The video version of this podcast can be found here: · https://youtu.be/n-tqArOvxcI This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in July 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement. Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast: · Redcircle: https://redcircle.com/shows/primary-care-guidelines · Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK · Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for July 2026 can be found here: · https://www.nice.org.uk/guidance/published?from=2026-07-01&to=2026-07-30 The updated NICE guideline on low back pain and sciatica in over 16s: assessment and management [NG59] can be found here: · https://www.nice.org.uk/guidance/ng59 The updated NICE guideline on Osteoporosis: risk assessment [NG259] can be found here: · https://www.nice.org.uk/guidance/ng259 The new updated NICE guideline on Heavy menstrual bleeding: assessment and management [NG88] can be found here: · https://www.nice.org.uk/guidance/ng88 Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in July 2026, focusing on what is relevant in Primary Care only. This month, we have three areas to cover: updated guidance on low back pain and sciatica, updated guidance on heavy menstrual bleeding, and a brand-new guideline on osteoporosis risk assessment. Right, let’s jump into it. Let’s start with osteoporosis risk assessment. NICE says to assess fragility fracture risk in all people aged 50 and over, and in women who have experienced menopause, if they have had a previous fragility fracture or currently use, or frequently use, systemic glucocorticoids. It also says to consider assessment in all men aged 75 and over, all women aged 65 and over, and younger people with risk factors. These include 2 or more falls in the last year, hip fracture in a first-degree relative, BMI below 18.5, smoking, alcohol intake over 14 units per week, or other risk factors such as, for example, endocrine or gastrointestinal conditions, multiple myeloma, Parkinson’s disease, immobility, COPD, autoimmune disease, and CKD stage 4 or 5. For people under 50, the threshold is higher: we should assess risk after a previous hip or vertebral fragility fracture, 2 or more major osteoporotic fractures, or another major risk factor. For people aged 40 to 90, we should use FRAX or QFracture to estimate 10-year major osteoporotic fracture risk. For people aged 30 to 39, we should use QFracture. For people over 90, we should remember that FRAX assumes age 90, while QFracture calculates risk up to age 100. We should seek specialist advice for people under 30 or with rare bone diseases. We should offer DXA to people aged 30 and over with a previous hip or vertebral fragility fracture, a single major osteoporotic fragility fracture in the last 2 years, or 2 or more fragility fractures. We should also consider DXA when the 10-year major osteoporotic fracture risk is 10% or more. When starting treatment, we should usually do a baseline DXA unless it is not tolerated or feasible. If DXA is delayed, we should consider fast-tracking within 6 weeks if anabolic treatment is likely, or starting antiresorptive treatment if anabolic treatment is unlikely. NICE also discusses DXA-based vertebral fracture assessment, or VFA. What is VFA exactly? VFA is an extra spine image done using the DXA scanner to look for vertebral fragility fractures. We should consider VFA in men aged 70 and over and women aged 60 and over. In younger people, we should consider VFA during DXA if there has been a previous major osteoporotic fracture, signs or symptoms of vertebral fracture, systemic glucocorticoid use, or exceptionally low bone mineral density for age. For treatment decisions, we should consider FRAX or QFracture risk scores, DXA results if available, previous fragility fractures, and risk factors. For people aged 50 and over, and women who have experienced menopause, we should consider treatment after a previous hip or vertebral fragility fracture, or high-dose systemic glucocorticoids. We should also consider treatment with a T-score of minus 2.5 or less, or minus 1.5 or less if there is previous fragility fracture, systemic glucocorticoid use, or other risk factors. Treatment can also be considered without DXA if the person meets assessment criteria but DXA is not tolerated or feasible, for example in frail older people. If someone declines treatment, we should advise when and how to re-access the service if they change their mind or circumstances change. If 10-year risk is below 10%, we should reassess if circumstances change, or at 5 years. If 10-year risk is 10% or more, or DXA was done but treatment criteria were not met, we should do the same, but consider repeat DXA within 2 to 3 years if they were close to treatment criteria. Now let’s move to low back pain and sciatica. In this update NICE has withdrawn the recommendations on psychological therapy and combined physical and psychological programmes for low back pain or sciatica. The rest of the primary care approach is largely unchanged. We should think about alternative diagnoses, including red flags, cancer, infection, trauma, and inflammatory disease. Management may involve exercise programmes, with or without manual therapy. We should not routinely offer imaging. If referring, we should explain that imaging may still not be needed and that imaging should only be considered by a specialist if it is likely to change management. For self-management, we should encourage normal activities and consider group exercise programmes for suitable patients. Manual therapy, including manipulation, mobilisation, or massage, can be considered only as part of a package that includes exercise. For medicines, NICE says not to offer gabapentinoids, other antiepileptics, oral corticosteroids, benzodiazepines, or opioids for low back pain and sciatica. If prescribing NSAIDs, we should consider gastrointestinal, liver and cardio-renal toxicity, age, and other risk factors and use the lowest effective dose for the shortest possible time. Weak opioids, with or without paracetamol, can be considered for acute low back pain only if NSAIDs are contraindicated, not tolerated, or ineffective. But NICE says not to offer paracetamol alone for low back pain. It also says not to routinely offer opioids for acute low back pain, and not to offer opioids for chronic low back pain. Finally, let’s look at heavy menstrual bleeding. The update is about serum ferritin testing. Previously, NICE advised not to routinely test serum ferritin in women with heavy menstrual bleeding. That recommendation has now been removed because of the risk of iron deficiency. Heavy menstrual bleeding can have a major impact on quality of life, and management should focus on this rather than blood loss alone. If there are no related symptoms, NICE says we can consider pharmacological treatment without physical examination. However, we should offer examination if there is intermenstrual bleeding, pelvic pain, pressure symptoms, or if considering a levonorgestrel-releasing intrauterine
