Clarity’s Diagnosis and Treatment Guidance

Significant Changes:
• Palliative care – oral — reviewed. Literature searches were conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. Minor restructuring of the topic was undertaken and recommendations updated in line with new evidence and guidelines.

• Palliative care – secretions — reviewed. Literature searches were conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic.

• Palliative care – nausea and vomiting — reviewed. Literature searches were conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic.

• Palliative care – malignant skin ulcer — reviewed. Literature searches were conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic.

• Palliative cancer care – pain — reviewed. Literature searches were conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic.

• Dementia — reviewed. A literature search was conducted in March 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Some minor structural changes have been made to this topic, but no major changes to clinical recommendations.

Minor Changes:
• Nausea/vomiting in pregnancy — minor update. Domperidone has been added as a second-line treatment option and prescribing information has been added.

• Lipid modification – CVD prevention — minor update. Rosuvastatin added as a drug interaction with gemfibrozil in line with the updated Summary of Product Characteristics.

• Conjunctivitis – infective — minor update. The recommendation that use of chloramphenicol eyes drops is contraindicated in children aged under 2 years has been added.

• Atrial fibrillation — minor update. The topic has been updated to align with the updated NICE guideline Atrial fibrillation: diagnosis and management and includes the recommendation to use the ORBIT bleeding risk assessment tool when considering starting anticoagulation in people with atrial fibrillation, and that a direct oral anticoagulant should be used first-line in people considered to be at risk of stroke.

• Cervical screening — minor update. Information that cervical dysplasia is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Cervical cancer and HPV — minor update. Information that cervical dysplasia is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Shingles — minor update. Information that herpes zoster is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Hepatitis B — minor update. Information that hepatitis B is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Glandular fever (infectious mononucleosis) — minor update. Information that mononucleosis-like illness is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Chest infections – adult — minor update. Information that community-acquired pneumonia is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Platelets – abnormal counts and cancer — minor update. Information that thrombocytopenia lasting for over 4 weeks is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Seborrhoeic dermatitis — minor update. Information that seborrhoeic dermatitis/exanthema is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Psoriasis — minor update. Information that severe or atypical psoriasis is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Candida – oral — minor update. Information that unexplained oral candidiasis is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Diarrhoea – adult’s assessment — minor update. Information that unexplained chronic diarrhoea is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Chronic kidney disease — minor update. Information that unexplained chronic renal impairment is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• HIV infection and AIDs — minor update. Information on non-AIDS-defining indicator conditions and a recommendation to offer HIV screening to people with these conditions has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

• Immunizations – travel — minor update. Recommendations that Revaxis and Avaxim should be used with caution in people with phenylketonuria have been added to this topic in line with the manufacturers’ Summary of Product Characteristics.

• Hepatitis A — minor update. A recommendation that Avaxim should be used with caution in people with phenylketonuria has been added to this topic in line with the manufacturer’s Summary of Product Characteristics.

• Immunizations – childhood — minor update. A recommendation that Revaxis should be used with caution in people with phenylketonuria has been added to this topic in line with the manufacturer’s Summary of Product Characteristics.

• Appendicitis — minor update. A typographical error has been corrected.

• Diabetes – type 2 — minor update. Adverse effects of SGLT-2 inhibitors updated in line with revised manufacturer’s SPC.

• Cough — minor update. Links have been added within the section on management of sub-acute and chronic cough to the assessment and diagnosis sections.

• DMARDs — minor update. Clarification added on frequency of pneumococcal vaccination where a single pneumococcal vaccine is now recommended unless the person on DMARDs also has asplenic, splenic dysfunction or chronic renal disease.

• Contraception – emergency — minor update. A typographical error has been corrected.

• Hypothyroidism — minor update. Prescribing advice about patients who experience symptoms on switching between different levothyroxine products has been added to this topic in line with MHRA advice.

• Migraine — minor update. A recommendation that a discussion of the potential benefits and risks, and the importance of effective contraception for women and girls of childbearing potential when taking topiramate has been added to this topic in line with the updated NICE guideline Headaches in over 12s: diagnosis and management.

• Epilepsy — minor update. A recommendation to urgently refer women for specialist advice if they are taking antiepileptic drugs and planning to become pregnant has been added to this topic in line with the Medicines and Healthcare products Agency (MHRA) Drug Safety Update Antiepileptic drugs in pregnancy: updated advice following comprehensive safety review.

• Uveitis — minor update. Endophthalmitis was added as a sight-threatening differential diagnosis.

• Asthma — minor update. A typographical error has been corrected.

• Chronic obstructive pulmonary disease — minor update. A typographical error has been corrected.

Significant Changes:

• Obstructive sleep apnoea – reviewed. A literature search was conducted in January 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The recommendations have been updated in line with current evidence in the literature. No major changes to the recommendations have been made.

• Gilbert’s syndrome – reviewed. A literature search was conducted in February 2021 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, but the topic has been restructured.

• Immunization – childhood – reviewed. A literature search was conducted in January 2021 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 to clinical recommendations have been made.

• Chlamydia – uncomplicated genital – reviewed. A literature search was conducted in February 2021 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 to clinical recommendations have been made.

• Itch – widespread – reviewed. A literature search was conducted in December 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. In the Scenario on Management, the sections on management of itch of known and unknown cause have been merged to avoid repetition of text. The recommendations have been updated in line with current evidence in the literature. The recommendations on prescribing oral antihistamines have been amended to consider the use of non-sedating oral antihistamines first line unless there is a history of troublesome nocturnal itch. New sections on Cetirizine, Loratadine, and Fexofenadine have been added to the section on Prescribing information.

• Contraception – progestogen-only – reviewed. A literature search was conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic.

• Bruising – reviewed. A literature search was conducted in February 2021 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 restructuring. No major changes to the recommendations have been made.

• Earwax – reviewed. A literature search was conducted in March 2021 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, but the topic has been restructured.

Minor Changes:

• Epilepsy – minor update. Adverse effects of antiepileptic drugs updated to contain information on severe liver damage in children.

• Coronavirus – COVID-19 – minor update. Information on the Moderna COVID-19 vaccine has been added to this topic, information relating to immunization in pregnancy has been updated, as well as prevalence data. A typographical error has also been corrected.

• Scrotal pain and swelling – minor update. A typographical error has been corrected.

• Eczema – atopic – minor update. Updated to align with Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing [NICE, 2021].

• Sinusitis – minor update. A link to a patient information leaflet has been removed from the topic.

• Insomnia – minor update. Information on the risks associated with melatonin have been clarified to align with the updated NICE Key therapeutic topic on Insomnia.

• HIV infection and AIDs – minor update. Recommendations on post-exposure prophylaxis have been updated in line with the British Association for Sexual Health and HIV (BASHH) UK Guideline for the use of HIV Post-Exposure Prophylaxis 2021.

• Pyelonephritis – acute – minor update. Information on signs and symptoms of acute pyelonephritis have been clarified.

• Immunizations – travel – minor update. Adverse effects of meningococcal meningitis vaccination updated in line with revised manufacturer’s SPC.

• Opioid dependence – minor update. Drug interactions for methadone updated in line with revised manufacturer’s SPC.

• Depression – minor update. Suicide/suicidal thoughts and aggression in patients during discontinuation of venlafaxine has been added in line with updated manufacturer’s SPC. A typographical error has also been corrected.

• Deep vein thrombosis – minor update. A typographical error has been corrected.

• Malaria prophylaxis – minor update. Suicidal behaviour and psychiatric disorders have been added to the adverse effects of chloroquine in line with updated manufacturer’s SPC.

• Contraception – emergency – minor update. The section on types of emergency contraception has been clarified. Links have been amended in the section on continuing or starting regular contraception.

• Contraception – IUS/IUD – minor update. The recommendations on switching from a progestogen-only implant to the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (Cu-IUD) have been updated in line with the Faculty of Sexual and Reproductive Healthcare (FSRH) guideline Progestogen-only implant [FSRH, 2021].

New Topic:

• Platelets – abnormal counts and cancer – is a new topic. A literature search was conducted in January 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials. The evidence base has been reviewed in detail and recommendations are clearly justified and transparently linked to the supporting evidence.

Significant Changes:
• Mastitis and breast abscess – reviewed. A literature search was conducted 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 restructuring. No major changes to the recommendations have been made.

• Jaundice in adults – reviewed. A literature search was conducted 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 restructuring. No major changes to the recommendations have been made.

• Jaundice in the newborn – reviewed. A literature search was conducted 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 restructuring. No major changes to the recommendations have been made.

• Squint in children – reviewed. A literature search was conducted in December 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last version of this topic. No major changes to clinical recommendations have been made.

• Diabetes type 2 – reviewed. A literature search was conducted in November 2020 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 recommendations have been updated in line with current literature. Information on the hyperglycaemic emergency complication of hyperosmolar hyperglycaemic state (HHS) has been added.

• Tennis elbow – reviewed. A literature search was conducted in November 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been minor structural changes, and a recommendation not to use corticosteroids routinely for treating tennis elbow has been added to this topic.

• Anticoagulation – oral. A literature search was conducted in 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 to clinical recommendations have been made. However, sections on monitoring people taking anticoagulants during the COVID-19 pandemic has been included, based on the Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic [MHRA, 2020].

Minor Changes:
• Immunizations – seasonal influenza – minor update. Information added to reflect the authorization of the use of the recombinant quadrivalent vaccine (QIVr) in the 2020/2021 immunization programme.

• Neuropathic pain – drug treatment – minor update. Severe respiratory depression added as an adverse effect of pregabalin in line with updated manufacturer’s SPC.

• Generalized anxiety disorder – minor update. Severe respiratory depression added as an adverse effect of pregabalin in line with updated manufacturer’s SPC.

• Sciatica (lumbar radiculopathy) – minor update. Recommendations on offering neuropathic drugs at follow-up, and advising people with sciatica when to seek follow-up have been clarified.

• Boils, carbuncles, and staphylococcal carriage – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Bronchiectasis – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Cellulitis – acute – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Chest infections – adult – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Chlamydia – uncomplicated genital – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Cough – acute with chest signs in children – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Eczema – atopic – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Lacerations – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Leg ulcer – venous – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Olecranon bursitis – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Paronychia – acute – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Rosacea – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Sore throat – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Whitlow (staphylococcal and herpetic) – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Whooping cough – minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update.

• Epilepsy – minor update. The safety profile of valproate in paediatrics has been updated in line with revised manufacturer’s SPC.

• Coronavirus – COVID-19 – minor update. Prevalence figures have been updated and information that a new more transmissible variant of COVID-19 emerged in December 2020 has been added to this topic, along with updated information on vaccine dose schedules.

• Contraception – combined hormonal methods – minor update. Recommendations on switching from the progestogen-only implant to combined hormonal contraception have been updated in line with the updated Faculty of Sexual and Reproductive Healthcare (FSRH) guideline Switching or starting methods of contraception.

• Hyperthyroidism – minor update. Hypersensitivity reactions added as an adverse effect of propylthiouracil in line with updated manufacturer’s SPC.

• Diverticular disease – minor update. The duration of antibiotic treatment for uncomplicated acute diverticulitis has been updated in line with the NICE guideline Diverticular disease: diagnosis and management.

New Topic:
• Mental health in students – this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.