Summary of guidance relevant to general practice published in January 2011
- Anxiety - partial update
- Skin cancer prevention: information, resources and environmental changes
- Osteoporotic fractures - primary and secondary prevention
Anxiety - partial update
Priorities for implementation in general practice from the clinical guideline on generalised anxiety disorder (GAD) and panic disorder (with or without agoraphobia) in adults
[new 2011] indicates that the evidence has been reviewed and the recommendation has been updated or added in the 2011 update to this guideline.
General practitioners should:
- Identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly. [new 2011]
- Consider the diagnosis of GAD in people presenting with anxiety or significant worry, and in people who attend primary care frequently who:
- have a chronic physical health problem or
- do not have a physical health problem but are seeking reassurance about somatic symptoms (particularly older people and people from minority ethnic groups) or
- are repeatedly worrying about a wide range of different issues. [new 2011]
- For people with GAD whose symptoms have not improved after education and active monitoring, offer one or more of the following as a first-line intervention, guided by the person's preference:
- individual non-facilitated self-help
- individual guided self-help
- psychoeducational groups. [new 2011]
- For people with GAD and marked functional impairment, or those whose symptoms have not responded adequately to first line interventions:
- Offer either:
- an individual high-intensity psychological intervention (cognitive behavioural therapy (CBT) or applied relaxation) or
- drug treatment (see below for more information on drug treamtments)
- Provide verbal and written information on the likely benefits and disadvantages of each mode of treatment, including the tendency of drug treatments to be associated with side effects and withdrawal syndromes.
- Base the choice of treatment on the person's preference as there is no evidence that either mode of treatment (individual high-intensity psychological intervention or drug treatment) is better. [new 2011]
- If a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI). Consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions. [new 2011]
- Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the 'British national formulary' on the use of a benzodiazepine in this context. [new 2011]
- Do not offer an antipsychotic for the treatment of GAD in primary care. [new 2011]
Referral for specialist treatment should be considered if the person with GAD has severe anxiety with marked functional impairment in conjunction with:
- a risk of self-harm or suicide or
- significant comorbidity, such as substance misuse, personality disorder or complex physical health problems or
- self-neglect or
- an inadequate response to step 3 interventions. [new 2011]
NICE recommends that combination treatments should only be undertaken by practitioners with expertise in the psychological and drug treatment of complex, treatment-refractory anxiety disorders and after full discussion with the person about the likely advantages and disadvantages of the treatments suggested.
For more information, see the Quick Reference Guide for CG 113, Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults.
Support tools to help put this guidance into practice
We have prepared:
- A slide set which would be useful to promote discussion of this guidance at a practice meeting
- A costing statement and costing template to help you to identify the costs and savings of putting this guideline into practice
- Audit support to enable you to evaluate the clinical and the information and support recommendations in this guideline
- A baseline assessment tool so that you can assess where your practice will need to make changes to comply with this guideline
New support tools available now
The Guide to self-help resources for people with GAD signposts to 37 free on-line resources produced by government organisations, large charities or other national organisations, to help people with GAD to manage their symptoms. The guide is designed to be used on-line so you can include the link to http://guidance.nice.org.uk/CG113/SelfHelp, in any information that is routinely given to people who present with GAD.
A set of Clinical case scenarios for primary care is also available. This educational resource presents five scenarios of people presenting in primary care with symptoms of anxiety, including details of the person's initial presentation, their past medical history and the clinician's summary of the situation after examination. The clinical decisions surrounding diagnosis and management are then examined using a question and answer approach. These clinical case scenarios would be an invaluable part of your practice's education and training programme.
Skin cancer prevention: information, resources and environmental changes
The guidance recommends that commissioners, organisers and planners of national, mass-media skin cancer primary prevention campaigns continue to develop, deliver and sustain these campaigns to raise and maintain awareness of the risks of UV exposure and how to protect against it.
GPs should ensure that patients are given a balanced picture of both the risks of overexposure and the benefits of being out in the sun, such as boosting vitamin D levels and increasing the likelihood of being physically active.
Patients should be given advice on when and how to protect themselves to avoid sunburn. This includes spending time in the shade between 11 am and 3 pm when the sun is at its strongest, and selecting and applying an appropriate sunscreen (at least SPF 15).
The guidance 'Skin cancer: prevention using public information, sun protection resources and changes to the environment' is available at www.nice.org.uk/guidance/PH32
You may find some of the slides in the slide set useful as the basis for discussion in a practice meeting.
Osteoporotic fractures - primary and secondary prevention
NICE has reconsidered the analysis relating to strontium ranelate for the prevention of osteoporotic fractures, following a Court of Appeal ruling. This has resulted in no change to the recommendations compared with those issued in 2008 and updated in January 2010.
Strontium ranelate should be offered only to postmenopausal women who are unable to tolerate oral bisphosphonates and other recommended drugs, and who are at high risk of osteoporotic fractures.
Support tools to help put NICE guidance on prevention of osteoporosis into practice
We have prepared:
- A slide set for guidance on primary prevention, and one for secondary prevention, which would be useful to promote discussion of this guidance at a practice meeting
- Costing templates for primary prevention and secondary prevention, to help you to identify the costs and savings of putting this guideline into practice
- Audit support for primary prevention, and for secondary prevention to enable you to evaluate the clinical and the information and support recommendations in this guideline
Summary of NICE advice on the prevention of osteoporosis
Alendronate is recommended as a treatment option for primary prevention of osteoporotic fragility fractures in women aged 70 years or older who have an independent clinical risk factor for fracture or an indicator of low bone mineral density (BMD) and are confirmed to have osteoporosis (a T-score of -2.5 SD or below). In women aged 75 years or older who have two or more independent risk factors for fracture or low BMD, a DXA scan may not be required if considered inappropriate or unfeasible.
Alendronate is also recommended for primary prevention of osteoporotic fragility fractures in postmenopausal women younger than 70 years who have confirmed osteoporosis and:
- an independent clinical risk factor for fracture for those aged 65-69 years
- an independent clinical risk factor for fracture and at least one additional indicator of low BMD for those younger than 65 years.
If alendronate is unsuitable, risedronate and etidronate are recommended alternative options. Strontium ranelate is a recommended option for women considered unsuitable for alendronate, risedronate and etidronate. Raloxifene is not recommended as a treatment option.
Alendronate is recommended in all postmenopausal women who have confirmed osteoporosis. Women aged 75 years or older may not need a DXA scan if considered clinically inappropriate. For women who cannot take alendronate, risedronate and etidronate are recommended. For women who cannot take alendronate, risedronate and etidronate, strontium ranelate and raloxifene are recommended options. Teriparatide is a recommended alternative for women who can't take any of the previous recommended options or who've had an unsatisfactory response to alendronate, risedronate or etidronate.
This page was last updated: 29 June 2011