Understanding Paget’s Disease of the Bone

Paget’s disease of the bone is a condition characterized by increased and uncontrolled bone turnover. It is believed to be caused by excessive osteoclastic resorption followed by increased osteoblastic activity. Although it is a common condition, affecting 5% of the UK population, only 1 in 20 patients experience symptoms. The most commonly affected areas are the skull, spine/pelvis, and long bones of the lower extremities. Predisposing factors include increasing age, male sex, northern latitude, and family history.

Symptoms of Paget’s disease include bone pain, particularly in the pelvis, lumbar spine, and femur. The stereotypical presentation is an older male with bone pain and an isolated raised alkaline phosphatase (ALP). Classical, untreated features include bowing of the tibia and bossing of the skull. Diagnosis is made through blood tests, which show raised ALP, and x-rays, which reveal osteolysis in early disease and mixed lytic/sclerotic lesions later.

Treatment is indicated for patients experiencing bone pain, skull or long bone deformity, fracture, or periarticular Paget’s. Bisphosphonates, either oral risedronate or IV zoledronate, are the preferred treatment. Calcitonin is less commonly used now. Complications of Paget’s disease include deafness, bone sarcoma (1% if affected for > 10 years), fractures, skull thickening, and high-output cardiac failure.

Overall, understanding Paget’s disease of the bone is important for early diagnosis and management of symptoms and complications.

An elevated risk of developing osteoporosis is linked to low body mass, not obesity.

Understanding the Causes of Osteoporosis

Osteoporosis is a condition that affects the bones, making them weak and brittle. It is more common in women and older adults, with the prevalence increasing significantly in women over the age of 80. However, there are many other risk factors and secondary causes of osteoporosis that should be considered. Some of the most important risk factors include a history of glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture, low body mass index, and smoking. Other risk factors include a sedentary lifestyle, premature menopause, certain ethnicities, and endocrine disorders such as hyperthyroidism and diabetes mellitus.

There are also medications that may worsen osteoporosis, such as SSRIs, antiepileptics, and proton pump inhibitors. If a patient is diagnosed with osteoporosis or has a fragility fracture, further investigations may be necessary to identify the cause and assess the risk of subsequent fractures. Recommended investigations include blood tests, bone densitometry, and other procedures as indicated. It is important to identify the cause of osteoporosis and contributory factors in order to select the most appropriate form of treatment. As a minimum, all patients should have a full blood count, urea and electrolytes, liver function tests, bone profile, CRP, and thyroid function tests.

Adenomyosis is the condition where the tissue lining the uterus (endometrium) grows into the muscular wall of the uterus (myometrium).

Dysmenorrhoea is a condition where women experience excessive pain during their menstrual period. There are two types of dysmenorrhoea: primary and secondary. Primary dysmenorrhoea affects up to 50% of menstruating women and is not caused by any underlying pelvic pathology. It usually appears within 1-2 years of the menarche and is thought to be partially caused by excessive endometrial prostaglandin production. Symptoms include suprapubic cramping pains that may radiate to the back or down the thigh, and pain typically starts just before or within a few hours of the period starting. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, and combined oral contraceptive pills are used second line for management.

Secondary dysmenorrhoea, on the other hand, typically develops many years after the menarche and is caused by an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but this only applies to normal copper coils.

Strategies for Preventing Alcohol Relapse

For individuals with alcohol-use disorders, preventing relapse is crucial for maintaining sobriety. Here are some strategies that can help:

1. Join a local Alcoholics Anonymous group or other self-help groups that require total abstinence. Active participation in these groups can offer the best chance of preventing relapses.

2. Limit consumption to socially appropriate amounts. Even small amounts of alcohol can trigger a relapse, so individuals who have completed a detoxification program are encouraged not to drink at all.

3. Take disulfiram as prescribed. This medication can cause unpleasant symptoms when alcohol is consumed, making it a deterrent for those who struggle with alcohol use. However, it should only be taken in the context of an appropriate alcohol detoxification program.

4. Take naltrexone as prescribed. This medication can help reduce cravings for alcohol, but it should not be taken as a deterrent before attending a party.

5. Plan a definite number of drinks before attending a party. However, individuals who have completed a detoxification program are still encouraged not to drink at all to prevent relapse.

By implementing these strategies, individuals with alcohol-use disorders can increase their chances of maintaining sobriety and preventing relapse.

The patient’s symptoms of prodrome and bloody diarrhoea are indicative of a Campylobacter infection, which is the most common bacterial cause of infectious intestinal disease in the UK. The incubation period for this infection is typically 1-6 days, which aligns with the patient’s presentation. Bacillus cereus, which is associated with food poisoning from reheated rice, typically has a shorter incubation period and would not usually cause bloody diarrhoea. Clostridium difficile infection is more commonly found in hospital settings and is linked to antibiotic use, but there are no risk factors mentioned for this patient. Salmonella enteritidis, which has a shorter incubation period and is associated with severe vomiting and high fever, is less likely to be the cause of the patient’s symptoms.

Campylobacter: The Most Common Bacterial Cause of Intestinal Disease in the UK

Campylobacter is a Gram-negative bacillus that is responsible for causing infectious intestinal disease in the UK. The bacteria is primarily spread through the faecal-oral route and has an incubation period of 1-6 days. Symptoms of Campylobacter infection include a prodrome of headache and malaise, diarrhoea (often bloody), and abdominal pain that may mimic appendicitis.

In most cases, Campylobacter infection is self-limiting and does not require treatment. However, the British National Formulary (BNF) recommends treatment with antibiotics if the patient is immunocompromised or if symptoms are severe (high fever, bloody diarrhoea, or more than eight stools per day) and have lasted for more than one week. The first-line antibiotic for Campylobacter infection is clarithromycin, although ciprofloxacin is an alternative. It is important to note that strains with decreased sensitivity to ciprofloxacin are frequently isolated.

Complications of Campylobacter infection may include Guillain-Barre syndrome, reactive arthritis, septicaemia, endocarditis, and arthritis. It is important to seek medical attention if symptoms are severe or persist for an extended period of time.

Due to his history of bladder cancer and obesity, pioglitazone is not recommended and contraindicated. Instead, sitagliptin, a DPP-4 inhibitor, is the most suitable option. Exenatide, which typically leads to weight loss, is beneficial for obese individuals with diabetes, but it does not meet the NICE criteria for body mass index of 35 kg/m².

NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.

Understanding the CURB-65 Score for Mortality Prediction in Pneumonia

Pneumonia is a serious respiratory infection that can lead to mortality, especially in older patients. Several factors can increase the risk of death, including elevated urea levels, low blood pressure, leukopenia, and atrial fibrillation. To predict mortality in pneumonia, healthcare professionals use the CURB-65 score, which considers five parameters: confusion, urea >7 mmol/l, respiratory rate >30/min, systolic blood pressure <90 mmHg or diastolic blood pressure <60 mmHg, and age >65 years. Each parameter scores a point, and the higher the total score, the higher the associated mortality.

Based on the CURB-65 score, healthcare professionals can make informed decisions about treatment and admission to hospital. Patients with a score of 0 or 1 can be treated at home with oral antibiotics, while those with a score of 2 should be considered for hospital admission. Patients with a score of 3 or higher should be admitted to hospital, and those with a score of 4-5 may require high dependency or intensive therapy unit admission. However, individual circumstances, such as the patient’s performance status, co-morbidities, and social situation, should also be considered when making treatment decisions.

In summary, the CURB-65 score is a valuable tool for predicting mortality in pneumonia and guiding treatment decisions. By considering multiple factors, healthcare professionals can provide the best possible care for patients with this serious infection.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the primary treatment for relieving symptoms of ankylosing spondylitis (AS). It is recommended to co-prescribe a proton pump inhibitor to protect the stomach. If one NSAID is ineffective, switching to another may be helpful. Slow-release NSAIDs may be beneficial for morning stiffness and pain. Colchicine is not recommended for AS due to severe side-effects. Paracetamol and codeine have no direct evidence for treating AS symptoms, but may be used in conjunction with NSAIDs if appropriate. Surgery may be necessary in cases of structural damage, severe deformity, spinal instability, or neurological deficit. Oral corticosteroids should be avoided due to long-term side-effects, but intra-articular injections may provide relief during acute flares. Tumor necrosis factor-alpha (TNF-α)-blocking drugs are effective in reducing symptoms and inflammation in those with persistent, active inflammation. Rituximab has no role in treating seronegative arthritis.

Treatment Options for Atrial Fibrillation: A Comprehensive Guide

Atrial fibrillation (AF) is a common cardiac arrhythmia that requires prompt and appropriate management to prevent complications. Here are some treatment options for AF:

Rate Control: This is recommended for patients who have had AF for more than 48 hours. Beta-blockers are the first-line treatment unless there is a contraindication such as asthma. Calcium channel blockers can also be used.

Digoxin: This drug can be used as rate control if the patient cannot have beta-blockers or calcium channel blockers. However, it should only be used as a third-line treatment or as an adjunct because it has been shown to increase mortality. It is also only effective in sedentary patients.

DC Cardioversion: This can be used to treat new-onset AF if the patient has had it for less than 48 hours. It can also be considered in patients who have had it for longer than that, once they have been on stable anticoagulation for at least 3 weeks.

Flecainide: This is a class Ic antiarrhythmic drug that can be used as chemical cardioversion in new AF (<48 hours) or if a patient has been anticoagulated for >3 weeks.

Rhythm Control: Nice guidelines advise that rhythm control can be used if AF onset was <48 hours ago, but should be avoided if longer ago because it can increase the risk of stroke from an atrial thrombus. In longer cases, rate control should be used, which is with beta-blockers or rate-limiting calcium channel blockers. Digoxin can be used third line or as an adjunct. In conclusion, the appropriate treatment for AF depends on the duration of the arrhythmia, the patient’s comorbidities, and other factors. It is important to consult with a healthcare professional to determine the best course of action.

Common Kidney Diseases and Their Clinical Features

Immunoglobulin A (IgA) Nephropathy, Kimmelstiel Wilson Lesions, Cast Nephropathy, Minimal Change Disease, and Thin Basement Membranes are some of the common kidney diseases that affect people. Each of these diseases has unique clinical features that help in their diagnosis.

IgA Nephropathy, also known as Berger’s disease, is the most common cause of glomerulonephritis worldwide. It is characterized by predominant IgA deposition in the glomerular mesangium. Clinical features range from asymptomatic haematuria to rapidly progressive glomerulonephritis.

Kimmelstiel–Wilson Lesions, also known as nodular glomerulosclerosis, is a complication of diabetes mellitus. It is characterized by the formation of nodules of hyaline material in regions of glomerular capillary loops in the glomerulus.

Cast Nephropathy, also known as myeloma cast nephropathy, is the formation of urinary casts in the renal tubules from free immunoglobulin light chains, causing intratubular obstruction and damage, which leads to renal failure in the context of multiple myeloma.

Minimal Change Disease, also known as lipoid nephrosis or nil disease, arises from a histopathologic lesion in the glomerulus and is characterized by intense proteinuria leading to oedema and intravascular volume depletion.

Thin Basement Membranes is a group of inherited heterogeneous disorders involving the basement membranes of the kidney and frequently affecting the cochlea and eye as well. It is characterized by splitting and lamellation of the glomerular basement membrane.

In conclusion, understanding the clinical features of these common kidney diseases is crucial in their diagnosis and management.

It is not recommended to prescribe anaesthetic eye drops to patients with corneal ulcers as it can potentially worsen the condition by slowing down the healing process.

Understanding Corneal Ulcers

A corneal ulcer is a condition that occurs when there is a defect in the cornea, which is usually caused by an infection. It is important to note that corneal abrasions, on the other hand, are typically caused by physical trauma. There are several risk factors that can increase the likelihood of developing a corneal ulcer, including contact lens use and vitamin A deficiency, which is particularly common in developing countries.

The pathophysiology of corneal ulcers can vary depending on the underlying cause. Bacterial, fungal, and viral infections can all lead to the development of a corneal ulcer. In some cases, contact lens use can also be associated with a type of infection called Acanthamoeba keratitis.

Symptoms of a corneal ulcer typically include eye pain, sensitivity to light, and excessive tearing. Additionally, a focal fluorescein staining of the cornea may be present.

For a patient with poorly controlled moderate hypertension who is already taking an ACE inhibitor, calcium channel blocker, and thiazide diuretic, the recommended next step would be to add spironolactone if their potassium level is less than 4.5mmol/L. Atenolol may be considered as a fourth-line agent if the potassium level is over 4.5mmol/L, but spironolactone is preferred according to NICE guidelines. Hydralazine should not be used outside of specialist care, and indapamide is not the best option as the patient is already taking a thiazide diuretic. Prazosin is an alternative to spironolactone, but spironolactone is preferred given the lower potassium level.

NICE Guidelines for Managing Hypertension

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.

Before considering thrombolysis for a patient, it is crucial to ensure that their blood pressure is well-controlled. If the patient’s blood pressure is above 200/120mmHg, thrombolysis cannot be performed. In such cases, medications like Labetalol are administered to rapidly lower the blood pressure. The other options mentioned are not suitable as the patient’s chest and BM examinations were normal. Additionally, statins do not play a role in the acute management of stroke.

The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.

Dyspepsia, abdominal pain, nausea, and anorexia are among the early signs of stomach cancer. This type of cancer is uncommon and is more likely to occur in individuals over the age of 50, particularly those with pernicious anemia. Pancreatic cancer is linked to the onset of diabetes. Bone pain is a typical symptom of myeloma. Recurrent infections, bleeding, and bruising are common symptoms of acute leukemia.

Management of Dyspepsia and Referral for Possible Cancer

Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.

For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

Post-Thrombotic Syndrome: A Complication of Deep Vein Thrombosis

Post-thrombotic syndrome is a clinical syndrome that may develop following a deep vein thrombosis (DVT). It is caused by venous outflow obstruction and venous insufficiency, which leads to chronic venous hypertension. Patients with post-thrombotic syndrome may experience painful, heavy calves, pruritus, swelling, varicose veins, and venous ulceration.

In the past, compression stockings were offered to patients with DVT to reduce the risk of post-thrombotic syndrome. However, current recommendations state that elastic graduated compression stockings should not be used to prevent post-thrombotic syndrome or VTE recurrence after a proximal DVT. This recommendation does not cover the use of elastic stockings for the management of leg symptoms after DVT.

Once post-thrombotic syndrome has developed, compression stockings are a recommended treatment. Other recommendations include keeping the leg elevated. It is important for healthcare providers to recognize the potential complications of DVT and to provide appropriate management to prevent the development of post-thrombotic syndrome.

Once the predicted values are obtained, the FEV1:FVC ratio can be evaluated. If this ratio is less than 70, it indicates a potential issue.

Understanding Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.

The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.

Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.

The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.

Trinucleotide repeat disorders exhibit earlier onset in successive generations due to anticipation, which is often accompanied by an escalation in symptom severity.

Trinucleotide repeat disorders are genetic conditions that occur due to an abnormal number of repeats of a repetitive sequence of three nucleotides. These expansions are unstable and can enlarge, leading to an earlier age of onset in successive generations, a phenomenon known as anticipation. In most cases, an increase in the severity of symptoms is also observed. It is important to note that these disorders are predominantly neurological in nature.

Examples of trinucleotide repeat disorders include Fragile X, Huntington’s, myotonic dystrophy, Friedreich’s ataxia, spinocerebellar ataxia, spinobulbar muscular atrophy, and dentatorubral pallidoluysian atrophy. Friedreich’s ataxia is unique in that it does not demonstrate anticipation.

The tricuspid valve is the valve most commonly affected by infective endocarditis in intravenous drug users.

Aetiology of Infective Endocarditis

Infective endocarditis is a condition that affects patients with previously normal valves, rheumatic valve disease, prosthetic valves, congenital heart defects, intravenous drug users, and those who have recently undergone piercings. The strongest risk factor for developing infective endocarditis is a previous episode of the condition. The mitral valve is the most commonly affected valve.

The most common cause of infective endocarditis is Staphylococcus aureus, particularly in acute presentations and intravenous drug users. Historically, Streptococcus viridans was the most common cause, but this is no longer the case except in developing countries. Streptococcus mitis and Streptococcus sanguinis are the two most notable viridans streptococci, commonly found in the mouth and dental plaque. Coagulase-negative Staphylococci such as Staphylococcus epidermidis are the most common cause of endocarditis in patients following prosthetic valve surgery.

Streptococcus bovis is associated with colorectal cancer, with the subtype Streptococcus gallolyticus being most linked to the condition. Non-infective causes of endocarditis include systemic lupus erythematosus and malignancy. Culture negative causes may be due to prior antibiotic therapy or infections caused by Coxiella burnetii, Bartonella, Brucella, or HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella).

A young patient has a small fibroadenoma <3 cm, which is highly suggestive on imaging. There is no increase in the risk of breast cancer, so a core-needle biopsy is not necessary. Watchful waiting is appropriate, and cryoablation may be used for larger fibroadenomas. Fine-needle aspiration is only necessary for larger lumps or in older patients. Understanding Breast Fibroadenoma Breast fibroadenoma is a type of breast mass that develops from a whole lobule. It is characterized by a mobile, firm, and smooth lump in the breast, which is often referred to as a breast mouse. Fibroadenoma accounts for about 12% of all breast masses and is more common in women under the age of 30. Fortunately, fibroadenomas are usually benign and do not increase the risk of developing breast cancer. In fact, over a two-year period, up to 30% of fibroadenomas may even get smaller on their own. However, if the lump is larger than 3 cm, surgical excision is typically recommended. In summary, breast fibroadenoma is a common type of breast mass that is usually benign and does not increase the risk of breast cancer. While it may cause concern for some women, it is important to remember that most fibroadenomas do not require treatment and may even resolve on their own.

For a newly diagnosed patient with hypertension and a history of type 2 diabetes mellitus, it is recommended to add an ACE inhibitor or an angiotensin receptor blocker regardless of age. In this case, Ramipril, an ACE inhibitor, would be the appropriate choice. However, if the patient did not have a history of type 2 diabetes, the initial management would be to prescribe a calcium channel blocker such as amlodipine, especially if the patient is over 55 years old. If the blood pressure remains high, a thiazide-like diuretic or calcium channel blocker can be added to the ACE inhibitor. If the blood pressure still remains elevated, a combination of ACE inhibitor, calcium channel blocker, and thiazide-like diuretic can be considered. Indapamide is a thiazide-like diuretic that can be used in combination with an ACE inhibitor or as an additional therapy with an ACE inhibitor and calcium channel blocker if the blood pressure is not well controlled. Bisoprolol, a beta-blocker, can also be considered if the blood pressure remains high despite the combination of ACE inhibitor, calcium channel blocker, and thiazide-like diuretic.

NICE Guidelines for Managing Hypertension

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.