NICE summaries
The purpose of this page is to allow you to quickly brush up on the relevant NICE guidance, (and sometimes other national guidelines[1]) in common areas, split up by common topics body system/pathologies. Try to memorise them all in one sitting (really - don't do this)...
Cancer is a huge topic, affecting every organ system, so I've dropped the guidance into each sub section...
Cardiovascular
AF
Atrial fibrillation is very common. If they are haemodynamically stable, then you want to do an ECG to confirm. Once confirmed, consider starting anticoagulation, and think about Rate/Rhythm control.
Anticoagulation
Do a CHA2DS2Vasc. Try the free online tool, or calculate yourself:
CHA2DS2Vasc | Score |
---|---|
CCF | 1 point |
Hypertension | 1 point |
Age (more than 65) | 1 point |
(or if more than 75) | 2 points |
Diabetes | 1 point |
Stroke | 2 points |
Vascular
Disease |
1 point |
The proper tool has a point for gender too, but that needlessly confuses things with the guidance. Ignore gender, and anyone that scores 2 or more needs to be considered for anticoagulation.
You then do a HASBLED score, which tells you their risk of bleeding. Score 3 or more, and it becomes less sensible to start warfarin.
HASBLED | Score |
---|---|
Hypertension | 1 |
Age (65+) | 1 |
Stroke | 1 |
Kidney issues | 1 |
Knackered liver | 1 |
Unstable INR | 1 |
Alcohol use | 1 |
You then start them on Warfarin. You can definitely also consider a NOAC, they appear to be pretty equally good.
Rhythm Control
If fits the criteria below, then refer for cardioversion. (Will need warfarinisation before cardioversion for at least 4 weeks.)
- New onset AF
- AF with reversible cause
- Heart failure suspected to be caused by AF
Rate Control
Most people - your standard 70 year old with an incidental finding of AF on examination - will need rate control. You want to:
- Keep pulse under 100.
- Start with bisoprolol.
- Consider adding in diltiazem or digoxin if not working.
- Still struggling? Refer.
Chest Pain
Medical Emergency - Likely acute coronary syndrome with active chest pain will need sending to hospital by ambulance.
You need to give them:
- GTN
- Aspirin 300mg
- Do an ECG
- Measure O2 saturation, consider giving oxygen.
If they have no pain currently, but have had within the last 72 hours, will likely still need to go to hospital for ECG and Troponin.
Stable chest pain
Assess them, looking for cardiac risk factors, especially diabetes, smoking and hyperlipidaemia.
For most of them, you will want to do further tests to identify likelihood of angina. This will often be an exercise ECG, myocardial perfusion scan or similar. Either way, best access route is usually rapid access chest pain clinic.
Managing angina
Once you've confirmed angina, manage it with[2]:
- GTN spray
- Lifestyle interventions
- Beta blocker (or calcium channel blocker)
- Aspirin 75mg
- Statin - atorvastatin 80mg.
- ACE inhibitor if they have diabetes
Familial hypercholesterolaemia
Inherited as an autosomal dominant condition. Anyone with cholesterol over 7.5 or LDL more than 4.9 needs to be considered for this[3].
- Be alert for tendon xanthomas in the family.
- MI in 1st degree relative under 60
- MI in 2nd degree relative under 50
Management
Pretty simple. They will likely need:
- DNA testing
- Lifelong statins.
- Aggressive lifestyle modification.
Heart Failure
Heart failure diagnosis is pretty easy. Suspect heart failure[4]?
- If they've had a previous MI, just refer them for an urgent echo and specialist review.
- Otherwise, measure a BNP or NTproBNP.
- If BNP is under 100 (or 400 for NTproBNP), chill out, unlikely to be heart failure.
- 100-400 (400-2000 NTproBNP), refer for routine assessment.
- 400+ (2000+ NTproBNP), needs an urgent review like with MI.
Make sure you do an ECG too!
Management of CCF
- Lifestyle management, as ever.
- ACE inhibitor and beta blocker for everyone.
- Diuretics for symptoms.
- Only give aspirin if known CHD - see recommendations in chest pain section.
HGV drivers are disqualified from driving if symptomatic!
Hypertension
Measure their blood pressure (obviously). You will get one of three findings[5]:
- BP is less than 140/90. Normotensive woohoo! Recheck BP at least every 5 years.
- BP more than 140/90:
- Offer ambulatory BP monitoring (or home BP monitoring if unable to do ABPM)
- If ABPM its less than 135/85, they are normotensive
- More than 135/85, you need to check their 10 year CVD risk. If above 20%, start treatment. Otherwise, just nag them about lifestyle.
- More than 150/95, no need to worry about 10 year CVD risk, just start treatment.
- Look for end organ damage with an ACR, urine dip, bloods, ECG and fundoscopy.
- Offer ambulatory BP monitoring (or home BP monitoring if unable to do ABPM)
- BP more than 180/110, start treatment straight away, don't bother with ABPM.
Anti-hypertensives
Commence antihypertensives in following order, stepping up if condition not controlled:
- Look at their age:
- Age less than 55? Start an ACE Inhibitor
- Age more than 55, or patient is black? Start a Calcium channel blocker.
- ACE + CCB
- ACE + CCB + indapamide 2.5mg OM
- ACE + CCB + indapamide + one of below + consider referral
- if K+ less than 4.5, spironolactone
- if K+ more than 4.5, increase indapamide
- alpha blocker
- beta blocker
Peripheral artery disease
In anyone with symptoms of peripheral artery disease, especially intermittent claudication[6]...
- Examine for pale, hairless legs
- Check pedal pulse
- Measure ankle branchial pressure index (ABPI)
- ABPI less than 0.9 makes PAD likely
- ABPI less than 0.5 points to critical ischaemia
Management
Start them on clopidogrel 75mg OD, atorvastatin 80mg and refer to vascular!
Statins
Primary prevention with statins is based pretty heavily on the QRISK2 tool (try it here)[7]. Start atorvastatin 20mg in anyone with one of these:
- Over 85
- Who scores more than QRISK 10%
- Chronic kidney disease
- Type 1 Diabetes? If over 40, or had diabetes more than 10 years then start the pills!
In anyone with CVD, you'll want to start atorvastatin 80mg.
Monitoring
Before starting, check:
- Lipids (don't need to be fasting)
- HbA1c
- Kidney function
- LFTs
- TSH
- Pregnancy status - should not be started in pregnancy!
After three months
- Check lipids if secondary prevention (aiming 40% reduction in non-HDL)
- Recheck LFTs. If less than three times normal AST/ALT, no need to stop.
Annually
- First year, check LFTs.
- Following years no monitoring required.
Muscle pains
- Check CK.
- If more than 5 times normal, consider stopping or reducing statin.
Dermatology
Acne vulgaris
Managing acne involves some helpful people skills[8]
- Reassure them that it will usually settle without scarring.
- Unrelated to diet or stress.
- Not caused by poor hygiene, can be worsened by washing.
- Smoking can make it worse!
Mild acne
- Wash no more than twice a day.
- Avoid scrubbing.
- Use a water based emollient instead of soap if needed.
- Try a topical retinoid (isotretinoin) or benzoyl peroxide as first line.
- Consider azelaic acid if above not tolerated.
- Offer a COCP to anyone needing contraception, as it can help reduce acne.
Moderate acne
- Add in a topical antibiotics with one of the topical agents above if not helping. Ideally don't give for more than 12 weeks.
- Consider oral antibiotics combined with a topical retinoid or benzoyl peroxide.
- Use tetracycline, oxytetracycline, doxycyline or lymecycline.
- Don't use without a topical agent
- Don't give both topical and oral antibiotics.
Severe acne
If all that has failed, refer them to Dermatology, who will consider starting oral isotretinoin.
Psoriasis
As with eczema, the first step of treatment is regular use of emollient.[9]
Skin cancer
Malignant Melanoma
Refer to rule out melanoma with any pigmented lesion with 3 or more points (see below)[10].
Major features (worth 2 points each)
- Change in size
- Irregular shape
- Irregular colour
Minor features (worth 1 point each)
- Largest diameter ≥7mm
- Inflammation
- Oozing
- Change in sensation.
Other skin cancers
Also refer under 2WW anything that you feel may be a SCC. Suspected BCC should be sent under a routine referral.
Endocrine
Diabetes
Eyes and ENT
Geriatrics
GI
Upper GI cancer
You will want to refer via 2WW anyone with an upper abdominal mass that suggests stomach cancer, or anyone over 40 with jaundice.
Send for urgent OGD
- Dysphagia
- 55+ with weight loss and pain/reflux symptoms.
Send for non-urgent OGD
- Haematemesis
- 55+ with:
- Non resolving dyspepsia.
- Upper abdo pain and anaemia
- Raised platelets with any upper GI symptoms
- Nausea and vomiting with weight loss/reflux/pain
Send for urgent CT
Anyone who is 60+ with weight loss and any of these:
- Diarrhoea or constipation
- Back pain
- Abdominal pain
- Nausea/Vomiting
- New diabetes
Some of these are a bit odd, because you would probably already be sending on a Lower GI cancer referral...
Consider urgent USS
Anyone who has a mass that feels like an enlarged liver or gallbladder mass deserves a cheeky USS.
Lower GI cancer
It's 2WW time for any of the following[10]:
- Any age with unexplained anal mass or ulceration.
- 40+ with weight loss and abdo pain
- 50+ with unexplained rectal bleeding
- 60+ with iron deficiency anaemia or changes in bowel habit.
- Positive FOB test.
Consider 2WW referral
- Any abdominal mass
- Younger than 50 with rectal bleeding plus:
- Abdominal pain
- Change in bowel habit
- Weight loss
- Iron deficiency anaemia
Offer FOB testing
- 50+ with abdominal pain +/- weight loss.
- Less than 60 with change in bowel habit or iron deficiency anaemia.
- More than 60 with any anaemia.
Gynaecology
Ovarian cancer
You need to refer urgently if you suspect ascites, or find any unexpected pelvic/abdominal mass[10].
Consider ovarian malignancy and do CA125 if
- 50+ woman with bloating, early satiety, pelvic pain, or increased urinary symptoms.
- Any unexplained weight loss, fatigue or bowel habit changes.
- New onset of IBS in women over 50.
The key is that ovarian cancer is easily missed and diagnosed late, so always have it at the back of your mind.
Endometrial cancer
Send anyone 55+ with postmenopausal bleeding via 2WW[10]. Consider it strongly in anyone under 55 too.
Go for an urgent USS if...
- 55+ with unexplained vaginal discharge for the first time, or with thrombocytosis, or with haematuria.
- Haematuria with anaemia, raised platelets or high blood sugars.
Other gynae cancers
If the cervix is abnormal in appearance, they are going to need an urgent referral[10]. Same with any weird vulval lumps, ulcers or bleeding.
Haematology
Leukaemia
Do an FBC within 48 hours in any children or adults with one of these[10]:
- severe pallor or tiredness
- generallised lymphadenopathy
- unexplained persistent infections
- bleeding or bruising issues
- hepatosplenomegaly
In children with these bleeding or bruising issues or hepatosplenomegaly, admit for an immediate specialist review - they coiuld have severe marrow suppression!
Lymphoma
Refer anyone with unexplained lymphadenopathy or splenomegaly for 2WW[10]. Refer kids even more urgently. Especially think about fever, night sweats, SOB, itchiness, weight loss.
Myeloma
In patients over 60 with bone pain, particularly back pain or unexplained fractures do FBC, serum calcium and ESR/plasma viscosity.
If they have raised calcium, or raised viscosity, do protein electrophoresis and Bence Jones protein urine test within 48 hours. Refer with 2WW if these suggest myeloma[10].
Immunisations
Lifestyle
Obesity
Smoking
Mental Health
Musculoskeletal
Neurology
Brain and CNS cancer
Adults with a progressive loss of CNS functions, or any sign of intracranial lesion should have an urgent MRI[10]. Children should have an urgent Neurology review.
Paeds
Childhood cancers
All the below need a 2WW referral to rule out neuroblastomas, retinoblastomas and Wilm's tumours[10]...
- Palpable abdominal mass
- Absent red reflex
- Unexplained visible haematuria
Respiratory
Lung cancers
In
anyone with a suggestive CXR, or anyone over 40 with unexplained haemoptysis you need to refer them through 2WW[10].
Otherwise, consider:
Urgent CXR if over 40 and 2 of these:
- Significant smoking/asbestos history
- Cough
- Fatigue
- SOB
- Chest pain
- Weight loss or loss of appetite
Consider urgent CXR if over 40 and
Anything weird, such as recurrent chest infections, clubbing, neck or supraclavicular lymphadenopathy or weird chest findings on examination.
Sexual Health
Contraception
UKMEC guidance says the combined pill should be avoided in anyone:
- 35+ who smokes
- BMI over 35
- Breastfeeding, or within 3 weeks of giving birth.
- High blood pressure or vascular disease
- History of DVT (or high risk for one)
- With previous stroke
- Migraine with aura.
- Personal history of breast cancer, or BRCA1 positive.
- Diabetes with end organ damage.
- Liver cancer
- Current gall bladder disease.
- Lupus
Cancer risk
The Combined Oral Contraceptive increases risk of some female cancers. The easy way to remember risk: Oral = Oh no!
Oh no! Outermost, Improves Innermost:
- Increases risk of outermost female cancers - breast and cervical
- Decreases risk of innermost - ovarian and endometrial
Pregnancy
Urology
Male Stuff
Refer any of the following via 2WW:
- Lumpy scary-feeling prostate on DRE[10].
- PSA above the age specific range (Generally anything much over 5).
- Painless enlargement or change in testicle shape.
- Firm penile mass or ulceration after STI excluded/treated.
Consider DRE and PSA test
- Any urinary symptoms, such as urgency, frequency, nocturia, etc.
- Erectile dysfunction
- Visible haematuria
Exclude UTI with these too.
Consider USS
- For any unexplained or unusually persistent testicular symptoms.
Bladder and kidney cancer
Two groups to look for:
- 45+ with visible haematuria without UTI as the cause
- 60+ with microscopic haematuria and dysuria or raised WCC.
Consider non urgent referral
Anyone over 60 with recurrent UTI with no obvious cause.
Women's Health
Breast cancer
Breast clinic under a 2WW for anyone[10]:
- Over 30 with a concerning breast lump with or without pain.
- 50+ with nipple changes or discharge.
Consider 2WW referral for anyone
- With skin changes that suggest breast cancer
- 30+ with axillary lump with no obvious cause.
Clinical Genetics referral
First step is to understand what a first, second and third degree relative is - its simply just the number of steps from you along a family tree:
- First degree: parents, siblings, children
- Second degree: grandparents, aunts, nephew, grandchild, half-sibling, etc
- Third degree: great-grandparents, great aunt/uncle, first cousin, great grandchild, great niece or great nephew
Refer to Clinical Genetics if breast cancer in:
- any 1st degree female relatives under age of 40
- any 1st degree male relatives at any age
- any two 1st and 2nd degree relatives
- any three 1st, 2nd and 3rd
- any 1st or 2nd with breast plus any 1st or 2nd with ovarian cancer
References
- ↑ The GP Update Handbook - Red Whale 2016 - http://www.gp-update.co.uk/
- ↑ NICE on the management of stable angina - NICE 2011, CG126 https://www.nice.org.uk/guidance/cg126/chapter/1-Guidance : Last accessed 28 January 2016
- ↑ NICE Familial Hypercholesterolaemia Guidelines - NICE 2008, CG71 - https://www.nice.org.uk/guidance/cg71/chapter/1-Guidance : Last accessed 28/1/16
- ↑ NICE Chronic heart failure in adults: management - NICE 2010, CG108 https://www.nice.org.uk/guidance/cg108/chapter/1-Guidance : Last accessed 28 January 2016
- ↑ NICE Hypertension in adults: diagnosis and management - NICE 2011, CG127 https://www.nice.org.uk/guidance/cg127/chapter/1-Guidance : Last accessed 28/1/2016
- ↑ NICE Peripheral arterial disease: diagnosis and management NICE 2012, CG147 https://www.nice.org.uk/guidance/CG147/chapter/1-Guidance : Last accessed 29 January 2016
- ↑ NICE Cardiovascular disease: risk assessment and reduction, including lipid modification NICE 2014, CG181 https://www.nice.org.uk/guidance/cg181/chapter/1-Recommendations : Last accessed 29 January 2016
- ↑ NICE Acne Vulgaris CKS September 2014 - http://cks.nice.org.uk/acne-vulgaris#!management : Last accessed 29 January 2016
- ↑ NICE Psoriasis: assessment and management CG153 October 2012 - https://www.nice.org.uk/guidance/cg153/chapter/1-Guidance: Last accessed 29 January 2016
- ↑ 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 10.11 10.12 NICE Suspected Cancer recognition and referral - NICE July 2015, NG12 http://pathways.nice.org.uk/pathways/suspected-cancer-recognition-and-referral : Last accessed 29 January 2016