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Round Up Email December 2021

This month's Round Up includes a key facts review of diabetes and pancreatic cancer and an update in the management of a threatened miscarriage.

Question 1
Orthostatic hypotension (OH) or postural hypotension – what are the treatment options for managing orthostatic hypotension? Can combinations of therapies be used? Which therapy is associated with scalp tingling as a potential side effect?: Postural hypotension
1) With respect to orthostatic hypotension, which statement is false?
- Combination therapy with midodrine and fludrocortisone is contraindicated
- Orthostatic hypotension is defined as a reduction of systolic BP of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing up
- A possible side effect of midodrine is troublesome scalp-tingling
Question 2
Diabetes and cancer – cancer referral guidance suggests that new onset diabetes in a patient over 60 years may be a presentation of pancreatic cancer. This "key facts" page on GPnotebook describes the risk of pancreatic cancer in patients with diabetes; as well as detailing the risk of pancreatic cancer in patients with new-onset diabetes in the elderly.: Diabetes and pancreatic cancer
2) With respect diabetes and pancreatic cancer, which statement is false?
- epidemiological investigations have found that long-term type 2 diabetes mellitus is associated with a 1.5- to 2.0-fold increase in the risk of pancreatic cancer
- older subjects with new-onset diabetes have an approximately 3 fold higher risk of having pancreatic cancer compared to the general population
- been reported that the prevalence of diabetes and impaired glucose tolerance in pancreatic cancer cases is as high as 80%
Question 3
Threatened miscarriage – updated with evidence and guidance regarding the use of vaginal micronized progesterone in women with a threatened miscarriage in early pregnancy who have a history of a previous miscarriage.: Threatened abortion
3) With respect to management of threatened miscarriage, which statement is false?
- NICE state that offer vaginal micronised progesterone 400 mg twice daily to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage
- NICE state that if the use of vaginal micronized progesterone is indicated and a fetal heartbeat is confirmed, continue progesterone until 4 completed weeks of pregnancy
- a key finding, first observed in the PROMISE trial, and then replicated in the PRISM trial, was that treatment with vaginal micronized progesterone 400 mg twice daily was associated with increasing live birth rates according to the number of previous miscarriages
Question 4
SGLT2 inhibitors in diabetic renal disease in type 2 diabetes - updated guidance suggests different levels of urine albumin creatinine ratio (ACR) when SGLT2 inhibitors are indicated and when they should be considered.: NICE guidance - diabetic renal disease in type II diabetes
4) With respect to SGLT2 inhibitors in diabetic renal disease in type 2 diabetes, which statement is false?
- NICE guidance states for adults with CKD and type 2 diabetes, offer an SGLT2 inhibitor, in addition to an ARB or an ACE inhibitor at an optimised dose if ACR is more than 30 mg/mmol
- NICE guidance states for adults with type 2 diabetes and chronic kidney disease who are taking an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate), consider an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) ifACR is between 3 and 30 mg/mmol
- NICE guidance states for adults with type 2 diabetes and chronic kidney disease then an SGLT2 inhibitor is contraindicated if the eGFR is less than 30 ml/min
Question 5
Bisphosphonates in osteoporosis – and update of this section on GPnotebook: Bisphosphonates in the treatment of osteoporosis
5) With respect to bisphosphonates in osteoporosis, which statement is false?
- Bisphosphonates inhibit osteoclastic activity and hence bone resorption
- Frequent infusion of intravenous bisphosphonates in patients with cancer is thought to be associated with osteonecrosis of the jaw
- The need for continued therapy with bisphosphonates should be re-evaluated in individual patients at regular intervals based on the benefits and potential risks, particularly after 2 or more years of use
Question 6
breast implant associated anaplastic large cell lymphoma (ALCL) – a "key facts" description of this condition.: Breast implant associated anaplastic large cell lymphoma (ALCL)
6) With respect to breast implant associated anaplastic large cell lymphoma (BIA-ALCL), which statement is false
- In the UK, the current estimated incidence of BIA-ALCL, based on confirmed cases, is 1 per 15,000 implants sold
- The most common symptom for people with BIA-ALCL around breast implants, is fluid collecting around the implant ('late' seroma)
- in 2016, the World Health Organisation (WHO) defined a new type of anaplastic large cell lymphoma (ALCL), which is, itself, an uncommon type of Hodgkin lymphoma with several subtypes

Round Up Email December 2021

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6