Guidance

Diagnose with NT-proBNP and echocardiography. Offer an SGLT2 inhibitor for HFpEF in addition to treating congestion and comorbidities.

• Do not delay a specialist review when NT-proBNP is significantly raised.
• Review diuretic dose against weight, renal function and congestion, not a fixed schedule.
• SGLT2 inhibitors have an evidence-based role in HFpEF independent of diabetes.

On this panel: Margaret Ellison

Stage by eGFR and albuminuria. Use sick-day rules for ACEI/ARB, diuretics, metformin and SGLT2i. Expect a small eGFR dip after SGLT2i or RAS blockade.

• Metformin is contraindicated below eGFR 30 and needs review below 45.
• Hyperkalaemia limits RAS and MRA intensification — treat the potassium, not only the drug.
• Cardiorenal agents outperform isolated glycaemic escalation in CKD.

On this panel: Margaret Ellison, Priya Ramanathan

High-intensity statin, DAPT, ACEI/ARB and beta-blockade after ACS, plus smoking cessation and diabetes agents with MACE benefit.

• LDL target after ACS is <1.4 mmol/L.
• Smoking cessation is a disease-modifying intervention, not lifestyle advice.
• SGLT2 inhibitors are indicated in T2DM after ACS even when HbA1c is near target.

On this panel: James Whitaker

Stop ACE inhibitors and statins before conception. Offer 5 mg folic acid, aim HbA1c <48 mmol/mol if safe, and a TSH <2.5 mU/L.

• Do not wait for a positive pregnancy test to stop teratogens when conception is planned.
• Retinal screening before pregnancy.
• Insulin remains the glucose-lowering mainstay in T1DM pregnancy.

On this panel: Priya Ramanathan

Z-drugs, strong anticholinergics and antipsychotics increase falls, confusion and mortality. Deprescribe before adding bone protection.

• Oxybutynin is a high-anticholinergic bladder drug — prefer non-drug measures or mirabegron.
• Antipsychotics are not first-line for Parkinsonian night symptoms.
• Treat the fall, then the fracture risk.

On this panel: Harold Bennett, Margaret Ellison

Diagnostic tap for new or worsening ascites. Albumin-covered large-volume paracentesis. Pause NSBB and diuretics in HRS or SBP <90.

• Hyponatraemia plus rising creatinine is a stop-diuretic signal.
• Lactulose to 2–3 soft stools/day remains the HE backbone; rifaximin after a second episode.
• Abstinence and transplant timing are part of pharmacology, not a separate conversation.

On this panel: Elena Voss

Pulmonary rehabilitation after an exacerbation. Review inhaled triple therapy against eosinophils and pneumonia risk. Recurrent oral steroids warrant bone protection.

• Device technique often outperforms a new molecule.
• Warfarin INRs shift during steroid courses — recheck early.
• Do not extend a 5-day prednisolone course by default.

On this panel: Thomas Adeyemi

DOACs first-line for AF in most people. Dose by age, weight and creatinine. Falls are a reason to treat fall risk, not an automatic contraindication.

• Apixaban 2.5 mg BD if two of: age ≥80, weight ≤60 kg, creatinine ≥133.
• NSAIDs with anticoagulants are a bleed event waiting to happen.
• Steroids, antibiotics and amiodarone destabilise warfarin.

On this panel: Margaret Ellison, Thomas Adeyemi, James Whitaker