Agilio: Diagnosis and Treatment Guidance

9th April 2024

Agilio: Diagnosis and Treatment Guidance

This update contains 6 significant changes, 29 minor changes and 1 new topic.

Significant Changes:

• Breast cancer – managing FH — reviewed. A literature search was conducted in January 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. More detail on risk factors has been added. No major changes to clinical recommendations have been made.
• Cirrhosis — reviewed. A literature search was conducted in January 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last version of this topic. The recommendations have been updated in line with current evidence in the literature. A section on the assessment of a person with suspected cirrhosis has been added. The criteria on when to consider palliative care referral have been expanded. The recommendations on primary care management of a person with cirrhosis have been updated and expanded.
• Depression – antenatal and postnatal — reviewed. A literature search was conducted in October 2023 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 recommendations have been made.
• Impetigo — reviewed. A literature search was conducted in December 2023 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 recommendations have been made, but the topic has been restructured.
• Otitis media – acute — reviewed. A literature search was conducted in January 2024 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 to the topic, with no major changes to the clinical recommendations.
• Pyelonephritis – acute — reviewed. A literature search was conducted in November 2023 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 recommendations have been made.

Minor Changes:

• Anaemia – B12 and folate deficiency — minor update. Recommendations from the NICE guideline Vitamin B12 deficiency in over 16s: diagnosis and management have been incorporated into this topic.
• Aphthous ulcer — minor update. Adverse effects of doxycycline updated in line with the manufacturer’s SPC.
• Bites – human and animal — minor update. Fixed eruption added as an adverse effect of doxycycline as per the manufacturer’s SPC.
• Bronchiectasis — minor update. Information on the use of fluoroquinolones was added to the ciprofloxacin prescribing section in line with a review published by the MHRA. Fixed eruption added as an adverse effect for doxycycline as per the manufacturer’s SPC.
• Chest infections – adult — minor update. Fixed eruption added as an adverse effect of doxycycline as per the manufacturer’s SPC.
• Chlamydia — minor update. Information on the use of fluoroquinolones was added to the ofloxacin prescribing section in line with a review published by the MHRA. Fixed eruption added as an adverse effect of doxycycline as per the manufacturer’s SPC.
• Chronic kidney disease — minor update. A minor typographical error has been corrected.
• Cough – acute with chest signs in children — minor update. Adverse effects of doxycycline updated in line with manufacturer’s SPC.
• Diabetes type 2 — minor update. Phimosis has been added as an adverse effect of dapagliflozin in line with the manufacturer’s SPC.
• Dyspepsia – proven peptic ulcer — minor update. Information on the use of fluoroquinolones was added to the levofloxacin prescribing section in line with a review published by the MHRA.
• Dyspepsia – proven functional — minor update. Information on the use of fluoroquinolones was added to the levofloxacin prescribing section in line with a review published by the MHRA.
• Dyspepsia – unidentified cause — minor update. Information on the use of fluoroquinolones was added to the levofloxacin prescribing section in line with a review published by the MHRA.
• Earwax — minor update. A link has been provided to a patient information leaflet and information on bulb syringing has been added to the basis for recommendation in the section on how to remove earwax.
• Eczema — minor update. Link added to the National Eczema Society regarding the advice not to use aqueous cream as an emollient.
• Gastroenteritis — minor update. Information that people with confirmed cryptosporidiosis or giardiasis should not go swimming for 2 weeks after the last episode of diarrhoea has also been added to the sections on management of confirmed causes.
• Gonorrhoea — minor update. Information on the use of fluoroquinolones was added to the ciprofloxacin prescribing section in line with a review published by the MHRA.
• Heart failure – chronic — minor update. Genital infections have been added as an adverse effect of dapagliflozin in line with the manufacturer’s SPC.
• Leg ulcer – venous — minor update. Adverse effects of doxycycline updated in line with manufacturer’s SPC.
• Lyme disease — minor update. Fixed eruption added as an adverse effect of doxycycline as per the manufacturer’s SPC.
• Pelvic inflammatory disease — minor update. Information on the use of fluoroquinolones was added to the levofloxacin and moxifloxacin prescribing sections in line with a review published by the MHRA. Fixed eruption added as an adverse effect of doxycycline as per the manufacturer’s SPC.
• Poisoning and overdose — minor update. Information about the Specialist Pharmacy Service (SPS) has been updated.
• Rosacea — minor update. Fixed eruption added as an adverse effect of doxycycline as per the manufacturer’s updated SPC.
• Scabies — minor update. Ivermectin 3 mg has been licensed for use in the treatment of scabies. The management advice has been updated to include this information and new prescribing advice has also been added.
• Scrotal pain — minor update. Information on the use of fluoroquinolones was added to the ofloxacin and levofloxacin prescribing sections in line with a review published by the MHRA. Adverse effects of doxycycline updated in line with the manufacturer’s SPC.
• Sinusitis — minor update. Fixed eruption added as an adverse effect of doxycycline as per the manufacturer’s SPC.
• Smoking cessation — minor update. Added information about the risk of panic attacks with bupropion in line with an update of the manufacturer’s SPC.
• Spondyloarthritis and psoriatic arthropathy — minor update. Some minor formatting changes have been made to this topic.
• Urethritis – male — minor update. Information on the use of fluoroquinolones was added to the ofloxacin prescribing section in line with a review published by the MHRA. Adverse effects of doxycycline updated in line with the manufacturer’s SPC.
• Urticaria — minor update. A minor typographical error has been corrected.

New Topic:

• Abortion — this is a new Prodigy topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

12th March 2024

Agilio: Diagnosis and Treatment Guidance

This update contains 9 significant changes, 20 minor changes and 1 new topic.

Significant Changes:

• Amenorrhoea — reviewed. A literature search was conducted in January 2024 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; however, the definitions of primary and secondary amenorrhoea have been amended to reflect expert opinion in guidelines and recent review articles.
• Dermatitis – contact — reviewed. A literature search was conducted in January 2024 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 recommendations have been made.
• DVT prevention for travellers — reviewed. A literature search was conducted in October 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The moderate risk category has been removed in line with the latest guidelines from the British Society for Haematology and the American Society of Hematology, and accordingly minor changes to the recommendations have been made. A section on pregnancy has been added.
• Febrile seizure — reviewed. A literature search was conducted in December 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No significant changes to recommendations have been made.
• MRSA in primary care — reviewed. A literature search was conducted in December 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. Minor structural changes have been made to the topic to align with up-to-date evidence, with no changes to the clinical recommendations.
• Polymyalgia rheumatica — reviewed. A literature search was conducted in January 2024 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 recommendations have been made.
• Rheumatoid arthritis — reviewed. A literature search was conducted in December 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic.
• Sepsis — reviewed. A literature search was conducted in February 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. Recommendations have been aligned to the updated NICE guideline Suspected sepsis: recognition, diagnosis and early management.
• Vaginal discharge — reviewed. A literature search was conducted in October 2023 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.

Minor Changes:

• Benzodiazepine and z-drug withdrawal — minor update. Added information about prescribing diazepam to people who are breastfeeding with caution.
• Contraception – sterilization — minor update. Information that Essure® micro-inserts have been discontinued has been added to this topic.
• Coronavirus – COVID 19 — minor update. Link added to the JCVI statement on COVID-19 vaccination in spring 2024.
• Cough – acute with chest signs in children — minor update. Neurotoxicity has been added as a possible adverse effect of cefaclor treatment in line with the manufacturer’s updated SPC.
• Dyspepsia – proven functional — minor update. Link added to the JCVI statement on COVID-19 vaccination in spring 2024.
• Dyspepsia – unidentified cause — minor update. Doses of H2-receptor antagonists aligned to BNF.
• Generalized Anxiety Disorder — minor update. An adverse effect of hyperprolactinaemia relating to Citalopram has been added in line with an update to the manufacturer’s SPC. Interaction between pregabalin and morphine sulfate has been added in line with an update to the manufacturer’s SPC. Added information about prescribing diazepam to people who are breastfeeding with caution.
• Lyme disease — minor update. Infantile hypertrophic pyloric stenosis added as a possible adverse effect of azithromycin after use in neonates.
• Meningitis – bacterial meningitis and meningococcal disease — minor update. The risk stratification tables for people with suspected sepsis have been updated in line with the updated NICE guideline Sepsis: recognition, diagnosis and early management.
• Nausea/vomiting in pregnancy — minor update. Topic updated to include recommendations from the RCOG, 2024 Guideline The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No.69).
• Neuropathic pain – drug treatment — minor update. Interaction between gabapentin/pregabalin and morphine sulfate has been added in line with an update to the manufacturer’s SPC.
• NSAIDs – prescribing issues — minor update. Kounis syndrome has been added as a possible adverse effect of ibuprofen in line with the manufacturer’s updated SPC.
• Obsessive-compulsive disorder— minor update. An adverse effect of hyperprolactinaemia relating to Citalopram has been added in line with an update to the manufacturer’s SPC.
• Palliative care – cough — minor update. Adverse effects of morphine have been added in line with an update to the manufacturer’s SPC.
• Palliative care – dyspnoea — minor update. Adverse effects of morphine have been added in line with an update to the manufacturer’s SPC.
• Polycystic ovary syndrome— minor update. Updated the topic in line with recommendations in the International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2023 issued by the International PCOS Network. Updates include; refinements to the diagnostic criteria have been made. New advice on the assessment of PCOS in the post-menopause has been added. All women with PCOS should be offered a lipid profile and glycaemic testing with an oral glucose tolerance test regardless of BMI.
• Pressure ulcers — minor update. Broken link to Waterflow score updated.
• Restless legs syndrome — minor update. Adverse effects of ropinirole and rotigotine updated in line with updated manufacturer’s SPC.
• Varicose veins — minor update. A link has been to the NHS England Decision support tool: making a decision about treatment for varicose veins.
• Whooping cough — minor update. Infantile hypertrophic pyloric stenosis added as a possible adverse effect of azithromycin after use in neonates.

New Topic:

• Adult malnutrition — new topic. A literature search was conducted in November 2023 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.

13th February 2024

Agilio: Diagnosis and Treatment Guidance

This update contains 6 significant changes, 87 minor changes and 1 new topic.

Significant Changes:

• Diarrhoea – adults assessment — reviewed. A literature search was conducted in October 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. There are no changes to the recommendations.
• Mumps — reviewed. A literature search was conducted in November 2023 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 recommendations have been made.
• Neck pain – whiplash injury — reviewed. A literature search was conducted in November 2023 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, including the addition of short sections on prevalence, causes and complications, but no major changes to the recommendations.
• Osteoarthritis — reviewed. A literature search was conducted in October 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The recommendations and basis for recommendation sections have been updated in line with current evidence in the literature.
• Sinusitis — reviewed. A literature search was conducted in September 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 clinical recommendations have been made. However, the classification of chronic sinusitis has been updated in line with the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020).
• UTI – women — reviewed. A literature search was conducted in October 2023 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. The criteria used to diagnose urinary tract infection (UTI) and when to arrange dipstick testing of urine have been updated in line with the UK Health Security Agency (UKHSA) quick reference tool for primary care. The Scenario on the management of UTI with haematuria has been updated in line with the National Institute for Health and Care Excellence (NICE) guideline on Suspected cancer: recognition and referral (NICE 2023). The topic has undergone minor restructuring to improve clarity and navigation. The Prescribing information section has been expanded in line with current Prodigy style. Information on possible neurological adverse effects of cefalexin added in line with updated SPC.

Minor Changes:

• Acne vulgaris — minor update. The formatting of the prescribing section has been updated to conform to the structure of other topics.
• Allergic rhinitis — minor update. Cetirizine doses for people with renal impairment updated in line with manufacturer’s SPC.
• Angina — minor update. Adverse effect of lupus-like syndrome added and also non-cardiogenic pulmonary oedema in overdose for people prescribed diltiazem in line with an update to the manufacturer’s SPC.
• Anticoagulation – oral — minor update. Added information regarding the risk of coadministration of oral steroids with fluoroquinolones.
• Asthma — minor update. Recommendations relating to COVID-19 infection have been removed from this topic. Information about the onset of action of beta-2 agonists aligned to SPC.
• Atrial fibrillation — minor update. Changes to the order of wording for warfarin and DOACs in the anticoagulants section. Adverse effect of lupus-like syndrome added and also non-cardiogenic pulmonary oedema in overdose for people prescribed diltiazem in line with an update to the manufacturer’s SPC.
• Bipolar disorder — minor update. A typographical error has been corrected. Information about the availability of MHRA safety and educational materials to reduce the risk of harm from valproate has been added to this topic.
• Boils, carbuncles and staphylococcal carriage — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Bronchiectasis — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC). Recommendations relating to COVID-19 infection have been removed from this topic. Information on the use of fluoroquinolones and reporting adverse reactions was added in line with the Drug Safety Update published by the MHRA MHRA, 2023.
• Cardiac arrest – out of hospital care — minor update. Disparity in percentage of attempted bystander CPR rectified.
• Cellulitis – acute — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Chest infections – adult — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Chlamydia – uncomplicated genital — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC). Information on the use of fluoroquinolones and reporting adverse reactions was added in line with the Drug Safety Update published by the MHRA.
• Chronic kidney disease — minor update. Information that empagliflozin is an option for treating CKD has been added in line with the NICE Technology Appraisal [TA942]. Referral criteria revised to align with NICE Chronic kidney disease: assessment and management [NG203].
• Chronic pain — minor update. Added additional information regarding duloxetine and dosing following the publication of a Cochrane review advising that doses of greater than 60 mg provided no additional benefit.
• Constipation — minor update. Information that other medicines should not be taken orally for one hour before, during and for one hour after taking macrogol products has been added to this topic in line with the updated manufacturer’s SPC for Movicol.
• Constipation in children — minor update. Information that other medicines should not be taken orally for one hour before, during and for one hour after taking macrogol products has been added to this topic in line with the updated manufacturer’s SPC for Movicol.
• Contraception – Assessment — minor update. Levonorgestrel intrauterine systems (LNG-IUSs) are now referred to as levonorgestrel intrauterine devices (LNG-IUDs). The FSRH updated the terminology to align with other international organisations.
• Contraception – IUC — minor update. Length of use of LNG-IUD revised to 8 years maximum for Mirena® in line with an update to the manufacturer’s summary of product characteristics.
• COPD — minor update. Recommendations relating to COVID-19 infection have been removed from this topic. Information about the onset of action of beta-2 agonists aligned to SPC.
• Corticosteroids – inhaled — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Corticosteroids – oral — minor update. Added information regarding the risk of coadministration of oral steroids with fluoroquinolones.
• Cough – acute with chest signs in children — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC). Information about the onset of action of beta-2 agonists aligned to SPC.
• COVID — minor update. Acute disseminated encephalomyelitis (ADEM) has been added as a possible adverse effect of Vaxzevria® vaccination in line with the updated SPC. The recommendation to consider benzodiazepine for managing anxiety or agitation, and the recommendations on medicines for end of life care have been removed from this topic in line with the updated NICE guideline COVID-19 rapid guideline: Managing COVID-19.
• Cow’s milk allergy — minor update. Cetirizine doses for people with renal impairment updated in line with manufacturer’s SPC.
• Crohn’s disease — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Delirium — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Dementia — minor update. Cautions for rivastigmine updated in line with manufacturer’s SPC.
• Depression — minor update. An adverse effect of leukopenia relating to paroxetine has been added in line with an update to the manufacturer’s SPC. Revisions have been made to the Stopping antidepressants section following comments from an expert reviewer.
• Diverticular disease — minor update. Information on possible neurological adverse effects of cefalexin added in line with updated SPC.
• DMARDs — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Dyspepsia – proven peptic ulcer — minor update. Information on the use of fluoroquinolones and reporting adverse reactions was added in line with the Drug Safety Update published by the MHRA MHRA, 2023.
• Eczema – atopic — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC). Recommendations relating to COVID-19 infection have been removed from this topic.
• Epilepsy — minor update. Replaced the quality statements to align with the new quality standard published by NICE Epilepsies in children, young people and adults Quality standard [QS211]. Information about the availability of MHRA safety and educational materials to reduce the risk of harm from valproate has been added to this topic.
• Erectile dysfunction — minor update. Broken link removed.
• Gallstones — Minor update. A link has been added to the NHS England Decision support tool: making a decision about gallstones.
• Generalized anxiety disorder — minor update. An adverse effect of leukopenia relating to paroxetine has been added in line with an update to the manufacturer’s SPC.
• Gonorrhoea — minor update. Information on the use of fluoroquinolones and reporting adverse reactions was added in line with the Drug Safety Update published by the MHRA MHRA, 2023.
• Heart failure – chronic — minor update. Typographical error in the summary corrected. Reference to furosemide SPC added.
• Hypercholesterolaemia – familial — minor update. Recommendations on follow-up updated in line with the updated NICE guideline Cardiovascular disease: risk assessment and reduction, including lipid modification.
• Hypertension — minor update. Adverse effect of lupus-like syndrome added and also non-cardiogenic pulmonary oedema in overdose for people prescribed diltiazem in line with an update to the manufacturer’s SPC.
• Incontinence – urinary, in women — minor update. Added information relating to a licensed dose of desmopressin medication for women with troublesome nocturia and urgency incontinence.
• Insomnia — minor update. A recommendation to consider offering daridorexant for people with chronic insomnia has been added in line with the NICE technology appraisal Daridorexant for treating long-term insomnia.
• Itch – widespread — minor update. Cetirizine doses for people with renal impairment updated in line with manufacturer’s SPC.
• Leg ulcer – venous — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Lipid modification – CVD prevention — minor update. Recommendations updated in line with the NICE guideline Cardiovascular disease: risk assessment and reduction, including lipid modification, including a new recommendation on the target lipid level for secondary prevention of CVD in people taking lipid-lowering treatment.
• Malaria — minor update. Prognosis section updated in line with the UKHSA, 2024 publication Guidelines for malaria prevention in travellers from the UK.
• Malaria – prophylaxis — minor update. Prognosis section updated in line with the UKHSA, 2024 publication Guidelines for malaria prevention in travellers from the UK.
• Mastitis and breast abscess — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Measles — minor update. Information on the time window for post-exposure prophylaxis has been added in line with the updated UK Health Security Agency (UKHSA) National measles guidelines.
• Meibomian cyst (chalazion) — minor update. Minor restructuring and re-wording of the referral management section undertaken.
• Menorrhagia (heavy menstrual bleeding) — minor update. A link has been added to the NHS England Decision support tool: making a decision about managing heavy periods.
• Multiple sclerosis — minor update. Detail added on genetic risk following publication of a Nature article Elevated genetic risk for multiple sclerosis emerged in steppe pastoralist populations.
• Nausea/vomiting in pregnancy — minor update. Adverse effects of domperidone updated in line with updated SPC.
• Neuropathic pain — minor update. Added additional information regarding duloxetine and dosing following publication of a Cochrane review advising that doses of greater than 60 mg provided no additional benefit.
• Neutropenic sepsis — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• OCD — minor update. An adverse effect of leukopenia relating to paroxetine has been added in line with an update to the manufacturer’s SPC.
• Olecranon bursitis — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Palliative care – constipation — minor update. Information that other medicines should not be taken orally for one hour before, during and for one hour after taking macrogol products has been added to this topic in line with the updated manufacturer’s SPC for Movicol.
• Palliative care – cough — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Palliative care – dyspnoea — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Palliative care – general issues — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Paronychia – acute — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Pelvic inflammatory disease — minor update. Information on the use of fluoroquinolones and reporting adverse reactions was added in line with the Drug Safety Update published by the MHRA, 2023.
• Polycystic Ovary Syndrome — minor update. Broken link fixed.
• Postnatal care — minor update. Added NHS England guidance GP six to eight week maternal postnatal consultation to the new policies section.
• Pre-patellar bursitis — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Prostatitis – acute — minor update. Information on the use of fluoroquinolones and reporting adverse reactions was added in line with the Drug Safety Update published by the MHRA, 2023.
• PTSD — minor update. An adverse effect of leukopenia relating to paroxetine has been added in line with an update to the manufacturer’s SPC.
• Restless legs syndrome — minor update. Restless legs augmentation syndrome (earlier onset of symptoms in the evening/afternoon, increase in symptoms, and involvement of other extremities) added as very common adverse effect to pramipexole in line with the manufacturer’s summary of product characteristics.
• Rosacea — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Sarcoidosis — minor update. A typographical error has been corrected.
• Scabies — minor update. Clarification added on the management approach to people with possible resistant scabies.
• Scrotal pain and swelling — minor update. A link has been added to the NHS England Decision support tool: making a decision about inguinal hernia.
• Self Harm — minor update. Update to the text relating to assessment of suicide risk added.
• Sepsis — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Shingles — minor update. Topic summary changed to advise that people aged over 60 years are now eligible for vaccination.
• Skin cancers – recognition and referral — minor update. Updated quality statements to new 2024 standard.
• Sore throat – acute — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Stroke and TIA — minor update. Further clarification made on the recommendation to avoid use of statins for secondary prevention in people with a history of intracerebral haemorrhage, as all people with stroke will be offered statins (unless contraindicated) in secondary care after a diagnosis.
• Trigeminal neuralgia — minor update. Adverse effects and interactions for carbamazepine updated in line with manufacturer’s SPC.
• Ulcerative colitis — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.
• Urethritis – male — minor update. Information on the use of fluoroquinolones and reporting adverse reactions was added in line with the Drug Safety Update published by the MHRA, 2023.
• Urticaria — minor update. Cetirizine doses for people with renal impairment updated in line with manufacturer’s SPC.
• UTI-children — minor update. Information on possible neurological adverse effects of cefalexin added in line with updated SPC.
• Whitlow (staphylococcal and herpetic) — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).
• Whooping cough — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer’s Summary of Product Characteristics (SPC).

New Topic:

• Spondyloarthritis and psoriatic arthropathy — this is a new Prodigy topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

5th December 2023

Agilio: Diagnosis and Treatment Guidance

This update contains 6 significant changes and 28 minor changes.

Significant Changes: 

• Allergic rhinitis— reviewed. A literature search was conducted in August 2023 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. Recommendations in the Management section have been updated in line with current literature. Information on risk factors and on prescribing intranasal corticosteroids and the combined intranasal corticosteroid with antihistamine sprays has been added. The section on prescribing intranasal chromones has been removed as these are not available in the UK.
• Miscarriage— reviewed. A literature search was conducted in August 2023 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.
• Neck pain – cervical radiculopathy — reviewed. A literature search was conducted in October 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Minor structural changes have been made to the topic to align with up-to-date evidence. Short sections detailing risk factors and complications which can arise due to cervical radiculopathy have been added.
• Nappy rash — reviewed. A literature search was conducted in September 2023 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 recommendations have been made.
• Dysmenorrhoea — reviewed. A literature search was conducted in October 2023 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 recommendations have been made.
• Post-traumatic stress disorder — reviewed. A literature search was conducted in October 2023 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.

Minor Changes:

• Acne vulgaris — minor update. Recommendations on advice to give people who are being referred for possible isotretinoin treatment, and details on follow-up added in line with the MHRA drug safety update Isotretinoin (Roaccutane): introduction of new safety measures, including additional oversight of the initiation of treatment for patients under 18 years of age.
• Asthma — minor update. Revised the text on prescribing oral steroids to all patients with an acute asthma attack.
• Blackouts and syncope — minor update. To align with changes in the NICE guidelines Hypertension in adults: diagnosis and assessment [NG136] and Transient loss of consciousness (‘blackouts’) in over 16s [CG109]. Previous recommendation to assess a person with possible orthostatic hypotension was to measure blood pressure after three minutes standing has been revised to assess after at least 1 minute of standing.
• Boils, carbuncles, and staphylococcal carriage — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Bronchiectasis — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Candida – female genital — minor update. Information added that the manufacturers of fluconazole advise a washout period of approximately 1 week (5-6 half-lives) before becoming pregnant, in line with the updated summary of product characteristics.
• Candida – oral — minor update. Information added that the manufacturers of fluconazole advise a washout period of approximately 1 week (5-6 half-lives) before becoming pregnant, in line with the updated summary of product characteristics.
• Candida – skin— minor update. Information added that the manufacturers of fluconazole advise a washout period of approximately 1 week (5-6 half-lives) before becoming pregnant, in line with the updated summary of product characteristics.
• Cellulitis – acute — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Chickenpox — minor update. The recommendation to seek immediate specialist advice for people who are immunocompromised and have suspected chickenpox has been clarified with the addition of information that immediate admission may be necessary for administration of intravenous aciclovir.
• Coronavirus – COVID-19 — minor update. Information about the potential adverse effects of myocarditis and pericarditis associated with COVID vaccines updated in line with manufacturers’ summary of product characteristics.
• Depression — minor update. Hyperprolactinaemia added as a possible adverse effect of citalopram in line with updated SPC.
• Diabetes – type 2 — minor update. The section on antidiabetic drugs has been clarified and prescribing information on tirzapetide has been added.
• Eczema – atopic — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Gastroenteritis — minor update. The recommendation to prescribe tinidazole for treatment of giardiasis and the prescribing information have been removed from this topic as the product has been discontinued in the UK, and replaced with a recommendation to prescribe metronidazole as well as appropriate prescribing information.
• Heart failure – chronic — minor update. Information that empagliflozin is now also recommended by NICE as an option for treating symptomatic chronic heart failure with preserved or mildly reduced ejection fraction on the advice of a heart failure specialist has been added to this topic in line with the NICE technology appraisal Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction. The heart failure classification for people with an LVEF of 40%, or 50% has also been clarified.
• Impetigo — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Itch in pregnancy — minor update. Information in the secondary care management section was revised. We have removed the timeline for elective caesarean sections in women with intrahepatic cholestasis, as recent evidence suggests a reduction in gestational age from 37 weeks downwards to 35 in some cases to reduce foetal mortality.
• Leg ulcer – venous — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Mastitis and breast abscess — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Olecranon bursitis — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Otitis externa — minor update. The recommendation for using systemic quinolones in the initial management of otitis externa has been removed.
• Otitis media with effusion — minor update. The recommendation for using systemic quinolones in the initial management of otitis externa has been removed.
• Paronychia – acute — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Pityriasis versicolor — minor update. Information added that the manufacturers of fluconazole advise a washout period of approximately 1 week (5-6 half-lives) before becoming pregnant, in line with the updated summary of product characteristics.
• Pre-patellar bursitis — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.
• Trichomoniasis — minor update. Recommendations relating to tinidazole, and the prescribing information section for tinidazole have been removed from this topic as the product has been discontinued in the UK.
• Whitlow (staphylococcal and herpetic) — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer’s summary of product characteristics.

14th November 2023

Agilio: Diagnosis and Treatment Guidance

This update contains 5 significant changes, 11 minor changes and 1 new topic.

Significant Changes:

• Diarrhoea – prevention and advice for travellers – reviewed. A literature search was conducted in August 2023 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.
• Faltering Growth – reviewed. A literature search was conducted in June 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No changes to clinical recommendations have been made, but the topic has been restructured.
• Neck pain – acute torticollis – reviewed. A literature search was conducted in September 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Minor structural changes have been made to the topic to align with up-to-date evidence. A short section detailing some complications which can arise in people with acute torticollis has been added.
• Pelvic inflammatory disease — reviewed. A literature search was conducted in August 2023 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. The topic has undergone minor restructuring to improve clarity and navigation. A section on the antibiotic Levofloxacin has been added to the Prescribing information section.
• Seborrhoeic dermatitis – reviewed. A literature search was conducted in September 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic.

Minor Changes:

• Anticoagulant – oral – minor update. Adverse effect of nephropathy added to edoxaban in line with an update to the manufacturer’s summary of product characteristics.
• Chickenpox – minor update. Revised information in the basis for recommendation on antiviral treatment post-exposure prophylaxis for all pregnant women to align with the UK Health Security Agency Guidelines on post exposure prophylaxis (PEP) for varicella/shingles.
• Eczema – atopic – minor update. Added manufacturer’s SPC link to the erythromycin suspension prescribing section.
• Endometriosis – minor update. Zalkya (dienogest) 2 mg added to the new product availability to treat endometriosis.
• Gonorrhoea – minor update. Advice to reduce the dose of ceftriaxone in adults with severe renal impairment in combination with hepatic impairment, if the estimated glomerular filtration rate (eGFR) is less than 10 mL/minute/1.73 m2, has been amended to if creatinine clearance is less than 10 ml/min. This is in accordance with the advice outlined in the BNF.
• Greater trochanteric pain syndrome – minor update. A typographical error has been corrected.
• Heart failure – chronic – minor update. Some recommendations in the sections on management have been clarified.
• neuropathic pain drug treatment – minor update. Revision to the information regarding use of creatinine clearance for dose adjustments for prescribing gabapentin and pregabalin in people with renal impairment.
• Non-alcoholic fatty liver disease – minor update. A typographical error has been corrected.
• Psoriasis – minor update. Information that aqeuous cream can be used as a soap substitute has been removed from this topic in line with updated advice from the National Eczema Society and withdrawal of the SPS article Using aqueous cream as a soap substitute for skin washing.
• Stroke – minor update. The recommendation to avoid use of statins for secondary prevention in people with a history of intracerebral haemorrhage has been removed and information added to the basis to explain this change, based on a large trial which demonstrated no difference in adverse impact. The topic was also aligned with the recommendations contained in the updated NICE guideline [NG236] Stroke rehabilitation in adults October 2023.

New Topic:

• Sarcoidosis – this is a new Prodigy topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

10th October 2023

Agilio: Diagnosis and Treatment Guidance

This update contains 8 significant changes and 11 minor changes.

Significant Changes: 

• Bacterial vaginosis — reviewed. A literature search was conducted in July 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 core recommendations have been made, but the advice on screening for sexually transmitted infections and the use of intravaginal gels has been updated based on the manufacturers’ recommendations. There have been minor changes made to the structure of the topic.
• Cardiac arrest – out of hospital care — reviewed. A literature search was conducted in August 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. There have been minor structural changes to the topic, with the addition of two scenarios, ‘Out of hospital post-resuscitation care’ and ‘Terminating resuscitation’. Vasopressor and antiarrhythmic paediatric dose recommendations have been added to the ‘Basis for Recommendation’ for the management of shockable and non-shockable rhythm sections. Minor changes to the recommendations have been updated in line with current guidance, including an update to the recommended lidocaine dose (from 1 mg/kg to 100 mg).
• Chilblains — reviewed. A literature search was conducted in July 2023 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 recommendations have been made.
• Domestic abuse — reviewed. A literature search was conducted in July 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic name has been changed from ‘Domestic violence and abuse’ to ‘Domestic abuse’, and the content has been updated in line with current evidence in the literature. The topic has undergone minor restructuring to improve clarity and navigation.
• Hyperhidrosis — 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 management recommendations have been updated in line with the current literature.
• Obsessive-compulsive disorder — reviewed. A literature search was conducted in August 2023 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. No major changes to the recommendations have been made.
• Pulmonary embolism — reviewed. A literature search was conducted in August 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 have been made to the recommendations.
• Urinary tract infection (lower) – men — reviewed. A literature search was conducted in August 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic.

Minor Changes:

• Antiplatelet treatment — minor update. A reference to a study about the risks of antiplatelet therapy has been added to the basis for recommendation in the section on preventing dyspepsia. The wording relating to antiplatelets and atrial fibrillation has been revised.
• Attention deficit hyperactivity disorder — minor update. Added new product availability of melatonin for treatment of insomnia in children and adolescents aged 6-17 years with attention deficit hyperactivity disorder (ADHD), where sleep hygiene measures have been insufficient.
• Back pain – low (without radiculopathy) — minor update. Added information to the red flag section based on NICE guidance contained in [NG234] 2023 Spinal metastases and metastatic spinal cord compression.
• Chronic obstructive pulmonary disease — minor update. Updated NICE quality statements to align with the publication of revised quality statements for COPD.
• Coronavirus – COVID 19 — minor update. Additional information added about the potential adverse effect of myocarditis in line with the updated manufacturer’s Summary of Product Characteristics.
• Diabetes – type 2 — minor update. Delayed gastric emptying has been added as a possible adverse effect of semaglutide in line with the manufacturer’s updated Summary of Product Characteristics. Revised threshold for prescribing dapagliflozin in chronic kidney disease to align with NICE TA775.
• GORD in children — minor update. Information that use of omeprazole suspension in infants with GORD is unlicensed has been removed, as a licensed product is now available.
• Mastitis and breast abscess — minor update. The dose of metronidazole recommended for recurrent mastitis updated to reflect the availability of 400mg dose.
• Otitis media with effusion — minor update. Topic update to align with the NICE guideline Otitis media with effusion in the under 12s [NG233]. The need for referral for formal assessment including tympanometry and hearing tests in a child has been refined and revised. The section on screening has been deleted. The advice for parents and children has been expanded in line with advice from NICE.
• Sciatica (lumbar radiculopathy) — minor update. New symptoms added to Red flag symptoms and signs to bring topic in line with NICE guidance in [NG234] Spinal metastases and metastatic spinal cord compression.
• Sleep disorders – shift work and jet lag — minor update. Added new product availability of melatonin for short-term treatment of jet-lag.
• Smoking cessation — minor update. Change of wording in pregnancy follow-up to align with wording elsewhere in the topic regarding definition of non-smoker.