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4561. Palliative care - cough

on, the other half of your prescription with the list of medicines prescribed by your doctor, or the package insert if the medicine was bought over-the-counter. [ ; ; ; ] Morphine Morphine Morphine should be titrated in the same way as for pain relief. The initial starting dose will depend on the person's previous exposure to opioids. For more information about the use of morphine in pain relief, see the Prodgiy topic on . For someone not already taking an opioid, a dose of 2.5 mg regularly every 4 hours (...) guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There have been changes made to the recommendations regarding corticosteroid use. Also a new CKS topic covering general issues in palliative care has been written which replaces the general advice written in the previous CKS guidance. January 2006 — minor update. Prescriptions for diamorphine updated to reflect the change

2016 NICE Clinical Knowledge Summaries

4562. Raynaud's phenomenon

(including the hands and feet) warm. Avoiding or stopping smoking. Minimizing stress. Exercising regularly. If lifestyle measures fail, a trial of nifedipine as prophylaxis should be considered. For young people aged 13 to 17 years, specialist advice is required before treating. For adults 18 years of age or older, either an immediate- or modified-release preparation can be prescribed. Up to three-quarters of people experience adverse effects, such as oedema, palpitations, headache, flushing (...) and management have been simplified. No major changes to recommendations have been made except that it is now advised to seek specialist advice before prescribing nifedipine for young people aged 13 to 17 years. Prescribing information has been added for nifedipine. Previous changes Previous changes December 2008 to June 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked

2016 NICE Clinical Knowledge Summaries

4563. Palliative care - general issues

and harms of prescribing or administering medicines. The benefits and harms of not prescribing or administering medicines. The possible risk of the person suddenly deteriorating (for example, catastrophic haemorrhage or seizures) for which urgent symptom control may be needed. If anticipatory medicines are administered: Monitor for benefits and any side effects at least daily, and give feedback to the lead healthcare professional. Adjust the individualised care plan and prescription as necessary Basis (...) to specialist services, when necessary. During the course of the illness, the patient's needs as well as the needs of their family or carers, should be assessed (and managed) at key points (e.g. at the time of diagnosis, around treatment episodes, as treatments end, at the time of a relapse, and when death is approaching). This includes assessing and managing: Preferred care setting. Anticipatory prescribing. Managing common physical symptoms such as nausea and vomiting or breathlessness. Psychological

2016 NICE Clinical Knowledge Summaries

4564. Non-alcoholic fatty liver disease (NAFLD)

of worsening liver inflammation and fibrosis. See the sections on lifestyle advice in the CKS topics on and for more information. Advise on drinking alcohol within national recommended limits. See the CKS topic on for more information. Ensure that associated conditions such as hypertension, hyperlipidaemia, and type 2 diabetes mellitus are optimally managed. See the CKS topics on , and for more information. Be aware that people with NAFLD do not have any additional risks of hepatotoxicity if prescribed (...) statin drug treatment, and people already taking statins should continue to take them as prescribed. Provide advice on sources of information and support for people with NAFLD, such as the which has a patient guide on . The National Institute for Health and Care Excellence (NICE, available at ) also provides a patient information leaflet on . Basis for recommendation Basis for recommendation The recommendations on how to manage a person with suspected non-alcoholic fatty liver disease (NAFLD

2016 NICE Clinical Knowledge Summaries

4565. Palliative care - constipation

. Preventing constipation How should I prevent constipation when prescribing a constipating drug? When introducing an opioid (or any other constipating drug), advise the person of the risks of constipation, and prescribe a stimulant laxative (such as senna or dantron-containing laxative) at the time of first prescription, rather than waiting until constipation is established. Aim for a regular bowel movement, without straining, every 1 – 3 days. Dose of senna: If not constipated start with 15 mg at bedtime (...) treatments may be necessary for faecal loading and/or impaction, such as a suppository or enema. A laxative should be prescribed to prevent constipation when starting any potentially constipating drug, such as opioid analgesics. The laxative dose needs to increase with increases in opioid dose. Have I got the right topic? Have I got the right topic? From age 16 years onwards. This CKS topic covers the symptomatic management of constipation in people who are receiving palliative care and incorporates

2016 NICE Clinical Knowledge Summaries

4566. Palliative care - secretions

recommendations have been made. February to May 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.There have been changes to the recommendations for treatment of infected secretions. January 2006 — minor update. Prescriptions for diamorphine updated to reflect the change in handwriting requirements for controlled drug prescriptions. Issued in February 2006 (...) and are not easily managed by other means, occasionally it is appropriate to prescribe an antibiotic in an imminently dying patient if the death rattle is caused by profuse purulent sputum associated with an underlying chest infection. Consider giving a single dose of a broad spectrum antibiotic. If there has been a convincing response to the first dose of antibiotic, consider giving a second dose (seek specialist advice first). Basis for recommendation Basis for recommendation This recommendation is based

2016 NICE Clinical Knowledge Summaries

4567. Palliative care - nausea and vomiting

the most appropriate route. Prescribed regularly and as required. Reviewed every 24 hours. Continued unless symptoms have resolved. If a single first-line anti-emetic does not relieve nausea and vomiting: The cause of nausea and vomiting should be re-assessed. The anti-emetic dose should be optimized and/or the route of administration re-assessed. If symptoms persist after 2 or 3 doses of optimal first-line anti-emetic, a different anti-emetic or a combination of anti-emetics with complementary action (...) and vomiting in a palliative care situation; malignant bowel obstruction has been included, but in less detail than previously. January 2006 — minor update. Prescriptions for diamorphine updated to reflect the change in handwriting requirements for controlled drug prescriptions. Issued in February 2006. October 2005 — minor technical update. Issued in November 2005. March 2004 — written in March 2004. Validated in June 2004 and issued in July 2004. Update Update New evidence New evidence Evidence-based

2016 NICE Clinical Knowledge Summaries

4568. Palliative care - dyspnoea

), which has replaced prescribing of oxygen on FP10 prescriptions. Key documentation for Home Oxygen Services (including s) is available from your local Primary Care Trust or online at [ ] Adverse effects What are the adverse effects of home oxygen therapy? Oxygen therapy has potential psychosocial and drug-induced adverse effects which can influence patient acceptability and tolerability, and hence compliance. Psychosocial adverse effects include: Psychological dependence. Being deprived of oxygen (...) update. The 2013 QOF options for local implementation have been added to this topic. February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic. November 2012 — reviewed. A literature search was conducted in August 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Changes have been made to the section on when to offer a benzodiazepine. The section on prescribing oral

2016 NICE Clinical Knowledge Summaries

4569. Morton's neuroma

. Outcome measures Outcome measures No outcome measures were found during the review of this topic. Audit criteria Audit criteria No audit criteria were found during the review of this topic. QOF indicators QOF indicators No QOF indicators were found during the review of this topic. QIPP - Options for local implementation QIPP - Options for local implementation Nonsteroidal anti-inflammatory drugs (NSAIDs) Review the appropriateness of NSAID prescribing widely and on a routine basis, especially (...) in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (for example, older people). If an NSAID is needed, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less). Use the lowest effective dose and the shortest duration of treatment necessary to control symptoms. Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or for people over 45 years with low back pain

2016 NICE Clinical Knowledge Summaries

4570. Carpal tunnel syndrome

. Corticosteroid injection – this should only be carried out in primary care if appropriate expertise is available; otherwise, refer to orthopaedics or an intermediate musculoskeletal assessment and treatment service if available locally. Do not prescribe NSAIDS or diuretics to treat CTS. Follow up people treated for carpal tunnel in primary care monthly to ensure that symptoms have resolved — advise the person to return for earlier review if symptoms worsen or new features develop. Provide people with CTS (...) , as a good practice point, that workers with CTS syndrome exposed to hand-transmitted vibration, have their risk from vibration exposure assessed and dependant on medical advice and practicalities, have their exposure reduced [ ]. The Washington State Department states that where possible, job modification (such as reducing the intensity of manual tasks) may prevent progression and promote recovery from CTS [ ]. CTS is a prescribed disease in workers whose job entails a lot of repeated regular palmar

2016 NICE Clinical Knowledge Summaries

4571. Diabetes - type 1

does not cover the prescribing of insulin or the management of women with type 1 diabetes who are pregnant, planning a pregnancy, or breastfeeding. It also does not cover the diagnosis and management of impaired glucose regulation, or make detailed recommendations on the diagnosis and management of other types of diabetes. There are separate CKS topics on , , and . The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact

2016 NICE Clinical Knowledge Summaries

4572. Breast pain - cyclical

pain [ ] and a lack of good quality evidence to support its use. For this reason, in 2002, the UK Medicines Control Agency withdrew the prescription licence from evening primrose oil to treat breast pain [ ]. Progestogen-only contraceptives There is weak evidence from a cross-sectional survey to suggest that parenteral medroxyprogesterone acetate reduces cyclical breast pain compared with control [ ], but it is insufficient to recommend this as a treatment. There is weak evidence that oral (...) an electronic format is encouraged. External reviewers are not paid for commenting on the draft topics. Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group). All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation. All reviewers are invited to be acknowledged on the website.All reviewers

2016 NICE Clinical Knowledge Summaries

4573. Olecranon bursitis

search was conducted in August 2016 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, although minor restructuring of the topic has been undertaken. Previous changes Previous changes July 2015 — minor update. The prescribing information section for clarithromycin and erythromycin has been re-written for clarity. July 2013 — minor update (...) . Outcome measures Outcome measures No outcome measures were found during the review of this topic. Audit criteria Audit criteria No audit criteria were found during the review of this topic. QOF indicators QOF indicators No QOF indicators were found during the review of this topic. QIPP - Options for local implementation QIPP - Options for local implementation Non-steroidal anti-inflammatory drugs (NSAIDs) Review the appropriateness of NSAID prescribing widely and on a routine basis, especially

2016 NICE Clinical Knowledge Summaries

4574. Pruritus ani

been made. March 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made. April to August 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major change to the recommendations. Prescriptions for hydroxyzine have been removed, as the drug is not specifically (...) stools and to prevent intestinal obstruction. If the person is constipated, see the CKS topics on and for information on management. Manage any symptoms. If the perianal skin is excoriated, consider prescribing a soothing cream or ointment containing bismuth subgallate or zinc oxide. See the section on for more information. If the perianal skin is inflamed, consider prescribing a mildly potent topical corticosteroid (such as hydrocortisone 1% cream or ointment) to be used for no longer than 7 days

2016 NICE Clinical Knowledge Summaries

4575. Pityriasis rosea

, and providing first contact or primary healthcare. How up-to-date is this topic? How up-to-date is this topic? Changes Changes February to March 2016 — reviewed. A literature search was conducted in February 2016 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. Previous changes Previous changes May 2014 — minor update. A link to prescriptions (...) %) ointment or cream applied once or twice daily for up to 4 weeks. The choice of potency depends on the severity of itch. For information on prescribing topical corticosteroids, see in the CKS topic on . A sedating oral antihistamine, such as hydroxyzine or chlorphenamine given at night (both off-label indications) if itching affects sleep for example . If there is no relief of itch after 2 weeks of treatment, the antihistamine should be discontinued. For more information, including the appropriate doses

2016 NICE Clinical Knowledge Summaries

4576. Addison's disease

procedures, and the emergency management of an adrenal crisis. Scenario: Management Scenario: Management From age 1 month onwards. Treatment How is Addison's disease treated? Treatment regimens for Addison's disease are usually initiated and adjusted by a specialist endocrinologist, but repeat prescriptions may be provided in primary care under a shared-care arrangement. Both glucocorticoid and mineralocorticoid replacement are needed, but androgen replacement is not routinely prescribed in the UK (...) if adrenal insufficiency is suspected. Admission to hospital may be required depending on the clinical picture and clinical judgement. The diagnosis of Addison's disease is usually confirmed in secondary care. An adrenocorticotrophic hormone stimulation (Synacthen®) test should be done. Treatment for Addison's disease is usually initiated and adjusted by a specialist endocrinologist, but repeat prescriptions may be provided in primary care under a shared care arrangement. Hydrocortisone is usually used

2016 NICE Clinical Knowledge Summaries

4577. Vitiligo

was conducted in January 2016 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. Previous changes Previous changes May 2014 — minor update. Links to prescriptions for sunscreens have been removed and replaced with examples of some sunscreens that can be prescribed in primary care. February to May 2010 — this is a new CKS topic. The evidence base (...) and their families. For further information offer the patient information leaflet , which can be found on the British Association of Dermatologists (BAD) website and is available at . Advise the person not to use sunbeds and to use appropriate protection from sunlight, such as a high-factor sunscreen with protection against ultraviolet A and B (for example Uvistat®, or Sunsense®). These can be prescribed on the NHS, but the prescription must be endorsed ACBS. Offer referral to a . Offer the option of no other

2016 NICE Clinical Knowledge Summaries

4578. Macular degeneration - age-related

practice is for patients who have been instructed to use aspirin by a physician to continue their aspirin therapy as prescribed'. Excessive exposure to sunlight. A UK Guideline from the Royal College of Ophthalmologists states that 'despite conflicting results it would seem prudent to advise sunglasses with 100% protection against UVA and UVB radiation in bright environments'. Previous cataract surgery. High levels of plasma fibrinogen. Hyperopia (long sightedness). High alcohol intake. Obesity (...) , and of the advantages conferred by registering. If and when appropriate, information on accessing low vision services which help a person to make the most of their remaining sight. The services may include: provision and training on the use of optical aids such as magnifiers, and advice on lighting, tactile aids, electronic aids, and other non-optical aids. Low vision services may be provided by social services, community optometrists, eye departments, or the voluntary sector. A person does not need

2016 NICE Clinical Knowledge Summaries

4579. Bruising

or radiotherapy may result in a bone marrow disorder (such as myelodysplasia or leukaemia). Hypothyroidism may affect the quality of skin and subcutaneous tissue. Nutritional status — children who only eat a limited diet can develop nutritional deficiencies, leading to a coagulopathy, vascular fragility, and abnormal bruising. Tiredness, weight loss, fever, and night sweats may suggest . Joint pain, swelling, or reduced range of movement may suggest a haemarthrosis. Ask about alcohol use, and any prescribed (...) bruising in primary care? How should I manage bruising in primary care? For simple bruising where there is no suspected underlying bleeding disorder: Prescribe simple analgesia such as paracetamol if required. See the CKS topic on for more information. For people taking warfarin with an abnormal clotting screen (a prolonged prothrombin time or increased international normalized ratio): If the person is monitored and managed in primary care, alter their warfarin dosage according to local protocols

2016 NICE Clinical Knowledge Summaries

4580. Achilles tendinopathy

with an eccentric loading programme [ ]. Prescribing information Prescribing information Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the (eMC), or the (BNF). Paracetamol and ibuprofen Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) For detailed prescribing information on paracetamol (...) , but they may not be acted upon before the clinical topic is issued onto the website. Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged. External reviewers are not paid for commenting on the draft topics. Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group). All reviewers are thanked

2016 NICE Clinical Knowledge Summaries

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