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:

April 2024

Abortion. This is a new CKS topic largely based on guidance from NICE, the Royal College of Obstetricians and Gynaecologists and the Royal College of Nursing.
Anaemia - B12 and folate deficiency. Recommendations from the updated NICE guideline on vitamin B12 deficiency in over 16s: diagnosis and management have been incorporated into this topic. 
Cirrhosis. A section on the assessment of a person with suspected cirrhosis has been added. The criteria on when to consider palliative care referral and recommendations on primary care management of a person with cirrhosis have been updated.
Multiple topics. Fixed eruption added as an adverse effect of doxycycline as per the manufacturer's summary of product characteristics document.

March 2024

Adult malnutrition. This is a new CKS topic. It's largely based on NICE guidance, British Association for Parenteral and Enteral Nutrition publications and the Malnutrition Pathway consensus document.
Deep vein thrombosis prevention for travellers. The moderate risk category has been removed in line with the latest guidelines from the British Society for Haematology and the American Society of Hematology. A section on pregnancy has been added and minor changes made to the recommendations.
Nausea/vomiting in pregnancy. Updated to include recommendations from the Royal College of Obstetricians and Gynaecologists.
Polycystic ovary syndrome. Updated in line with recommendations in the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Refinements to the diagnostic criteria have been made and advice on the assessment in the post-menopause has been added. 
Sepsis and meningitis - bacterial meningitis and meningococcal disease. Recommendations have been aligned to with our updated NICE guideline on suspected sepsis: recognition, diagnosis and early management.

December 2023

 Allergic rhinitis. Information has been added on risk factors and prescribing intranasal corticosteroids and the combined intranasal corticosteroid with antihistamine sprays. 
 Blackouts and syncope. Updated to align with changes in NICE guidelines on hypertension in adults: diagnosis and management and transient loss of consciousness in over 16s. The previous recommendation was to assess a person with possible orthostatic hypotension by measuring blood pressure after 3 minutes standing. This has been revised to assess after at least 1 minute of standing.
 Coronavirus – COVID-19. Information about the potential adverse effects of myocarditis and pericarditis associated with COVID-19 vaccines updated in line with the manufacturers' summary of product characteristics.
 Heart failure - chronic. Information has been added in line with our technology appraisal guidance on empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction.
 Multiple topics. Interactions section for flucloxacillin updated in line with updated manufacturers' summary of product characteristics.

November 2023

Chickenpox. Antiviral treatment post-exposure prophylaxis for all pregnant women revised to align with the UK Health Security Agency guidelines on post exposure prophylaxis for varicella/shingles. 
Pelvic inflammatory disease. Reviewed and section on the antibiotic levofloxacin has been added to the prescribing information section. 
Psoriasis. Information that aqueous cream can be used as a soap substitute has been removed from this topic in line with updated advice from the National Eczema Society. Withdrawal of the article: using aqueous cream as a soap substitute for skin washing. 
Sarcoidosis. A new CKS topic that covers the diagnosis of sarcoidosis and the management of suspected and confirmed sarcoidosis. 
Stroke and transient ischaemic attack. The recommendation to avoid use of statins for secondary prevention in people with a history of intracerebral haemorrhage has been removed. Information added to explain this change, based on a large trial which demonstrated no difference in adverse impact. The topic was also aligned with the recommendations contained in our updated guideline on stroke rehabilitation in adults.

July 2023

Autism in children. The section on 'management of behaviour that challenges' has been removed and a link added to the learning disabilities topic that covers this in detail.
Feverish children - risk assessment and management. Separate topics on risk assessment and management have been merged. A section on specific illnesses to consider when assessing fever has been added.    
Gastroenteritis and diarrhoea - adult assessment. A recommendation to ask about sexual history has been added. This is in line with the British Association of Sexual Health and HIV guideline for the management of sexually transmitted enteric infections.
Immunisations - childhood. The human papillomavirus (HPV) vaccination schedule has been updated. This is in line with the UK Health Security Agency's updated document on immunisation against infectious disease.
Smoking cessation. The carbon monoxide breath test result that should be used to identify women who require referral to NHS stop smoking services has been changed from 7ppm and above, to 4ppm and above.

June 2023

Abdominal aortic aneurysm screening. This is a new topic based on guidance from the UK Health Security Agency and NICE. 

Chronic kidney disease. Recommendations on lipid management of people with chronic kidney disease aligned with updated NICE guidance on cardiovascular disease: risk assessment and reduction, including lipid modification

Conduct disorders in children and young people. Definitions have been updated in line with the 11th revision of the World Health Organization's International Classification of Diseases (ICD-11). Additional recommendations on assessment in primary care have been added. 

Contraception - intrauterine contraception. Several sections have been updated in line with the Faculty of Sexual and Reproductive Healthcare's updated guideline on intrauterine contraception, including sections on contraceptive effectiveness, duration of use, risks and adverse effects.

Obesity. Recommendation from NICE guidance on semaglutide for managing overweight and obesity has been added. Semaglutide will be available when the manufacturer confirms launch of the drug in England.

Bronchiectasis, Sinusitis, Cellulitis, Pyelonephritis and several other topics. Potential adverse effects of co-amoxiclav added to include Kounis syndrome, aseptic meningitis, linear IgA disease and drug-induced enterocolitis syndrome (all of unknown frequency) as noted in an update to the manufacturer’s summary of product characteristics.

December 2022

November 2022

  • Angina. The information relating to contraindications and cautions for nitrates was updated.

  • Bipolar disorder. Information about the interaction between lithium and dapagliflozin was added.

  • Glaucoma. The adverse effects of topical prostaglandin analogues and prostamides were added.

  • Herpes simplex – genital. Recommendations were updated in line with current evidence. A prescribing information section was also added for oral antiviral drugs. This section may be used for episodic or suppressive therapy in primary care.

  • Menopause. Information was added to the adverse effects section. This refers to exogenous oestrogens that may induce or exacerbate symptoms of hereditary and acquired angioedema.

October 2022

  • Contraception - assessment, combined hormonal methods, IUS/IUD and progestogen only methods. The topics were aligned with updated guidelines from the Faculty of Sexual and Reproductive Healthcare on progestogen-only pills and progestogen-only implants. UK medical eligibility criteria for contraceptive use of drospirenone were added.

  • Depression. Topic updated in line with our guidance on the treatment and management of depression in adults.

  • Heart failure - chronic. Information added on empagliflozin for treating chronic heart failure with reduced ejection fraction. Information added to the prescribing section on managing SGLT-2 inhibitors.

  • Obesity. Topic aligned with our guideline on identification, assessment and management of obesity.

  • Psoriasis. The diagnosis and management sections were amended in line with current evidence.

September 2022

August 2022

  • Coronavirus - Covid-19. New version of the topic published in line with current evidence. 

  • Fibroids. Additional information added to the management section, which outlines specialist assessment and management options.

  • Gout. Updated recommendations on management of acute gout and prevention of gout in line with national guidelines. 

  • Dyspepsia - pregnancy-associated. Changes and red flag section added to prescribing recommendations for acid-suppressing drugs in line with our guidance on antenatal care and expert opinion. These take into account the long-term suspension of ranitidine. 
  • Diabetes - type 2. New section added on providing periodontitis advice in line with our guidance on diabetes.

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.