Clinical Knowledge Summaries Updates

The CKS provide primary care practitioners with a readily accessible summary of the evidence base and best practice guidance for over 370 topics. These cover 1,000 clinical presentations or patient scenarios, free to access in the UK.  These are circulated regularly by email, we will collate them under this tab for ease of reference.  

New topics and updates shared since:

July 2022

  • Corticosteroids – topical (skin), nose, and eyes. Updated the section on withdrawal of topical corticosteroids in line with some corticosteroids' summary of product characteristics.

  • Diabetes – type 2. Added the adverse effect of increased risk of vitamin B12 deficiency associated with metformin, based on a drug safety update from the Medicines and Healthcare products Regulatory Agency.

  • Generalised anxiety disorder. Reviewed the evidence base and made minor structural changes to the recommendations of this topic.

  • Shingles. Added the increased risk of Guillain-Barre syndrome from the use of Shingrix, based on the manufacturer's summary of product characteristics.

June 2022

  • Contraception - combined hormonal methods. Angioedema was added as an adverse effect in line with revised manufacturer's supplementary protection certificates.

  • Diabetes - type 2. Adverse effects and contraindications of metformin and SGLT-2 inhibitors were updated in line with revised manufacturer's supplementary protection certificates.

  • Epilepsy. Topic was updated to align with our guideline on epilepsies in children, young people and adults.

  • Gastro-oesophageal reflux disease in children. Due to the global withdrawal of ranitidine, its recommendation was changed to H2 receptor antagonists. Omeprazole dosing was revised to include an update from the BNF and to remove the advice that this is a special preparation, as there are oral suspensions available on prescription.

  • Cluster headache. Detailed information about sumatriptan and zolmitriptan preparations for acute treatment of cluster headache was added.

  • Irritable bowel syndrome. Diagnosis and management recommendations were updated in line with guidance from the NICE and the British Society of Gastroenterology.

May 2022

Headache – tension-type. The section on management in primary care has been updated to include the option of physiotherapy, regular exercise, cognitive behavioural therapy, and/or relaxation techniques for some people.

Neuropathic pain – drug treatment, benzodiazepines and Z-drugs withdrawal and opioid dependence. Information on assessment prior to initiation of medication and risk of dependence has been added in line with our guidance on medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults.

Asthma, chlamydia and Lyme disease. We've added drug interactions with azithromycin to include hydroxychloroquine and chloroquine in line with the manufacturer's supplementary protection certificates.

April 2022

Breastfeeding problems. The section on management of suspected ductal infection has been updated to support the judicious use of antimicrobials and to reflect a lack of evidence regarding the role of bacteria and yeast.

Hypertension. Acute respiratory toxicity has been added as a very rare adverse effect of hydrochlorothiazide in line with the updated manufacturer's summary of product characteristics. This update aligns with our hypertension in adults: diagnosis and management guidance.

Immunisations – childhood. Information added to clarify that the severe combined immunodeficiency screening result should be checked before giving BCG or rotavirus vaccines. Added a recommendation that people who have not had their first dose of HPV vaccine by the time they are 15 years old should be offered 2 doses given at least 6 months apart (UK Health Security Agency).

Otitis media – acute. Update to the follow-up advice on ear drops for children and young people and to the prescribing section on phenazone and lidocaine drops. This update aligns with our otitis media (acute): antimicrobial prescribing guideline.

Rehabilitation after traumatic injury. New topic based on our rehabilitation after traumatic injury guideline.

March 2022

Cervical cancer and HPV. The recommendations on assessment and management have been updated in line with current evidence. A new section on assessment has been added to the diagnosis section.

Chickenpox. Additional information has been added on when to consider admission to hospital for pregnant women with chickenpox. This is in-line with updated guidance from Public Health England.

Faecal incontinence in adults. This is a new topic.

Prostate cancer. Recommendations on risk stratification for people with newly diagnosed prostate cancer have been updated in-line with our guideline on prostate cancer: diagnosis and management guideline. The information on age-specific prostate-specific antigen thresholds for people with possible symptoms of prostate cancer have been updated in-line with our guideline on suspected cancer: recognition and referral. Recommendations on referral for suspected prostate cancer have also been updated in accordance with this guideline.

Scrotal pain and swelling. Recommendations on assessment and management have been updated in-line with current evidence. A prescribing information section has been added.

November 2021

Angio-oedema and anaphylaxis. Updated in line with the Resuscitation Council UK’s guideline on the emergency treatment of anaphylactic reactions. Recommendations to routinely administer intravenous or intramuscular chlorphenamine and hydrocortisone have been removed.

Bunions. The section on assessment has been moved to the diagnosis section to improve clarity and navigation. An extra section on surgical management has been added to the management section.

Heart failure – chronic. Advice to add iron studies as part of the assessment of a person with heart failure and to manage comorbidity of hypertension has been added. This is based on the European Society for Cardiology guideline on the diagnosis and treatment of acute and chronic heart failure.

Smoking cessation. History of epilepsy has been added to the contraindications and cautions section for nicotine replacement therapy in line with updated manufacturer's summary of product characteristics.

October 2021

Anaemia – iron deficiency. The topic has been updated in line with the British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults 2021.

Candida – female genital. The treatment regimens for acute vulvovaginal candidiasis and for women with uncontrolled diabetes or other causes of immunocompromise have been updated, in line with the British Association for Sexual Health and HIV national guideline on vulvovaginal candidiasis 2019. The scenarios on 'severe infection' and 'uncontrolled diabetes or immunocompromised' have been deleted, and their content incorporated into other scenarios, for clarity and ease of navigation.

Immunisations – seasonal influenza. A new recommendation has been added to this topic. Children aged over 2 years, with a history of severe anaphylaxis to egg, who have previously required intensive care management in hospital, can be offered the egg-free cell-based quadrivalent influenza vaccine. This is an alternative to referral to a specialist for immunisation in hospital.

Non-alcoholic fatty liver disease. Content has been updated on prevalence, aetiology, complications, diagnosis, and management.

Tiredness/fatigue in adults. Updated to include recommendations from the NICE guideline on myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome (ME/CFS): diagnosis and management 2021. Changes include the range of blood tests that are recommended in assessing a person with suspected CFS, the timescale for referral, the range of supportive measures that should be considered, and the follow up recommended in primary care.

September 2021

Allergic rhinitisCow’s milk allergy in childrenItch - widespread and Urticaria. Recommendations on use of cetirizine in people with renal impairment have been updated in line with the updated manufacturer's supplementary protection certificates (SPCs).

Bites – human and animalLeg ulcer – venousProstatitis – acute and Whooping cough. Adverse effects of co-trimoxazole updated in line with revised manufacturer's SPCs relating to the rare problem of severe respiratory toxicity with the potential to progress to Adult respiratory distress syndrome.

Carpal tunnel syndrome. A new section on specialist assessment and management has been created to provide additional information.

Chronic kidney disease. New recommendations and advice from NICE Chronic kidney disease guideline August 2021 were included.

Haemorrhoids. Updated advice on topical preparations for haemorrhoids and re-positioned the role of haemorrhoidal artery ligation in the treatment algorithm.

Obstructive sleep apnoea syndrome. New information from the NICE Obstructive sleep apnoea/hypopnoea syndrome, and obesity hypoventilation syndrome in over 16s, has been incorporated.