (>10% mortality). Hospital assessment should be considered for all patients with a score above 0, particularly those with a score of 2 or more.7 The severity of pneumonia usually correlates with the risk of mortality, but clinical judgment must be exercised alongside the CRB-65 score when making decisions about when to refer patients for hospital assessment.7 Factors such as social
circumstances, the wishes of the patient, and the stability of any co-morbid conditions should be taken into account.
The severity of pneumonia usually correlates with the risk of mortality
4
Give the right antibiotic at the right dose
National guidelines recommend amoxicillin 500 mg three times a day for 5 days as the first-line antibiotic for low-severity CAP, although local guidance may vary.4,7 Doxycycline (200 mg urgently then 100 mg once a day, or 100 mg twice a day) or clarithromycin (500 mg twice a day) are suitable alternatives, for example in those with a penicillin allergy.9,10 It is worth noting that there is a theoretical risk of doxycycline absorption being reduced by calcium intake, so patients taking calcium supplements should be advised to
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Infection Top tips
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
Table 1: CRB-65 score for community-acquired pneumonia8 Score one point for each factor present Confusion
New disorientation or abbreviated mental test score ≤8
Respiratory rate
≥30/min
Blood pressure
Systolic <90 mmHg, or diastolic ≤60 mmHg
65
Age ≥65 years
take these at a different time of day to doxycycline.11 Dual antibiotic therapy is not usually indicated for patients treated in the community, and is reserved for patients with moderate- to highseverity CAP.7
5
Give advice about simple measures
People with CAP should be advised to rest and to drink plenty of fluids. Smoking increases the risk of CAP and is likely to delay recovery.4 A diagnosis of CAP therefore affords a good opportunity to discuss smoking cessation. Paracetamol can help with fever or pleuritic pain.
6
Know when a chest X-ray is required
Most people with a clinical diagnosis of CAP suitable for treatment in the community do not require a chest X-ray. A chest X-ray is indicated if the diagnosis is in doubt and an X-ray will help with the differential diagnosis and acute management, if progress following treatment for a clinical diagnosis of CAP is not satisfactory, or if the patient is considered at risk of underlying lung pathology such as lung cancer.4
7
Send a sputum culture in selected cases
Most cases of CAP are caused by Streptococcus pneumoniae, 2,12 which
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is usually sensitive to first-line antibiotics in the UK. Therefore, a sputum culture is not necessary for most patients with low-severity CAP. It is helpful to send a sputum culture in patients with chronic lung disease such as chronic obstructive pulmonary disease (COPD) or bronchiectasis, because these patients are more likely to have had previous antibiotic courses and may have less common or more resistant pathogens requiring alternative antibiotics. Sputum culture should also be considered in patients who do not respond satisfactorily to first-line empirical antibiotics.4 If there is a suspicion of tuberculosis— for example, persistent productive cough, longer duration of symptoms, night sweats, and/or presence of risk factors such as social deprivation, ethnic origin, or older age—then sputum should be sent specifically for tuberculosis testing,4 which is not usually performed on routine sputum culture.
8
Identify patients who are not responding to treatment
In most cases of low-severity CAP, symptoms should begin to improve within 3 days of starting treatment.7 Unsatisfactory progress at this point should prompt a consideration of alternative diagnoses such as heart failure, an assessment for complications of CAP such as development of a parapneumonic pleural effusion, and a consideration of whether a chest X-ray or hospital assessment is now
required. Extending the course of antibiotics beyond 5 days is one possible management strategy in this situation,7 but it is important to consider these other factors in addition.
9
Be alert to repeated courses of antibiotics
If a patient has received several courses of antibiotics this should prompt a more detailed assessment. Consider whether these repeated courses are truly indicated, or if they represent the natural resolution of symptoms following CAP. If there is convincing evidence of ongoing illness, a search for an underlying problem should be considered. Most patients should undergo a chest X-ray and sputum culture at this point if they have not already done so,4 and additional investigations such as a peak flow diary or spirometry may be indicated if the history is suggestive of alternative pathology such as asthma or COPD. Persistent sputum production or persistent crackles on auscultation may require a CT scan or referral to secondary care to assess for bronchiectasis or pulmonary fibrosis.
10
Advise patients that symptoms will take time to fully resolve
A short course of antibiotics is recommended for low-severity CAP as microbiological clearance of pathogens usually occurs early. However, it takes longer for symptoms, clinical signs, and the radiological changes on chest X-ray to resolve. While fever and purulent sputum production usually improve quickly, other symptoms such as cough and lethargy take longer to resolve than the duration of the antibiotic course in most patients. Patients often expect a further course of antibiotics to expedite resolution of these symptoms. Explaining to patients the natural
history and resolution of the symptoms of CAP at the time of diagnosis may help reduce unnecessary additional antibiotic courses. The NICE guideline on pneumonia suggests that although the rate of improvement will vary based on the severity of pneumonia, most people can expect that by:7 a 1 week: fever should have resolved a 4 weeks: chest pain and sputum production should have substantially reduced a 6 weeks: cough and breathlessness should have substantially reduced a 3 months: most symptoms should have resolved but fatigue may still be present a 6 months: most people will feel back to normal.
Dr Sinan Eccles Consultant physician in respiratory medicine Royal Glamorgan Hospital, South Wales
Guideline 69. NICE, 2008. Available at: www. nice.org.uk/cg69
References 1. British Lung Foundation. Pneumonia statistics. statistics.blf.org.uk/pneumonia (accessed 21 September 2018).
7. NICE. Pneumonia in adults: diagnosis and management. Clinical Guideline 191. NICE, 2014. Available at: www.nice.org.uk/cg191
2. Woodhead M, Macfarlane J, McCracken J et al. Prospective study of the aetiology and outcome of pneumonia in the community. Lancet 1987; 329 (8534): 671–674.
8. Lim W, van der Eerden M, Laing R et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58 (5): 377–382.
3. Guest J, Morris A. Community-acquired pneumonia: the annual cost to the National Health Service in the UK. Eur Respir J 1997; 10 (7): 1530–1534.
9. Accord-UK Ltd. Doxycycline capsules BP 100mg — summary of product characteristics. December 2017. www.medicines.org.uk/emc/ product/5778/smpc
4. Lim W, Smith D, Wise M, Welham S. Annotated BTS guideline for the management of CAP in adults 2015. British Thoracic Society, 2015. Available at: www.brit-thoracic.org.uk/ standards-of-care/guidelines/bts-guidelinesfor-the-management-of-communityacquired-pneumonia-in-adults-update-2009/ annotated-bts-guideline-for-the-managementof-cap-in-adults-2015/
10. Accord Healthcare Ltd. Clarithromycin 500mg tablets — summary of product characteristics. May 2018. www.medicines.org.uk/emc/ product/6094/smpc
5. Little P, Stuart B, Moore M et al. 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; 13 (2): 123–129.
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11. MedicinesComplete. British National Formulary. about.medicinescomplete.com/ publication/british-national-formulary/ (accessed 21 August 2018). 12. Macfarlane J, Macfarlane R, Rose D et al. Prospective study of aetiology and outcome of adult lower-respiratory-tract infections in the community. Lancet 1993; 341 (8844): 511–514. G
6. NICE. Respiratory tract infections (selflimiting): prescribing antibiotics. Clinical
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View from the ground
Guidelines in Practice | October 2018 | Volume 21 | Issue 10
View from the ground Being an early career GP Entering the real world of general practice as a fully-fledged GP after recently completing GP training was very daunting. On reflection, I remember starting work as a foundation doctor and being excited about finally having a real job, with clinical responsibility and fewer assessments. In reality, there are just as many or more assessments. Recently qualifying as a GP, I can appreciate that this is actually where the fun starts. After graduating from medical school in Aberdeen, I spent 2 years in Edinburgh as a foundation doctor, followed by a locum year in Accident and Emergency before embarking on my 3 years of GP training. It is remarkable that GP training, a specialty requiring a vast knowledge base, can be completed in 3 years. In contrast, some hospital specialties take more than twice as many years. Why would anyone want to be a trainee for any longer? I often questioned whether I would be ready in 3 years. Would I know everything to be a successful GP? The answer is of course no. Now that I am qualified I am still learning and this, along with the verifiability of my days, are two of the most exciting parts of general practice. I was fortunate to have the opportunity to complete training in two very different areas. Six months of my general practice training were spent in an ex-mining town and my final ST3 year was spent in a popular beach town. Both jobs were busy and demanding but varied in their approach to how they managed this. Being able to have split training allowed me to appreciate how different practices can be run, the benefits and disadvantages of each system, and the importance of team work. It was also useful to determine the sort of practice I would like to work in after completing my training. I observed how staff shortages can add pressure to the practice partners, which also added to my responsibilities once I had passed the Clinical Skills Assessment (CSA). I was privileged in having caring partners who helped me to complete training. However, I often found the obstacles from the GP unit challenging and was certainly not alone in this regard in the training region. Having a supportive educational release group and tutor was important to ensure I was on track with the e-portfolio and CSA revision.
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At times I felt I was in the practice more than the practice partners. As I began to see more patients, my work load increased, not only with regard to the numbers of patients I was seeing but also from results, referrals, and phone calls. This added to the pressure while I was revising for the most expensive exam I had yet sat. I was also ensuring all competences and reflective logs were completed. It seemed like a constant list of targets: consulting in 10 minutes, passing CSA, and then preparing for the final Annual Review of Competence Progression (ARCP) panel. Occasionally I felt as though I was chasing my own tail but being flexible and organised ensured that everything was completed. I think it is important to take time to consider your options after completing training; there is no rush and there are currently plenty of job opportunities. Make sure you accept the job that is right for you. There is a lot to think about when considering work after completion of training: partnership, salaried, long-term locum positions, or individual locums. In addition to this it is important to consider how many sessions you want to work, the location of the practice, the population it serves, whether maternity pay is offered, how much pay is offered per session, and whether the practice seems like one you will fit in with. Each post has pros and cons but it was important for me to determine what I wanted. With time, I recognised that regular locum work is not for me and I started looking for a permanent role that could provide continuity. A further point to remember is the importance of peer support and opportunity to bounce ideas about. Although the landscape of general practice is changing I am looking forward to the excitement and opportunities ahead.
Dr Caroline Begg, Grange Medical Group, Edinburgh Respond to this article at: GinP.co.uk/oct18-vftg
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