Suspected adverse drug reactions may be subdivided on the basis of mechanism e.g. immunological (requiring sensitisation by previous exposure) versus nonimmunological; timing (e.g. immediate or delayed), or whether the p...Suspected adverse drug reactions may be subdivided on the basis of mechanism e.g. immunological (requiring sensitisation by previous exposure) versus nonimmunological; timing (e.g. immediate or delayed), or whether the phenomenon is dose dependent or not. In the NICE guideline the main approach is to classify the event according to whether it: is immediate (within an hour of drug administration) or delayed (hours or days); affects a single or multiple systems; is clinically severe/life threatening or not. An immediate, immunologically mediated, multisystem, life-threatening reaction would for example include anaphylaxis (type 1 or typically IgE- mediated hypersensitivity) especially if the clinical features (e.g. bronchospasm, hypotension) are suggestive. Serum mast cell tryptase should be tested ideally within two hours and certainly before four hours post reaction. Detailed investigation of suspected cases in a specialist clinic is ideally delayed for 4-6 weeks after the event. Adverse drug reactions need to be meticulously recorded and the patient fully informed. Documentation should include: date of reaction; drug name (chemical and generic); route of administration; time interval between first dose and event; and nature and severity of symptoms. Written guidance should be provided on which other chemically related drugs also need to be avoided. Specialist referral is indicated for: suspected anaphylaxis; severe/life- threatening episodes e.g. Stevens-Johnson syndrome; severe NSAID reactions with ongoing need for NSAID therapy; suspected penicillin allergy (if alternative antibiotics are not available); and problems related to general and local anaesthesia.
The postnatal period appears to be associated with higher rates of adjustment disorder, generalised anxiety disorder, and depression. Women who have a history of serious mental illness are at higher risk of developing a...The postnatal period appears to be associated with higher rates of adjustment disorder, generalised anxiety disorder, and depression. Women who have a history of serious mental illness are at higher risk of developing a postpartum relapse, even if they have been well during pregnancy. Psychiatric causes of maternal death are more common than some direct causes of death. UK rates increased from 13/100,000 in 2006-2008 to 16/100,000 in 2010-2012, higher than, for example, mortality caused by haemorrhage or anaesthetic complications of childbirth. Postnatal depression is more severe than baby blues, follows a chronic course and may relapse outside the perinatal period. Although 13% of patients already have depression in pregnancy, the majority tend to be diagnosed after delivery; up to 19% from childbirth to three months postpartum. NICE recommends using the Two Question Depression Screen and the Generalized Anxiety Disorder scale from the booking visit through to one year postpartum. A positive response to depression or anxiety questions warrants a full assessment using either PHQ-9 or the Edinburgh Postnatal Depression Scale. Bipolar disorder may present as a first depressive episode in pregnancy or the postnatal period. In the postpartum period women have a high risk of severe relapse. Postpartum psychosis has a sudden and dramatic presentation with delusions, mania, severe depression, or mixed episodes with wide fluctuations of symptoms and severe mood swings.
Endometriosis is defined as the presence of endometrial-like tissue outside the uterus. Deposits are commonly distributed on the ovaries, uterosacral ligaments, pouch of Douglas, rectum and sigmoid colon, bladder and ure...Endometriosis is defined as the presence of endometrial-like tissue outside the uterus. Deposits are commonly distributed on the ovaries, uterosacral ligaments, pouch of Douglas, rectum and sigmoid colon, bladder and ureter. Endometriosis is common, affecting 10% of the female adult population and up to 50% of women with infertility. Risk factors include early menarche, late menopause, delayed childbearing, vaginal outflow obstruction and a first-degree relative affected. Women commonly present to their GP with pelvic pain, painful intercourse or subfertility. Classically the pain starts several days before the period which is extremely painful. After the period, symptoms tend to improve until mid-cycle when the pattern repeats again. Patients also complain of fatigue. Abdominal palpation, bimanual and speculum examination are important to identify signs of endometriosis, but also to exclude alternative diagnoses such as fibroid uterus, infection or pregnancy. However, a normal examination does not exclude a diagnosis of endometriosis. Serum CA125 can be raised in endometriosis but is not specific or sensitive for the condition and is therefore not recommended as a screening test. A normal pelvic ultrasound scan does not exclude a diagnosis of endometriosis. The gold standard investigation for endometriosis is laparoscopy and biopsy with histological confirmation. Referral should be considered if pain is not controlled with simple analgesia or the diagnosis is suspected in a woman who is actively trying to conceive. Early referral should be considered in women with abnormal examination findings, or an abnormal ultrasound result.
Urticaria is characterised by transient wheals that consist of a swollen palpable centre often surrounded by an erythematous flare, associated with itching or, less commonly, a burning sensation. Individual wheals usuall...Urticaria is characterised by transient wheals that consist of a swollen palpable centre often surrounded by an erythematous flare, associated with itching or, less commonly, a burning sensation. Individual wheals usually disappear within 1 to 24 hours leaving normal skin. Wheals may be accompanied by angioedema, a more deep-seated flesh-coloured or erythematous swelling of skin or mucous membrane, which may last longer than 24 hours. Urticaria is classified as acute when it resolves within six weeks and chronic when its duration exceeds six weeks. Chronic urticaria is now sub-classified into chronic spontaneous urticaria (CSU) and chronic inducible urticaria. The prognosis for eventual recovery from spontaneous and inducible urticaria is excellent. However, the time course is unpredictable and may extend to years, often following a relapsing and remitting course. Urticaria results from the release of inflammatory mediators from dermal mast cells, resulting in vasodilatation, plasma extravasation, recruitment of immunologically active cells and sensory nerve stimulation. The cause of urticaria cannot usually be precisely identified for most affected individuals. IgE-mediated food allergy is rarely the cause of CSU in patients with the daily appearance of urticarial lesions, although it should be considered in CSU patients with intermittent symptoms. For patients with CSU a differential full blood count and inflammatory markers are all that are routinely recommended. It is also reasonable to test thyroid function and check for circulating thyroid autoantibodies as there is an association between CSU and thyroid autoimmunity.
Chronic kidney disease (CKD) is defined as either a reduction in measured kidney function (eGFR) or urinary abnormalities (haematuria/proteinuria) or a combination of both, present for more than 3 months. In the most rec...Chronic kidney disease (CKD) is defined as either a reduction in measured kidney function (eGFR) or urinary abnormalities (haematuria/proteinuria) or a combination of both, present for more than 3 months. In the most recent NICE guidelines the various CKD stages 1-5 are now represented by G (for GFR) categories (G1-5) which have the same eGFR thresholds as previous CKD guidelines. The urinary albumin:creatinine ratio (ACR) category is denoted as A (for albuminuria) with three categories: A1, A2 or A3. The ACR category has been introduced to emphasise that patients with higher levels of albuminuria have an increased risk of progression to end-stage renal disease. Individuals with newly identified reduced eGFR should have acute kidney injury excluded. All newly identified CKD patients should have blood pressure, dipstick urinalysis, random urine ACR or urine protein:creatinine ratio (PCR), glucose, cholesterol and full blood count checked at the earliest opportunity. An ultrasound scan should be offered to patients at increased risk. Cardiovascular events and progression of CKD are more common if albuminuria or proteinuria is present. Urine ACR has a greater sensitivity for low levels of proteinuria in comparison with PCR. Referral for patients with CKD should be based on assessment of kidney function (eGFR), the severity of proteinuria (urine ACR), concerns about poorly controlled BP, or suspected inherited renal disease. Most cases of CKD in the elderly are caused by the cumulative effect of other disease states, especially hypertension and atherosclerosis. The CKD classification system will identify many elderly patients with a low eGFR but without progressive kidney failure.
Glomerulonephritis is an important cause of kidney disease and, in the UK, the most common diagnosis in patients receiving chronic dialysis or waiting for kidney transplantation. A key feature is the presence of urinary...Glomerulonephritis is an important cause of kidney disease and, in the UK, the most common diagnosis in patients receiving chronic dialysis or waiting for kidney transplantation. A key feature is the presence of urinary abnormalities (proteinuria ± haematuria). Patients with nephrotic syndrome typically present with peripheral oedema, massive urinary protein loss and associated low serum albumin levels. Blood pressure and renal function, as measured by eGFR, are usually normal initially. Patients presenting with nephritic syndrome tend to be hypertensive with dipstick-positive or visible haematuria. There may be rapidly progressive renal dysfunction and fall in eGFR. Many patients will have a background genetic susceptibility to glomerulonephritis which may be triggered by environmental, infective or autoimmune factors. Autoimmunity, in combination with genetic factors, is responsible for a significant proportion of cases of glomerulonephritis. Infective agents such as viruses can precipitate minimal change disease. NSAIDs, lithium, penicillamine and heroin can cause nephrotic syndrome. Timely diagnosis and treatment of glomerulonephritis can help to minimise both the occurrence and severity of complications. All patients with glomerulonephritis should be managed according to CKD guidelines with CKD stage-appropriate measurement of renal function, blood pressure, and proteinuria.
Diabetes risk increases exponentially with increasing BMI particularly if fat accumulates centrally and/or in the skeletal muscle, liver and other organs such as the pancreas. Those with diabetes and co-existing obesity,...Diabetes risk increases exponentially with increasing BMI particularly if fat accumulates centrally and/or in the skeletal muscle, liver and other organs such as the pancreas. Those with diabetes and co-existing obesity, particularly if it is severe, are also at risk of other obesity-related conditions, such as cardiovascular disease, obstructive sleep apnoea, joint pain, many cancers and depression. In people with impaired glucose tolerance, modest weight loss can reduce the development of overt diabetes by 50% or more over four years. Once diabetes has developed weight loss can also be of benefit. Supporting patients to lose weight should be considered a key goal of diabetes care for all overweight and obese patients with type 2 diabetes. Increased physical activity improves insulin sensitivity and can help weight loss maintenance. Metformin is the first-line therapy and is generally considered weight neutral. Of the oral therapies available second line, DPP-IV inhibitors are weight neutral and the newer SGLT2 inhibitors can produce 2-3 kg of weight loss on average. Insulin often causes weight gain and patients should be counselled about this. Adjunctive treatment with metformin, SGLT2 inhibitors, DPP-IV inhibitors and GLP-1 analogues can help keep insulin doses lower and limit weight gain. Currently in the UK, obesity pharmacotherapy in type 2 diabetes is limited to orlistat which has been shown to improve glucose control. NICE recommends bariatric surgery as a clinically and cost effective option for obese patients with type 2 diabetes, particularly those with severe obesity. It typically results in 20-30% of body weight loss.
Risk factors for postherpetic neuralgia (PHN) include: increasing age; a prodrome of pain before rash onset; the degree of spread of the rash, particularly if it extends beyond a single dermatome; and severity of pain du...Risk factors for postherpetic neuralgia (PHN) include: increasing age; a prodrome of pain before rash onset; the degree of spread of the rash, particularly if it extends beyond a single dermatome; and severity of pain during the acute attack. Forty per cent of patients over 50 and 75% of those over 75 develop PHN following resolution of the rash. Patients develop persistent pain classified as PHN 120 days following rash onset. It can be either constant or paroxysmal and is commonly described as burning, stabbing or itching and located in the same dermatomal distribution as the shingles rash. Pain can lead to sleep disturbance, anorexia, reduced socialisation and reactive depression. Paracetamol should be tried initially for mild to moderate pain, either alone or in combination with codeine but there is no evidence to support the use of NSAIDs. Compared with other antidepressants, tricyclic antidepressants are the most likely to confer benefit in neuropathic pain. In frail elderly patients nortriptyline appears to be tolerated best. Both gabapentin and pregabalin can reduce pain and improve sleep patterns in patients with PHN. Patients with severe pain or those whose condition is affecting their daily activities and function should be referred to a specialist in pain management.