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Hot Topics Blog

Q&A review from Hot Topics Clinic Webinar 14.5.19

Rob Walker - 6 Jun, 2019

Hay fever

  • I’ve had patients asking me for a steroid injection for hay fever - can we do this?

Using regular IM steroid injections for hay fever was a widespread practice in Primary Care in the past but this is now not recommended. The British Society for allergy and clinical immunology (BSACI) advice against the use of injectable corticosteroids due to poor risk/benefit profile. There have been reports of bilateral avascular necrosis of the hip, as well as an increased risk of diabetes and osteoporosis with regular IM steroid injections for hay fever.

  • I’ve been told we should not use nasal beclomethasone for treatment of rhinitis due to the increased systemic absorption - is this correct?

The 2018 CKS review states that all intranasal corticosteroids available in the UK are equally effective. They do advise against twice daily dosing of beclomethasone in children due to higher systemic absorption and growth suppression, but do not recommend against its use in adults. The BSACI state that systemic absorption is minimal with mometasone and fluticasone, and that it is modest with other other preparations. So based on this intranasal beclomethasone is an option for rhinitis in adults but we should be aware of the potential increased systemic absorption especially if it is being used longer term.

  • What treatments can we use in pregnancy?

The BSACI has a useful review. One thing to remember is that one of the causes of rhinitis in pregnancy is the pregnancy itself, due to nasal vasodilation - so in some pregnant women rhinitis may be self-limiting. However, for women who do need treatment, nasal douching is recommended to reduce the need for antihistamines. The safety of nasal steroids has not been established in clinical trials in pregnant women, but the BSACI state that only minimal amounts get absorbed nasally and that fluticasone has a good safety record with the least systemic bioavailability when used nasally, and the CKS concurs that intranasal steroids can be used in pregnancy. The BSACI also state that there is ‘considerable clinical experience with chlorphenamine, loratadine and cetirizine in pregnancy’ and the CKS state that although these oral antihistamines should be used with caution in pregnancy, there is no evidence of harm. Decongestants should be avoided.

  • Is fexofenadine more effective than other antihistamines?

All antihistamines are effective and there is no convincing evidence that any one antihistamine is more effective than the others, but second generation non sedating antihistamines are recommended (e.g. loratadine or cetirizine) due to their reduced side effect profile. The BSACI review notes fexofenadine is the least sedating antihistamine, so may be the preferred option if reducing sedation is critically important. However it is worth reiterating that there is grade 1a evidence that intranasal steroids are superior to oral antihistamines on all aspects of allergic rhinitis.

  • I’ve heard eating local honey can help!

This is not mentioned in any evidence reviews and thanks to our colleague who works in an allergy clinic who replied in the webinar confirming there is no evidence to support this!

  • When should steroid nasal drops be considered?

There is high systemic absorption of steroid nasal drops (e.g. betamethasone) and so they are recommended for people with severe nasal obstruction (possibly with a short term nasal decongestant to help penetration) for a maximum of 1 week.

  • When should we recommend patients start their hay fever treatment?

The BSACI recommends intranasal steroids are started 2 weeks prior to a known allergen season to give maximal effect.


  • How often does acute diverticulitis present with RIF pain?

Diverticulae occur in the sigmoid colon in 85% of people with diverticular disease and only about 15% are found in the right colon, so the majority of people will present with LIF pain, however people of Asian origin have a higher incidence of right sided diverticular disease so may be at increased risk of presenting with right sided symptoms.

  • Is there any basis for the old advice of avoiding ‘skins, pips and seeds’ in diverticular disease?

This is not mentioned in the CKS review or any of the dietary sheets linked, so I’m afraid I can give you no clear advice on that one!

  • What about using antispasmodics for pain?

Again unfortunately this is not mentioned in any of the reviews I could find, so I am unsure if there is any evidence to support use of antispasmodics e.g. buscopan, but pragmatically I’m sure this is something we could consider in primary care if the patient has colicky abdominal pain.

  • I’m surprised about the recommendation to use ciprofloxacin for infective acute diverticulitis as a second line drug given the recent MHRA concerns?

The CKS guidance came out in March 2019, at the same time as the MHRA concerns. The CKS advise that if antibiotics are needed co-amoxiclav for a minimum of 7 days should be first line, with ciprofloxacin and metronidazole if true penicillin allergy. The MHRA advice highlights concerns over (very rare) reports of severe musculoskeletal and nervous system side effects which could be long-lasting or irreversible. The MHRA advise that quinolones should not be used for non-severe or self limiting infections, but can be considered for serious bacterial infections; given that the complications of acute diverticulitis can be severe or life-threatening it does seem reasonable to consider quinolone use in this situation if the patient has a true penicillin allergy.

Erectile dysfunction

  • Do we need to do genital or prostate examination in men presenting with erectile dysfunction?

Both CKS and BSSM (British Society for Sexual Medicine) recommend that all men have a genital exam (that is examining testes/penis) to look for signs of testosterone deficiency (e.g. small testicle size and lack of pubic hair) as well as structural penile disease (e.g. Peyronie’s disease). A DRE is recommended to ‘consider’ if any lower urinary tract symptoms are present especially outflow symptoms suggestive of prostatic enlargement.

  • What investigations should we do for erectile dysfunction?

We had a number of questions on this, including when to test for other hormones and whether we should use total or free testosterone. Both CKS and BSSM advise to check lipids and fasting glucose +/- Hba1c (to risk assess for CVD) as well as a serum total testosterone (TT) before 11 am in all men. If TT <12 nmol/L repeat testosterone levels and add LH/FSH and prolactin 4 weeks later. If TT borderline low (8-12nmol/L) initially, when repeating bloods do a free testosterone also. Consider thyroid function and PSA if clinically indicated. A diagnosis of testosterone deficiency can be made in the presence of typical symptoms/signs together with decreased TT or free testosterone.

  • Can losing weight improve erectile dysfunction?

Obesity and metabolic syndrome are risk factors for secondary testosterone deficiency and there is some (it appears weak) evidence that losing weight can improve erectile function. The same goes for increasing exercise and stopping smoking. Even if the evidence is weak it will certainly reduce their CVD risk. Oh and one last thing on risk factors….ask about cycling! There is evidence that long distance cycling can cause erectile dysfunction.

  • If PDE-5 inhibitors don’t work and we are considering vacuum erection devices, can they be prescribed or do we need to refer to urology?

We cannot prescribe vacuum devices so if men fail to respond to PDE-5 inhibitors we should consider referring to secondary care.

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Diabetes Awareness organised by Diabetes UK

Sarah Davies - 13 Jun, 2019

This week is the annual Diabetes Awareness Week organised by Diabetes UK. Working in primary care we cannot help but be “diabetes aware” with a significant number of the patients we see in every surgery either diagnosed with type 2 diabetes or at risk of the condition. I am currently sat in San Francisco Airport about to fly home to Wales after being fortunate enough to attend the American Diabetes Association conference 2019. It has been exciting to be here “live” to listen to the new advances and great to see several UK primary care practitioners represented on the international stage.

So, what is new and how will it affect us in primary care?

The strongest message from the conference for me was all about the kidney.  There has been a real shift in the approach to managing type 2 diabetes over recent years following on from the exciting studies showing cardiovascular protection from the newer classes of diabetes medications, i.e. the SGLT2 inhibitors (“gliflozins”) and a number of the GLP1 receptor agonists (injectable “glutides”). These led to the development of new consensus guidelines from the US and European diabetes associations advising us to prioritise these medications in our patients with type 2 diabetes and cardiovascular disease.   The cardiovascular outcome trials also showed evidence of renal protection, so renal outcome trials are ongoing. The first of these published a few months ago and its results and implications for clinical practice were discussed in depth during the conference.

The CREDENCE trial was a large multi-centre RCT of the SGLT2 inhibitor Canagliflozin in patients with type 2 diabetes and established chronic kidney disease. The primary endpoint was renal outcomes but secondary endpoints included cardiovascular outcomes. We are all aware of the increased cardiovascular risk associated with CKD. The trial was halted early due to the positive outcomes. They found a 30% relative risk reduction in the primary endpoint of end stage kidney disease, doubling of creatinine and renal or cardiovascular death. There was a number needed to treat of just 28 to prevent renal progression and 40 to prevent CV death, MI or stroke. Don’t forget that until now the only option for slowing renal disease has been ACE/ARBs. I spoke to one renal physician who very much felt these will be renal drugs and that their effect on lowing HBA1c is just a side effect! There are trials ongoing with the other SGLT2 inhibitors and indeed also in patients without diabetes.

Is this really a relevant finding for us? Well the answer is a definite yes. Diabetic kidney disease is an often complex situation to manage, so what should be our approach? Screening is vital and there were several reminders at conference of the importance of checking both eGFR and urinary ACR. The National Diabetes Audit data in the UK shows that our rates of urinary ACR measurements are falling so trying to improve this is a great practice project. It is important because a raised ACR is an independent cardiovascular risk factor and predicts a poor outcome.

Our priority in diabetic kidney disease is to optimise CV risk factors – good BP control, lipid management, ensuring patients are taking the maximum tolerated dose of ACE/ARB and of course lifestyle factors. I also feel that communication with patients is vital, informing them about their kidney disease encourages empowerment and engagement. Diabetes UK information prescriptions include one about kidney disease – a nice single piece of A4 we can give to patients with a good explanation, and can be integrated into computer systems to be pre-populated with their most recent results. An excellent resource.

In terms of management of HBA1c in renal disease we need to ensure that we prescribe appropriately according to eGFR and beware the associated increased risk of hypoglycaemia. The findings from CREDENCE and the renal outcomes seen in the CV trials support prioritising SGLT2 inhibitors in diabetic kidney disease. The American Diabetes Association has just updated its guidelines a s a result to recommend using SGLT2 inhibitors in patients with type 2 diabetes and kidney disease with eGFR > 30. At present our licence for these medications is an eGFR of 60 to commence and we can continue to prescribe down to 45 but then stop. We are likely to see this change over the next few years and NICE are in the process of reviewing and updating their guidelines for the management of type 2 diabetes in the light of all this new evidence.

As you can tell and as anyone who has been to the NB diabetes course will know, I am passionate and genuinely excited by these advances which will make real difference to outcomes for our patients with type 2 diabetes.

Now time for home and back to the normality of school runs and surgeries, with memories of San Francisco to keep me smiling!

Find out more about my Hot Topics Diabetes for Primary Care Course in Glasgow and London or the online webinar.

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