Agilio: Diagnosis and Treatment Guidance

Significant Changes:
• Erectile dysfunction — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. The topic has undergone minor restructuring to improve clarity and navigation. No major changes to clinical recommendations have been made. Detail about phosphodiesterase-5 (PDE-5) inhibitor dose escalation if initial treatment is ineffective or unsatisfactory has been added in the section on Follow-up.
• Ménière’s disease — reviewed. A literature search was conducted in February 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. No major changes to recommendations have been made.
• Menorrhagia (heavy menstrual bleeding) — reviewed. The topic title has been changed from ‘Menorrhagia’ to ‘Menorrhagia (heavy menstrual bleeding)’. A literature search was conducted in January 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No changes to clinical recommendations have been made.

Minor Changes:
• Acute kidney injury — minor update. The updated NICE quality standards have been added to this topic.
• Atrial fibrillation— minor update. Adverse effects and contraindications and cautions for diltiazem have been updated in line with the updated manufacturer’s Summary of Product Characteristics (SPC) for Slozem capsules.
• Bedwetting (enuresis) — minor update. Added information about the option to prescribe Demovo® for the treatment of primary enuresis in children over the age of 5.
• Bites – human and animal — minor update. A minor formatting change has been made to the section on wound care.
• Blepharitis — minor update. A minor typographical error has been corrected.
• Chronic kidney disease— minor update. Recommendations on giving people with CKD information about their 5-year risk of needing renal replacement therapy measured using the 4-variable Kidney Failure Risk Equation, and referring people with a 5-year risk of greater than 5% have been added to this topic in line with the NICE guideline Chronic kidney disease: assessment and management.
• Coronavirus – COVID-19 — minor update. Several uncommon adverse effects of the Vaxzevria and Comirnaty vaccines were added in line with the manufacturer’s SPC. Information that the Spikevax bivalent vaccine is now licensed for use in people aged over 6 years has been added to this topic in line with the updated manufacturer’s Summary of product characteristics.
• Diabetes – type 1 — minor update. The quality standards have been updated in line with updated NICE Quality standard Type 1 diabetes in adults [QS208].
• Diabetes – type 2 — minor update. Updated quality statements in line with the publication of NICE Diabetes type 2 Quality Standard [QS209]. Added recommendation to consider adding finerenone as an option for treating stage 3 and 4 chronic kidney disease (with albuminuria) associated with type 2 diabetes in adults in line with the NICE Technology Appraisal [TA877].
• Hypertension — minor update. Adverse effects and contraindications and cautions for diltiazem have been updated in line with the updated manufacturer’s Summary of Product Characteristics (SPC) for Slozem capsules.
• Obesity — minor update. The recommendation from the NICE technology appraisal Semaglutide for managing overweight and obesity [TA875] has been added to the management section of this topic.
• Rosacea — minor update. Information about alternative first-line antibiotic options have been added to this topic in line with The British Association of Dermatologists guidelines for the management of people with rosacea.
• Scarlet fever — minor update. Antibiotic recommendations updated in line with the UKHSA guideline Scarlet fever: managing outbreaks in schools and nurseries. A prescribing section for azithromycin has been added and prescribing information for erythromycin has been combined with the section on clarithromycin.
• Smoking cessation — minor update. Added information about the risk of bupropion unmasking Brugada syndrome in line with an update of the manufacturer’s SPC. Caution is advised in at risk patients.
• Urinary tract infection (lower) – women — minor update. The recommendation to screen for asymptomatic bacteriuria in pregnant women has been removed to align with the NICE Guideline Urinary tract infection (lower): antimicrobial prescribing [NG109].
New Topic:
• Pressure ulcers — new topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.”

Significant Changes:
• Burns and scalds — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No changes to clinical recommendations have been made.
• Colic — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The recommendations have been amended in line with current evidence. The diagnostic criteria for infantile colic have been updated in line with the Rome IV criteria for functional gastrointestinal disorders in infants and toddlers (2016).
• Dry eye disease (name changed from dry eye syndrome) — reviewed. A literature search was conducted in December 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomised controlled trials published since the last revision of the topic. The topic title has been changed from ‘Dry eye syndrome’ to ‘Dry eye disease’ in line with current terminology in the literature. The definition of dry eye disease has been updated in line with the international Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) publication TFOS DEWS II Definition and classification report (Craig 2017). No major changes to clinical recommendations have been made.
• Dyspepsia – unidentified cause – reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.
• Lacerations — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic.
• Leg cramps — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No major changes to clinical recommendations have been made.
• Polycythaemia/erythrocytosis – reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. Minor updates were applied to the topic structure and up-to-date literature was incorporated to provide supporting evidence for the guidance. The clinical definition of erythrocytosis was updated to reflect the current British Society for Haematology guidance. No further major changes to the clinical recommendations have been made.
• Vertigo — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No major changes have been made to recommendations.
• Vestibular neuronitis — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic.

Minor Changes:
• Allergic rhinitis — minor update. Removed the decongestant ephedrine 0.5% as these have been discontinued.
• Attention deficit hyperactivity disorder — minor update. Management in specialist settings updated to include the option of melatonin medication in use for children and young people with insomnia aged 6-17 with ADHD, where sleep hygiene measures have been insufficient.
• Cellulitis acute — minor update. Revised recommendation on prescribing antibiotics in people with cellulitis and lymphoedema to align with the British Lymphology Society and Lymphoedema Support Network guideline, 2022 Guidelines on the Management of Cellulitis in Lymphoedema.
• Constipation — minor update. Added information about avoiding concomitant use of macrogol and starch-based food thickeners in line with an update to the manufacturer’s SPC.
• Coronavirus – COVID 19 — minor update. Added new contraindication and adverse effect of the Janssen COVID-19 vaccine in line with an update to the manufacturer’s SPC.
• Dementia — minor update. Remove duplication of smoking as a risk factor in the summary and revised the wording in the assessment section relating to onset of vascular dementia.
• Dental abscess — minor update. The choice of antibiotic for dental abscess has been updated in line with the Faculty of Dental General Practice guideline Antimicrobial Prescribing in Dentistry.
• Dyspepsia – proven functional — Minor update. Interstitial nephritis added as an adverse effect of lansoprazole, in line with the manufacturer’s updated SPC.
• Dyspepsia – proven GORD — Minor update. Interstitial nephritis added as an adverse effect of lansoprazole, in line with the manufacturer’s updated SPC.
• Dyspepsia – Proven peptic ulcer — Minor update. Interstitial nephritis added as an adverse effect of lansoprazole, in line with the manufacturer’s updated SPC.
• Ectopic pregnancy — minor update. Information on secondary care management of threatened miscarriage has been removed from this topic and added to the Prodigy topic on Miscarriage.
• Epistaxis (Nosebleeds) — minor update. Patient information leaflet link updated.
• Heart failure – chronic — minor update. Updated the NICE Quality standards in line with the update NICE Quality standard Chronic heart failure in adults [QS9].
• Herpes simplex – genital — minor update. Tubulointerstitial nephritis added as a potential adverse effect of valaciclovir in line with an update to the manufacturer’s summary of product characteristics.
• Herpes simplex – oral — minor update. Tubulointerstitial nephritis added as a potential adverse effect of valaciclovir in line with an update to the manufacturer’s summary of product characteristics.
• Influenza – seasonal — minor update. Information that the Department of Health and Social Care (DHSC) notifies GPs directly if the national surveillance scheme indicates that influenza is circulating in the community has been added to this topic.
• Itch in pregnancy — minor update. Added information relating to phenothiazine derivatives potentiating QT interval prolongation based on an updated manufacturer’s SPC.
• Lipid modification – CVD prevention — minor update. Information regarding rosuvastatin interactions added in line with the manufacturer’s updated SPC.
• Hypercholesterolaemia – familial — minor update. Immune-mediated necrotizing myopathy added as a possible adverse effect and ledipasvir/sofosbuvir added to list of possible drug interactions for atorvastatin in line with the manufacturer’s updated SPC.
• Mastitis and breast abscess — minor update. Recommendation on emptying the affected breast in lactating women has been removed to align with the Academy of Breastfeeding Medicine Clinical Protocol 36, The Mastitis Spectrum, 2022.
• Meniere’s disease — minor update. Added information relating to phenothiazine derivatives potentiating QT interval prolongation based on an updated manufacturer’s SPC.
• Miscarriage — minor update. Information on secondary care management of threatened miscarriage has been added to this topic in line with the NICE guideline Ectopic pregnancy and miscarriage: diagnosis and initial management.
• Neuropathic pain – drug treatment — minor update. Toxic epidermal necrolysis added as a possible adverse effect of pregabalin in line with the updated Summary of Product Characteristics.
• Palliative care – constipation — minor update. Added information about avoiding concomitant use of macrogol and starch-based food thickeners in line with an update to the manufacturer’s SPC.
• Palliative care – oral — minor update. Clarification added about the use of betamethasone tablets for ulcers.
• Polymyalgia rheumatica — minor update. Hyperlinks to a charity organization have been updated.
• Pre-conception – advice and management — minor update. Updated the Quality Standards in line with the update NICE Quality standard [QS109] Diabetes in pregnancy.
• Scarlet fever — minor update. Antibiotic recommendations updated in line with the UKHSA Group A streptococcus in children. Interim clinical guidance summary issued on December 16. Typographical error in prescribing section amended.
• Seborrhoeic dermatitis — minor update. Information relating to selenium sulfide shampoo has been removed from this topic as the product has been discontinued in the UK.
• Shingles — minor update. Tubulointerstitial nephritis added as a potential adverse effect of valaciclovir in line with an update to the manufacturer’s summary of product characteristics
• Smoking cessation — minor update. Updated the quality standards in line with the publication of NICE, 2022 QS207 Tobacco: treating dependence.
• Sore throat — minor update. Antibiotic recommendations updated in line with the UKHSA Group A streptococcus in children. Interim clinical guidance summary issued on December 16. Antibiotic recommendations updated in line with the UKHSA Group A streptococcus in children. Interim clinical guidance summary issued on December 9.
• Type 1 diabetes — minor update. Added the quality standards from the updated NICE Diabetes in pregnancy Quality standard [QS109]. The section on managing foot problems has been updated in line with the NICE guideline Diabetic foot problems: prevention and management.
• Type 2 diabetes — minor update. Added the quality standards from the updated NICE Diabetes in pregnancy Quality standard [QS109]. The section on managing foot problems has been updated in line with the NICE guideline Diabetic foot problems: prevention and management.

New Topic:
• Long-term effects of coronavirus (long COVID) — this is a new Agilio topic. A literature search was conducted in October 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials. The recommendations have been made in line with current evidence in the literature.

Significant Changes:
• Alcohol – problem drinking — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes have been made to the recommendations.
• Back pain – low (without radiculopathy) — reviewed. A literature search was conducted in October 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring to improve clarity and navigation. The use of benzodiazepines for the management of muscle spasm associated with acute non-specific low back pain is no longer recommended, in line with the National Institute for Health and Care Excellence (NICE) guidance Low back pain and sciatica in over 16s: assessment and management (NICE 2020), which recommends the clinical and cost-effectiveness of benzodiazepines for the acute management of low back pain as an area for future research.
• Dyspepsia – proven GORD — reviewed. A literature search was conducted in October 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.
• Dyspepsia – proven peptic ulcer — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.
• Pre-conception – advice and management — reviewed. A literature search was conducted in October 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No major changes were made to recommendations.
• Shoulder pain — reviewed. A literature search was conducted in October 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No major changes to recommendations have been made.
• Warts – anogenital — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. Minor updates to structure and updated literature has been incorporated to provide supporting evidence for the guidance. No major changes to the clinical recommendations have been made.

Minor Changes:
• Anticoagulation – oral — minor update. Added a rare adverse effect of rivaroxaban of eosinophilic pneumonia in line with the manufacturer’s SPC.
• Antiplatelet treatment — minor update. A new caution has been added when prescribing ticagrelor as the manufacturer advises caution relating to people with sleep apnoea.
• Attention deficit hyperactivity disorder — minor update. Management in specialist settings updated to include the option of melatonin medication in use for children and young people with insomnia aged 6-17 with ADHD, where sleep hygiene measures have been insufficient.
• Coronavirus – COVID-19 — minor update. Heavy menstrual bleeding added as a possible adverse effect of booster vaccinations in line with the updated manufacturer’s Summaries of Product Characteristics for Comirnaty and Spikevax vaccines. Recommendations on assessment and management of suspected long COVID have been removed from this topic and links added to the new Agilio topic on Long-term effects of coronavirus (long COVID).
• Diabetes – type 1 — minor update. Recommendations on continuous blood glucose monitoring have been updated in line with the NICE guidelines Type 1 diabetes in adults: diagnosis and management, and Diabetes (type 1 and type 2) in children and young people: diagnosis and management. The NICE quality standard for children and young people has also been updated.
• Diabetes – type 2 — minor update. Added delayed gastric emptying as an adverse effect of lixisenatide as per the manufacturer’s updated SPC.
• Heart failure – chronic — minor update. Added information about concomitant use of losartan and grapefruit juice to be avoided as grapefruit juice decreases the therapeutic effect of losartan.
• Hypercholesterolaemia – familial — minor update. Information regarding interactions between ticagrelor and rosuvastatin added in line with the manufacturer’s updated SPC.
• Lipid modification – CVD prevention — minor update. Information regarding interactions between ticagrelor and rosuvastatin added in line with the manufacturer’s updated SPC.
• Lyme disease — minor update. Information that doxycycline prescribing for children aged 9-12 is an off-label indication added to the prescribing section of this topic.
• Raynaud’s phenomenon — minor update. Added adverse effects of anxiety reactions, sleep disorders, mood changes, and depression based on an update to the manufacturer’s SPC.