Primary Care Guidelines

About Primary Care Guidelines

A podcast intended for healthcare professionals wanting to keep up to date relevant information about clinical practice guidelines

Publisher

Juan Fernando Florido Santana

Category

education · health & fitness

Language

en

Explicit

No

First episode

6 Feb 2022

Latest episode

11 Oct 2026

Latest episodes

190 episodes in the feed.

1. 

   11 Oct 2026

   Podcast - NICE News - September 2026

   The video version of this podcast can be found here: ·       https://youtu.be/djfeYkbyoYU (https://youtu.be/djfeYkbyoYU) This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in September 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement. Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU (https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU) Free Download / Stream: https://alplus.io/halfway-through (https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU) Tracks: 00:00 – Introduction and welcome 00:25 – Suspected sepsis 02:13 – Psychosis and schizophrenia 04:04 – KardiaMobile 6L 05:38 – Thank you and good-bye There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast: ·       Redcircle: https://redcircle.com/shows/primary-care-guidelines ·       Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK ·       Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk (https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk) The Full NICE News bulletin for September 2026 can be found here: ·       https://www.nice.org.uk/guidance/published?from=2026-09-01&to=2026-09-30 The updated NICE guideline on Suspected sepsis in people aged 16 or over: recognition, assessment and early management [NG253] can be found here: ·       https://www.nice.org.uk/guidance/ng253 The updated NICE clinical guideline on Psychosis and schizophrenia in adults: prevention and management [DG178] can be found here: ·       https://www.nice.org.uk/guidance/cg178 The updated NICE Health Tech guidance on KardiaMobile 6L for measuring cardiac QT interval in adults having antipsychotic medication: early value assessment [HTG694] can be found here: ·       https://www.nice.org.uk/guidance/htg694 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in September 2026, focusing on what is relevant in Primary Care only. If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in September 2026, focusing on what is relevant in Primary Care only. This month, we have brief updates in two areas: suspected sepsis, and psychosis and schizophrenia, including QT interval monitoring in people taking antipsychotic medication. Right, let’s jump into it. Let's start with the updated NICE guideline on suspected sepsis in adults. The main change is that NICE has updated its recommendations on procalcitonin testing. And let’s remember that procalcitonin is a blood biomarker that tends to rise in bacterial infection and sepsis, and it can help estimate the likelihood of bacterial infection. However, NICE does not recommend procalcitonin testing in primary care, so these updated recommendations mainly relate to hospital care. So, what are the main messages for us in primary care? The first is simple: we should think about sepsis early whenever someone has a possible infection and appears significantly unwell. Let’s also remember that sepsis can present non-specifically, that the patient may not have a fever, and that we should be particularly careful when the history is difficult to obtain, for example because of communication difficulties, cognitive impairment, learning disability, etc.We should also refer suspected neutropenic sepsis immediately for hospital assessment. The second point is structured assessment. In hospital and ambulance settings, NEWS2 is used to assess adults with suspected sepsis who are not pregnant and have not recently been pregnant. However, in general practice, we may not always formally calculate NEWS2, but the principle is the same: we should assess physiology, including respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, level of consciousness and overall clinical concern. And the third main message is escalation and safety-netting. If the patient has high-risk features, we should arrange emergency transfer to hospital, usually by 999 ambulance, and pre-alert secondary care. Let's now look at the updated NICE guideline on psychosis and schizophrenia in adults. For us in primary care, this update is unlikely to change routine practice, because it relates to rapid neuroleptisation in secondary care. Rapid neuroleptisation refers to the use of repeated doses of antipsychotic medication over a short period to quickly control severe agitation. So, what are the main messages here for us in primary care? First, we should refer early if we suspect emerging psychosis. And if someone presents with sustained psychotic symptoms for the first time, we should not start antipsychotic medication in primary care unless this is done in consultation with a consultant psychiatrist. Second, we should take physical health monitoring very seriously. People with psychosis or schizophrenia, especially those taking antipsychotics, have a higher risk of physical health problems. This is important because cardiovascular disease and metabolic disease are major contributors to reduced life expectancy in people with severe mental illness. Some antipsychotics can cause weight gain, worsen glucose control, increase the risk of diabetes, affect lipids, raise prolactin, cause movement disorders, and prolong the QT interval. So, once monitoring responsibility is transferred from secondary care, we should do at least annual physical health checks and cardiovascular risk assessments, including weight, waist circumference, pulse and blood pressure, HbA1c, lipids, lifestyle advice including smoking, diet, and physical activity. We will also enquire about possible movement disorders and check prolactin where relevant. And this area links quite nicely with another updated NICE HealthTech guidance on KardiaMobile 6L for QT interval monitoring in adults taking antipsychotic medication. First, what is KardiaMobile 6L? It is a small portable ECG device that records a 6 lead ECG using electrodes placed on the fingers and left leg or ankle. Unlike a standard 12 lead ECG, it is designed as a quick point of care test and can estimate the QT interval, helping identify people at risk of drug induced QT prolongation. The guidance supports KardiaMobile 6L as an option for QT interval measurement in adults taking antipsychotic medication, while further evidence is generated, and it should be used alongside standard clinical assessment. It is intended to improve access to QT monitoring and reduce the need for conventional 12 lead ECGs in suitable patients. For us in primary care, the overall approach remains unchanged. We should continue to assess risk factors, including electrolyte abnormalities, structural heart disease, interacting medicines and previous prolonged QT interval issues. If ECG monitoring is required, local pathways may increasingly use portable technologies such as KardiaMobile 6L, but abnormal or uncertain results still require clinical interpretation and perhaps confirmation with a standard 12 lead ECG. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice, but only my summary and interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.

2. 

   27 Sept 2026

   Podcast - NICE Thyroid Disease Part 1: TFTs and Hypothyroidism

   The video version of this podcast can be found here: ·       https://youtu.be/kmIhZKT8SA8 (https://youtu.be/kmIhZKT8SA8) This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through a section of the NICE guideline on Thyroid disease: assessment and management [NG145], particularly the section on hypothyroidism, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this episode is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement. Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU (https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU) Free Download / Stream: https://alplus.io/halfway-through (https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU) There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast: ·       Redcircle: https://redcircle.com/shows/primary-care-guidelines ·       Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK ·       Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk (https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk) The NICE clinical guideline on Menopause: identification and management [NG23] can be found here: ·       https://www.nice.org.uk/guidance/NG23 (https://www.nice.org.uk/guidance/NG23) The resources consulted can be found here: Thyroid disease: assessment and management -NICE guideline [NG145] can be found here: ·       https://www.nice.org.uk/guidance/NG145 (https://www.nice.org.uk/guidance/NG145) Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to go through the NICE guideline on Thyroid disease, always focusing on what is relevant in Primary Care only. So let’s jump into it. We will check TFTs if there is: ●    a clinical suspicion of thyroid disease, bearing in mind that 1 symptom alone may not be indicative of thyroid disease ●    type 1 diabetes or other autoimmune diseases, (but we will not offer testing only because of type 2 diabetes). ●    new-onset AF ●    depression or unexplained anxiety ●    abnormal growth in children and young people, or with an unexplained change in behaviour or school performance. ●    And we will be aware that in menopausal women symptoms of thyroid dysfunction may be mistaken for menopause We will not test for TFTs during an acute illness unless we suspect the acute illness is due to thyroid dysfunction, because it may affect the test results. So, what tests do we do as initial screening when thyroid dysfunction is suspected? This will depend on whether we suspect a primary cause, that is, a cause arising from the thyroid gland, or a secondary cause, that is, a cause arising from the pituitary gland. So, we will always measure TSH. Then, if a primary cause is suspected in an adult: ●    if the TSH is high, that is, suggestive of hypothyroidism, we will need the free thyroxine (FT4) level ●    if the TSH is low, that is, suggestive of hyperthyroidism, we will need FT4 and free tri-iodothyronine (FT3) However, if we suspect a secondary cause, that is, pituitary disease, or if we are testing a child or young person, we will need results for both TSH and FT4 and: ●    If the TSH is low, that is, suggestive of hyperthyroidism, we will need FT3 So, in summary, we test TSH and T4 in hypothyroidism but in hyperthyroidism we need to add FT3 too. We can repeat these tests if symptoms worsen or new symptoms develop (but no sooner than 6 weeks from the most recent test). We will also ask patients about their biotin intake because a high consumption of biotin from dietary supplements may lead to falsely high or low test results. Looking at the management, and monitoring different rules may apply to children and young people and given that we are likely to be getting advice from the paediatricians , I will not cover them here. If a recommendation applies to children, I will mention it, but otherwise this episode will focus on adults unless otherwise specifically stated. So, we are going to cover: ●    Primary hypothyroidism: which is caused by an insufficient hormone production by the thyroid gland. In this situation the TSH is high, and FT4 is low. ●    Subclinical Primary hypothyroidism: This can sometimes happen as a precursor of clinical hypothyroidism and it is when the TSH is high, but FT4 is normal. So let’s start with the management of primary hypothyroidism So, for all people with confirmed primary hypothyroidism, that is, when we encounter a high TSH and a low FT4, we will: Check thyroid peroxidase antibodies (TPOAbs) But in adults, we will not repeat TPOAbs testing. If the antibody test is positive, it maybe worthwhile mentioning that NICE also recommends testing for coeliac disease in people with a diagnosis of autoimmune thyroid disease. For the actual management, for both adults and children, we will: Offer levothyroxine as first-line treatment and we will not routinely offer liothyronine or natural thyroid extract for primary hypothyroidism, either alone or in combination with levothyroxine, because there is not enough evidence that it offers benefits over levothyroxine monotherapy, and the long-term adverse effects are uncertain. We will start levothyroxine at a dosage of 1.6 micrograms per kilogram of body weight per day (rounded to the nearest 25 micrograms) for adults under 65 with primary hypothyroidism and no history of cardiovascular disease. However, if they are over 65 or with a history of cardiovascular disease, we will start levothyroxine at a dosage of 25 to 50 micrograms per day with titration How should we follow-up and monitor primary hypothyroidism? We will aim to maintain TSH levels within the reference range when treating with levothyroxine. If symptoms persist, we will adjust the dose to achieve optimal wellbeing, but we will avoid using doses that cause TSH suppression or thyrotoxicosis. We also need to be aware that the TSH level can take up to 6 months to return to normal for people who had a very high TSH or a prolonged period of untreated hypothyroidism. In terms of monitoring, we will need to measure TSH every 3 months until the level has stabilised (that is, until we have had 2 similar measurements within the reference range 3 months apart), and then once a year. But we will also check FT4 as well as TSH if they continue to have symptoms on levothyroxine. Let’s now look at subclinical hypothyroidism Once we have confirmed subclinical hypothyroidism, with a high TSH and normal FT4, we will also check TPOAbs. In terms of the management, we will: take into account features that might suggest underlying thyroid disease, such as, for example, symptoms of hypothyroidism, or raised levels of thyroid autoantibodies. Consider levothyroxine if the TSH is 10 mlU/litre or higher on 2 separate occasions 3 months apart, monitoring as per in hypothyroidism We will also consider a 6-month trial of levothyroxine for adults under 65 with subclinical hypothyroidism who have: ●    a high TSH but lower than 10 mlU/litre on 2 separate occasions 3 months apart, and ●    symptoms of hypothyroidism. If symptoms do not improve after starting levothyroxine, we will recheck the TSH and if the level remains raised, we will adjust the dose. If symptoms persist when TSH is within the reference range, we will stop levothyroxine and continue monitoring. So, how do we monitor untreated subclinical hypothyroidism and after stopping treatment? For them, we will check TSH and FT4: ●    once a year if they have features suggesting underlying thyroid disease, such as previous thyroid surgery or raised levels of thyroid autoantibodies, or ●    once every 2 to 3 years if they have no features suggesting underlying thyroid disease. We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.

3. 

   13 Sept 2026

   Podcast - NICE News - August 2026

   The video version of this podcast can be found here: ·       https://youtu.be/HJBi-1DAS60 (https://youtu.be/HJBi-1DAS60) This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in August 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement. Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU (https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU) Free Download / Stream: https://alplus.io/halfway-through (https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU) Tracks: 00:00 – Introduction and welcome 00:25 – Allergic rhinitis 03:22 – Acne vulgaris 07:21 – Thank you and good-bye There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast: ·       Redcircle: https://redcircle.com/shows/primary-care-guidelines ·       Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK ·       Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk (https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk) The Full NICE News bulletin for August 2026 can be found here: ·       https://www.nice.org.uk/guidance/published?from=2026-08-01&to=2026-08-31 The updated NICE technology appraisal on 12 SQ-HDM SLIT for treating allergic rhinitis and allergic asthma caused by house dust mites [TA1045] can be found here: ·       https://www.nice.org.uk/guidance/ta1045/ (https://www.nice.org.uk/guidance/ta1045/) The updated NICE technology appraisal on 12 SQ-Bet SLIT for treating moderate to severe allergic rhinitis or conjunctivitis caused by tree pollen in people 5 years and over [TA1087] can be found here: ·       https://www.nice.org.uk/guidance/ta1087 The updated NICE guideline on Acne vulgaris: management [NG198] can be found here: ·       https://www.nice.org.uk/guidance/ng198 The new updated NICE guideline on Heavy menstrual bleeding: assessment and management [NG88] can be found here: ·       https://www.nice.org.uk/guidance/ng88 (https://www.nice.org.uk/guidance/ng88) Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in August 2026, focusing on what is relevant in Primary Care only. This month, we have only two areas to cover: updated guidance allergic rhinitis and conjunctivitis, and an update on acne vulgaris. Right, let’s jump into it. There are two updates on allergic rhinitis that are very similar, so let’s take them together.They both involve sublingual immunotherapy for allergic rhinitis, and both updates expand the eligible population to include younger children. The first one is Acarizax, for house dust mite allergic rhinitis. It was recommended for people aged 12 to 65 and it now also includes children aged 5 to 11 years. The second is Itulazax, for allergic rhinitis or conjunctivitis caused by tree pollen from the birch group.It was recommended for adults and it now includes people aged 5 years and over. In both cases, the symptoms need to be moderate to severe, the diagnosis needs to be supported by a positive sensitisation test, such as skin prick testing or specific IgE, and symptoms must persist despite symptom-relieving treatment. So, what are these treatments? As we said Acarizax is for house dust mite allergic rhinitis, while Itulazax is for birch-related tree pollen allergic rhinitis or conjunctivitis. Both are sublingual immunotherapy tablets. Acarizax contains house dust mite allergen extract and Itulazax contains birch pollen allergen extract. Both are placed under the tongue and work by gradually desensitising the immune system to the relevant allergen. So these are not just another antihistamine or nasal spray. They are allergen immunotherapy treatments, aiming to modify the immune response itself rather than simply providing temporary symptom relief. In usual care, allergic rhinitis, with or without conjunctivitis, is treated first with standard medicines, such as antihistamines and intranasal corticosteroids. These immunotherapy treatments come later, when symptoms remain moderate to severe and persistent despite standard treatment. It is worth saying that Acarizax is not recommended for allergic asthma, even when house dust mite allergy may be triggering it. Having asthma does not necessarily prevent someone from receiving Acarizax for rhinitis, but the NICE recommendation is not for asthma treatment itself. Itulazax is for tree pollen allergy from the birch group, and it can be given for allergic rhinitis, conjunctivitis, or both. Although these may not be treatments that GPs routinely prescribe, they are useful to know about because we will see children and adults with persistent allergic rhinitis despite antihistamines and nasal steroids, and , in those cases, these options may be relevant for specialist referral or discussion. Let’s now look at the updated NICE guideline on acne vulgaris. This update is quite focused and NICE has amended references to polycystic ovarian syndrome, because this condition is now called polyendocrine metabolic ovarian syndrome, or PMOS. This name change was agreed by global consensus and reflects that this is a whole-body metabolic and hormonal condition, not a disease defined by ovarian cysts. Additionally the recommendation on triamcinolone injections has been withdrawn, but this is relevant to specialist care. For us in primary care, the main acne management is otherwise unchanged so let’s give it a very quick overview. For drug treatment, NICE recommends a 12-week course of one first-line treatment option, depending on severity and patient preference. For many patients, we can use a fixed-combination topical treatment, such as adapalene with benzoyl peroxide, or tretinoin with clindamycin. Adapalene with benzoyl peroxide has the advantage that it does not contain an antibiotic, but for mild to moderate acne, we can also consider benzoyl peroxide with clindamycin. For moderate to severe acne, we should usually use a topical treatment together with an oral antibiotic, either lymecycline or doxycycline. If the person cannot use lymecycline or doxycycline, we can consider trimethoprim or an oral macrolide, such as erythromycin. Topical benzoyl peroxide alone can also be considered if the other options are contraindicated, or if the person wants to avoid topical retinoids or antibiotics. We should not use topical antibiotic monotherapy, oral antibiotic monotherapy, or a combination of topical and oral antibiotics, because of the risk of antimicrobial resistance. We should also explain that treatment can take 6 to 8 weeks before improvement become noticeable. Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning pregnancy, so effective contraception or an alternative treatment is needed for people of childbearing age. If hormonal contraception is wanted, we should consider the combined oral contraceptive pill in preference to the progestogen-only pill. We should then review first-line treatment at 12 weeks. If the treatment includes an oral antibiotic and the acne has cleared, we should consider stopping the antibiotic but continuing the topical treatment. If the acne has improved but has not completely cleared, we should consider continuing the oral antibiotic with the topical treatment for up to 12 more weeks. We should only continue antibiotic-containing treatment for more than 6 months in exceptional circumstances, with review every 3 months, and we should stop the antibiotic as soon as possible. We should refer if there is diagnostic uncertainty, acne conglobata, or nodulo-cystic acne. We should also consider referral if acne is not responding to treatment, or if acne is causing scarring, persistent pigmentary change, or significant psychological distress. For PMOS and acne, we should use a first-line acne treatment option first. If that is not effective, we should consider adding co-cyprindiol or an alternative combined oral contraceptive pill. For people using co-cyprindiol, we should review at 6 months and discuss continuation or alternative options. We should consider specialist referral if acne and PMOS are associated with hyperandrogenism, or if there is severe acne resistant to standard treatment. So that is it, a review of the NICE updates relevant to primary care. We have come to the end of this episode. Remember that this is not medical advice, but only my summary and interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.

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