User blog: Rcgp Learning
Epilepsy is a common neurological disorder, with an estimated 87 people diagnosed in the UK every day (1). The clinical aspects of epilepsy are predominantly dealt with in secondary care but GPs may still be asked for practical advice from those living with the condition. Something that women may approach their GP about, for example, is advice on the methods of contraception available to them, and the potential risks involved when using these alongside their anti-epileptic drugs (AEDs).
It is recommended in the SIGN clinical guideline 143 on ‘Diagnosis and management of epilepsy in adults’, that advice about contraceptive methods should ideally be given to women with epilepsy before they become sexually active (2). However, to be able to do this, it’s important that GPs have access to the latest guidance on AEDs, and the possible drug interactions that could occur when using hormonal contraception.
For women with epilepsy, the advice they are given on hormonal contraception depends on the type of AED they are taking. AEDs can be separated into enzyme-inducing and non-enzyme inducing drugs, which can have different interactions when combined with hormonal contraception. The most common enzyme-inducing AEDs are carbamazepine, phenytoin, phenobarbital, primidone and topiramate.
Those taking enzyme-inducing drugs can be at risk if they are using any form of combined hormonal contraception. If the patient takes the combined oral contraceptive pill (COCP), they have more likelihood of breakthrough bleeding and contraceptive failure due to accelerated oestrogen metabolism. Enzyme-inducing drugs also increase progesterone metabolism, therefore it is recommended to avoid prescribing the progesterone-only oral contraceptive (POP) and progesterone implants. Progestogen injections and the levonorgestrel intrauterine system can be used, but patients should be made aware that the progestogen injection is associated with a reduction in bone density (2). In terms of emergency contraception, patients can choose between a copper intrauterine device (Cu-IUD) or a double dose of the levonorgestrel ‘morning after pill’ (2 x 1.5 mg tablet). Ullipristal emergency contraception is not suitable for use in women taking any enzyme-inducing anti-epileptics (2).
According to the Faculty of Sexual Reproductive Healthcare (FSRH), although lamotrigine is not thought to be an enzyme inducer, oral forms of contraception are not recommended due to potential interactions with the drug (3). Lamotrigine levels can be affected by combined hormonal contraceptives, causing a reduction in lamotrigine exposure, leading to reduced seizure control and the risk of toxicity in the hormone-free week. Conversely, the POP may increase lamotrigine levels.
Whilst sodium valproate is not an enzyme inducer, it carries a high risk of developmental disorders (four in 10) and birth defects (one in 10) when taken in pregnancy, so effective contraception is required (4). The progestogen-only implant, the progestogen-only injectable and intrauterine contraceptives are recommended options because they are less user-dependent than other methods and provide the best protection with 'typical' use (5).
The FSRH states that women with epilepsy can be reassured that the efficacy of both intrauterine contraception (Cu-IUD and LNG-IUS) and injectable contraception (DPMA) are not affected by any AED interactions (3). A full list of AEDs and recommended contraception methods can be found in the SIGN clinical guideline 143. For up to date information on potential interactions, you can refer to the online drug interaction checker on the Medscape website.
To find out more about patients living with epilepsy, please visit the Epilepsy Action website. From here, you can also read about Epilepsy Awareness Week, which runs from 14th – 20th May 2017. For further information on epilepsy or contraception, the RCGP also offers the following FREE eLearning courses:
Sudden Death in Epilepsy (SUDEP) and Seizure Safety - 0.5 CPD hours
Contraception – 1 CPD hour
RCGP members can also access the following resources on Epilepsy:
(1) Epilepsy Action. What is Epilepsy? [Internet] Available from: https://www.epilepsy.org.uk/info/what-is-epilepsy
(2) Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of epilepsy in adults. Edinburgh: SIGN; 2015. (SIGN publication no. 143). [May 2015]. Available from: http://www.sign.ac.uk
(3) Faculty of Sexual Reproductive Healthcare (FRSH). Clinical Guidance: Drug Interactions with Hormonal Contraception. [January 2017] Available from: https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-drug-interactions-with-hormonal/drug-interactions-final-15feb.pdf
(4) Medicines and Healthcare products Regulatory Agency. Toolkit on the risk of valproate medicines in female patients. [February 2016]. Available from: https://www.gov.uk/government/publications/toolkit-on-the-risks-of-valproate-medicines-in-female-patients
(5) Faculty of Sexual Reproductive Healthcare (FRSH). Statement from the Clinical Effectiveness Unit: Sodium Valproate and Pregnancy Risks. [February 2016]. Available from: https://www.fsrh.org/standards-and-guidance/documents/ceustatementsodiiumvalproate/ceustatementsodiiumvalproate.pdf
Cow’s Milk Protein Allergy (CMPA) is one of the most common food allergies in children and infants and unfortunately it can also be clinically complex to diagnose. Most of the presenting symptoms can overlap with many other conditions that are common in infants, such as eczema, reflux and colic. Some infants also experience respiratory problems, such as cough, chest tightness, wheezing or shortness of breath (1).There are two different types of CMPA; immunoglobulin E (IgE)-mediated CMPA and non-immunoglobulin E (non-IgE)-mediated CMPA. IgE-mediated allergies often provoke an immediate reaction to milk consumption, typically involving skin reactions. Conversely, non-IgE-mediated allergies produce a delayed reaction, which may take hours or days to present. These symptoms are commonly gastrointestinal.
Whilst it’s important to identify the different types of CMPA, it can be a challenge to diagnose them. According to a survey of 201 UK GPs in 2013, 92% would like to be clearer on the options for diagnosis, and 91% would like to increase their understanding of how to manage CMPA in their patients (2).
The NICE clinical knowledge summary on ‘Cow’s milk protein allergy in children’ recommends a skin prick test or IgE antibody blood test as the first step to diagnosing IgE-mediated CMPA. Non-IgE-mediated CMPA can be trickier to diagnose and NICE suggests a trial elimination of cow’s milk for around 2-6 weeks, before reintroducing it again (1). It is clear that whenever CMPA is suspected, a good allergy-focused clinical history is needed, including personal and family history of atopy and the effects of any dietary manipulation.
As the majority of CMPA cases first present in primary care, the Milk Allergy in Primary Care (MAP) Guideline was introduced to provide support to GPs. It guides users through the process of recognition, diagnosis and management of CMPA, in the form of interactive and downloadable guides (3). To access the interactive or PDF version of the MAP Guideline, click here.
Once a diagnosis has been established, the next challenge for GPs is deciding on how the allergy can be managed. If a diagnosis is confirmed in a breastfed baby, it’s recommended that the infant’s mother eliminates dairy from her own diet to prevent the transfer of cow’s milk proteins. It’s also suggested that a calcium supplement (1000mg/day) and a vitamin D supplement (10mcg/day) are prescribed to the mother during the elimination period (4). If they need some support in going ‘dairy-free’, it can be advised that most food labelling gives a clear indication of dairy content and that ‘free-from’ aisles are now common in most supermarkets. Following the elimination diet, the mother may need to be referred to a dietitian, who can advise on when she can start reintroducing dairy.
For bottle-fed babies, the two types of alternative formulas available are extensively hydrolysed formulas (eHFs) and amino acid formulas (AAFs). eHFs are most commonly the first choice for infants with mild to moderate CMPA, as they are less likely to cause an allergic reaction. AAFs are recommended for infants with more severe reactions to cow’s milk, and are tolerated by most babies with CMPA (5). You can find a list of the specialised formulas available in the NICE clinical knowledge summary on ‘Cow’s milk protein allergy in children’
If an infant is diagnosed with non-IgE-mediated CMPA, they should generally follow a cow’s milk protein-free diet until around 9-12 months of age. After this, cow’s milk and any cow’s milk containing foods can be gradually introduced to test whether the infant has developed a tolerance. To help with this process, a group of dietitians from the UK Wessex Allergy Network devised a Milk Ladder. This provides the best available information in terms of allergenicity of foods and the type of milk they contain. You can access the Milk Ladder here.
You can find further information about CMPA on the Allergy UK website. From here, you can also read about Allergy Awareness Week, which runs from 25th April – 1st May 2017. The RCGP offers a free eLearning course on Allergy, which gives you 1.5 CPD hours.
RCGP Members can also find out more about CMPA from the following:
Differentiating milk allergy (IgE and non-IgE mediated) from lactose intolerance: understanding the underlying mechanisms and presentations
Diagnosis & Assessment of Food Allergy in Children & Young People
(1) NICE. Clinical knowledge summary on ‘Cows milk protein allergy in children. [Internet] Available from: https://cks.nice.org.uk/cows-milk-protein-allergy-in-children#!topicsummary
(2) Act on CMPA campaign survey of 201 GPs. 2013. Data on file
(3) Allergy UK. ‘iMAP Guideline’. [Internet] Available from: https://www.allergyuk.org/health-professionals/mapguideline
(4) Ludman, S., Shah, &., Fox, A.T. ‘Managing Cow’s Milk Allergy in Children’ BMJ 2013;347:f5424. [Internet] Available from: http://www.bmj.com/content/347/bmj.f5424
Baker, G., Meyer, R. and Reeves, L. (2014) Food fact sheet: suitable milks for children with cow's milk allergy.The British Diabetic Association. [Internet] Available from: https://www.bda.uk.com/foodfacts/CowsMilkAllergyChildren.pdf
Prostate cancer is the most common cancer in men, with around 47,000 men diagnosed each year in the UK (1), causing 11,287 deaths in 2014 (2). March is Prostate Cancer Awareness Month, organised by Prostate Cancer UK, and with various prostate cancer events taking place throughout the month, you may find that more patients want to ask about PSA testing and whether they can have the test.
As GP referral is the route with the highest proportion of cases diagnosed at an early stage for prostate cancer, PSA testing in primary care is an important part of the diagnostic chain. The pros and cons of PSA testing in asymptomatic men has been passionately discussed over the years though there is evidence that in some patients it can pick up prostate cancer before symptoms appear and can even identify fast-growing cancers at an early stage.
The Prostate Cancer Risk Management Programme (PCRMP) was reviewed in 2016 to better inform GPs on the best approach. Based on the PCRMP guidelines (1) and suggestions from Prostate Cancer UK (2)(3), here are some key points to take away:
• Any man in the UK aged 50 and over who asks for a PSA test and carefully considers the implications with their GP is should be tested
• Those considered ‘high risk’ for prostate cancer are aged 50 or over, men with a family history of the disease and black men
• The PCRMP guidelines apply when discussing the test with asymptomatic men aged 50 and over who proactively ask about it, not high risk men or men of any age who have symptoms
• GPs should consider offering a digital rectal examination (DRE) to all asymptomatic men who have decided to have a PSA test
• The new recommended prostate biopsy referral value for men aged 50-69 has changed to ≥3.0ng/ml
• The PSA test can miss about 15% of cancers
• All men have the option to be re-tested in the future if their PSA test result is ‘normal’
If you would like to read more about PSA testing and the guidelines around it, here are some resources that may be useful for yourself and your patients:
PCRMP Pack – Further reading on the revised PCRMP guidelines from PHE
PSA Resource Pack – Expert information for healthcare professionals from Prostate Cancer UK
Best Practice Case Studies – A selection of case studies you could apply to your practice from Prostate Cancer UK
The Tool kit – A resource to help men who have been diagnosed with prostate cancer from Prostate Cancer UK
NHS decision aid – An online tool to help men decide whether to have the PSA test from the NHS
In addition to the resources above, you can also find a selection of eLearning materials from the RCGP. Our Prostate Cancer: Early diagnosis in General Practice course is FREE to all healthcare professionals and counts towards your CPD hours. If you’re an RCGP member, you can also access the following courses:
(1) Public Health England. Prostate specific antigen testing: summary guidance for GPs [Internet]. Available from: https://www.gov.uk/government/publications/prostate-specific-antigen-testing-explanation-and-implementation
(2) Cancer Research UK. Prostate cancer mortality statistics. [Internet]. Available from: http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/mortality
(3) Prostate Cancer UK. Prostate Cancer UK policy position on the PSA test [Internet]. Available from: http://prostatecanceruk.org/media/2493257/prostate-cancer-uk-policy-position-on-the-psa-test-2016.pdf
While an undeniable force for the good, the internet was not designed with children in mind. Nevertheless an astonishing one third of internet users are under the age of 18, with 12-15 year olds spending over 20 hours a week online. These figures demonstrate the extraordinary influence online media now has over young people, with parents rightly concerned about the impact digital devices have on their children’s wellbeing (1).
According to statistics from the Priory Group, teenagers and young people aged 14-25 are typically the most affected by eating disorders in the UK (2). They are also extremely likely to be active on social media, where they could be exposed to links promoting anorexia as a fashion or as a source of beauty, sharing tips and tactics on how to become and remain anorexic. So what do GPs need to know about pro-eating disorder pages?
Social media is more widespread than ever and with so much information pushed onto mobile devices and desktops, it can be hard to shield teenagers and young people. A survey by EU Kids Online found that 10% of children aged 9-16 had seen eating disorder websites before, with girls more commonly exposed to them than boys (3). Worryingly, these websites are rapidly filtering through to online social networks, such as Facebook, YouTube, Twitter, Instagram and Snapchat.
Pro-anorexia (pro-ana) and Pro-bulimia (pro-mia) websites are part of an online community, promoting eating disorders as a lifestyle. They provide interested users with tips on how to resist eating and suggestions on how to hide the symptoms of doing so from friends and family. They also post ‘thinspiration’: images and quotes to ‘motivate’ their readers. These messages of ‘support’ can easily influence teenagers and young people and the groupthink infusing these communities can provide them with a sense of belonging. They may also encourage sufferers not to listen to concerned adults, such as their parents and GPs.
Although it’s impossible to keep track of the amount of pro-ana and pro-mia information on the internet, there is an increasing number of anti-eating disorder websites out there too. Oksanen, Garcia, & Rasanen (2016) conducted a study into different eating disorder channels on YouTube. Their findings revealed that there is also an anti pro-ana community, who promote recovery and provide information on health organisations. The results of the study showed that anti pro-ana channels were actually more popular than pro-ana channels, generating more views, comments and ‘likes’ (3).
There is a plethora of conflicting messages for teenagers and young people online, and GPs may be relied upon for advice by patients and their parents. Therefore, it is a good idea to be aware of the impact of social media and online communities on your young patients. As an introduction to the topic, why not visit the sites of Anorexia and Bulimia Care or Beat, two of the UK’s eating disorder charities, to learn more about Eating Disorder Awareness week, which runs from 27th February to 5th March 2017.
For more information about the range of different eating disorders and how to manage them in general practice, the RCGP offers an eLearning course on ‘Eating Disorders’ which is FREE to access for all healthcare professionals and also gives you 1 hour towards your CPD.
(1) The Children’s Commissioner. ‘Growing up digital’ A report of the Growing Up Digital Taskforce. 2017 http://www.childrenscommissioner.gov.uk/sites/default/files/publications/Growing%20Up%20Digital%20Taskforce%20Report%20January%202016.pdf
(2) Priory group. ‘Eating disorder statistics’ [Internet] Available from: http://www.priorygroup.com/eating-disorders/statistics
(3) Oksanen A, Garcia D, Räsänen P. Proanorexia Communities on Social Media. Pediatrics. 2016;137(1):e20153372
We’re now on the other side of Christmas and New Year and are likely to be feeling the effects of over-indulging in our favourite food and drinks over the festive period. As fun as it is at the time, we all know that the party season can really take its toll on our health. Therefore, it may not surprise you that 1 in 6 people in Britain took part in Dry January last year.
Dry January is an initiative where participants abstain from alcohol for the whole of January. It’s the flagship campaign from the alcohol charity, Alcohol Concern and was launched around 6 years ago. It has continued to gather momentum each year as people begin to understand the positive effects it can have on their health.
The stats are pretty impressive when you take a look at the benefits of giving up alcohol for just 1 month. Alcohol Concern reports that 62% of participants last year had better sleep and more energy, while 49% said that they had lost weight. In 2013, Mehta and colleagues conducted a study on moderate drinkers and reported that a month without alcohol had an effect on their systolic blood pressure, taking it down from a mean of 135 to 127.
So how can you support patients who want to cut down on their alcohol intake?
It’s likely that they will have already heard of Dry January, and perhaps even attempted it before. However, perhaps they don’t realise that not only is it good for the health, it’s also a way to fundraise and take on a challenge with family, friends and colleagues. For those who need an extra push, Alcohol Concern have also launched a Dry January app. It’s free to download and helps users keep a record of their alcohol-free days, whilst boosting their motivation, with updates on how much money they have saved so far. For further encouragement, they also have an ‘Impact Calculator’ on their website, which calculates the average cost of and calories in a range of different alcoholic drinks. To view the ‘Impact Calculator’, you can visit the Alcohol Concern website here.
For further information on the Mehta (2013) study and some tips on how to approach the subject of alcohol intake with your patients, take a look at our ‘Health benefits of stopping alcohol for one month’ screencast. It’s FREE to all healthcare professionals and also counts towards your CPD hours.
If you want a more detailed look at the effects of alcohol and how to support and treat people who are dependent, the following eLearning courses are also free to access:
RCGP Members can also find out more from the following:
Mehta, G. et al. Short term abstinence from alcohol improves insulin resistance and fatty liver phenotype in moderate drinkers [Abstract 113] Hepatology 62 (Suppl. 1), 267A (2015)