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Right Decision Service newsletter: March 2024

Welcome to the Right Decision Service (RDS) newsletter for March 2024. Please forward this newsletter to others who may be interested. They can contact olivia.graham@nhs.scot to be added to the circulation list.

Promotion and communication resources

Promotional flyers are now available in the Learning and Support area of RDS:

What is RDS and what impact does it have? (infographic)

General RDS flyer

Being a partner in my care: Realistic medicine app for citizens

Managing medicines for patients and carers app

Home care decisions app

Child protection app (South Lanarkshire HSCP)

All except the infographic are also available as editable Word versions. Please contact his.decisionsupport@nhs.scot  if you would like Word versions.  

Redesign and improvements to RDS

Search and browse improvements are progressing well and the plan is still to release these in mid-May.  The first stages of work on archiving and version control are complete. User stories (requirements) are being defined for:

  • Deep linking to individual toolkit URLs/QR codes
  • Translating content from a structured Word document directly into RDS
  • Capability to review and edit changes made to shared content

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

A big thank you to all of you who have completed our Impact and Value questionnaire. The data from this will be really helpful in informing the first draft of the business case for long term provision of the RDS. This will be reviewed by the National Advisory Board for RDS later this month.

We welcome further responses. If you haven’t yet completed the survey, please follow this link, and please encourage other RDS toolkit leads and users to do so.

New toolkits

A few examples of toolkits published to live in the last month:

 

Toolkits in development

Some of the toolkits the RDS team are currently working on:

  • Updates to the Respiratory prescribing guidance and Manage Medicines for patients and carers toolkits
  • Respiratory Managed Clinical Network Pathways
  • Child abuse pathways in NHS Tayside
  • Patient information leaflet collection in NHS Borders
  • Referral management toolkit for NHS Borders
  • NHS Lothian – Infectious diseases; Acute oncology guidelines; Royal Infirmary of Edinburgh Emergency Care.

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Learning opportunities

The RDS Learning working group is progressing with developing training resources for editors, and intend to have resources to share by end of June. This includes resources for:

  • Each stage of the development journey for RDS toolkits – Scoping to Implementation/Evaluation and Maintenance.
  • RDS content governance.
  • Core functionality – learning bytes.

 

Editor webinars

Just a reminder that we are offering webinars for existing and potential new editors on the following dates:

  • Wednesday 10 April 3.30-4.30 pm
  • Thursday 18 April 12-1 pm

 

To book for one of these webinars, please complete the registration form at https://forms.office.com/e/eGjKqNVjeF

Quality audit

Many thanks to all of you who have met with me recently to complete or clarify your responses to the quality audit survey at the end of last year.  Work to complete the quality audit for all toolkits published on RDS prior to November last year will continue for the next few months.

Implementation projects

The RDS team is now working with Moray HSCP to evaluate impact of the new RDS toolkit “Preventing progress of diabetes”  (https://preventdiabetes.scot.nhs.uk ) to support people at high risk of diabetes type 2 and those who are candidates for remission. We are looking at the impact of use of the app with SMS prompts on people’s readiness for lifestyle change over an 8 week period. This includes comparing impact in people who have a call with a dietitian in addition to using the app to people who only use the app.

If you have any questions about the content of this newsletter, please contact us on his.decisionsupport@nhs.scot.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

 

Urticaria

Urticaria: A heterogeneous group of disorders characterized by dermal and/or subcutaneous and submucosal oedema. The most common underlying mechanism is release of histamine from mast cells with consequent capillary dilatation and tissue oedema. This is responsible for the weals of spontaneous and most inducible urticarias. A variety of other mechanisms are involved in other urticarial disorders. In the UK, approximately 15% of people experience urticaria at some time in their lives and the lifetime prevalence of chronic urticaria is 0.5–1%. For around 40–50% of people with urticaria, the cause of their condition is unknown. Symptoms of duration of less than 6 weeks are considered acute, and beyond this are chronic urticaria. 

Treatment/therapy

Mild: does not impact significantly on activities of daily living 

  • For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers 
  • Stop any histamine-releasing drugs if able, e.g. aspirin, codeine, ACE inhibitors, non-steroidal anti-inflammatory drugs; if possible, treat potential sources of infection; avoid triggers for inducible urticarias (such as heat, cold, etc). 
  • Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, loratadine or fexofenadine) for up to 3 months.

Moderate: symptomatic but does not impact on sleep/normal activities of daily living 

  • For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers 
  • Stop any histamine-releasing drugs if able, e.g. aspirin, codeine, ACE inhibitors, non-steroidal anti-inflammatory drugs; if possible, treat potential sources of infection; avoid triggers for inducible urticarias (such as heat, cold, etc). 
  • Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, loratadine or fexofenadine) for 3-6 months. If not controlled on once daily, consider double dose or increasing up to quadruple dose, reducing to lower doses when symptoms controlled. 
  • Suggest a FBC differential, ESR/CRP and TSH/TFT for patients where symptoms persist. 

Severe: frequent or significant lesions. Impacts on sleep or daily activities 

  • For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers (stop histamine-releasing drugs and avoid triggers for inducible urticarias, as for mild/moderate urticaria) 
  • Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, fexofenadine, or loratadine) for 3-6 months. If not controlled on once daily, consider double dose or increasing to quadruple dose, reducing to lower doses when symptoms controlled 
  • Give a short course of an oral corticosteroid (for example prednisolone 40 mg daily for 4-5 days) in addition to the low-sedating oral antihistamine if not controlled. Longer term steroids are not advised for chronic urticaria management in primary care. 
  • Referral if an oral corticosteroid is indicated in a child younger than 16 years of age.   
  • If rebound symptoms occur, seek specialist advice. Do not repeat the course of oral corticosteroid. 
  • Suggest a FBC differential, ESR/CRP and TSH/TFT. 
  • NICE guidance recommends montelukast as a second-line agent (unlicenced indication)

Referral management

Mild: does not impact significantly on activities of daily living 

Manage in primary care, seek advice and guidance if there is diagnostic uncertainty. 

 

Moderate: symptomatic but does not impact on sleep/normal activities of daily living 

Manage in primary care, seek advice and guidance if there is diagnostic uncertainty, particularly where individual lesions last more than 24 hours and/or fade with bruises (not bruising due to scratching) and/or are painful, or if there are systemic symptoms such as arthralgia or fever, or if there are persistently high inflammatory markers. This may suggest urticarial vasculitis, or diseases with urticaria-like rashes. 

Consider referral when symptoms are not well controlled on antihistamine treatment, or when disease is having a significant effect on quality of life.  

 

Severe: frequent or significant lesions. Impacts on sleep or daily activities 

Seek advice and guidance if there is diagnostic uncertainty, particularly where individual lesions last more than 24 hours and/or fade with bruises (not bruising due to scratching) and/or are painful, or if there are systemic symptoms such as arthralgia or fever, or if there are persistently high inflammatory markers. This may suggest urticarial vasculitis, or diseases with urticaria-like rashes. 

Consider referral when symptoms are not well controlled on antihistamines or other treatments listed above, or when disease is having a significant effect on quality of life. Refer people with forms of chronic inducible urticaria that may be difficult to manage in primary care, for example, solar or cold urticaria. 

Refer people with acute severe urticaria which is thought to be due to a food or latex allergy – check locally whether referral to specialist immunology services more appropriate. 

  • There are other treatment options in secondary care, including omalizumab and ciclosporin. 

Clinical resources

DLQI clinical tool: https://www.cardiff.ac.uk/medicine/resources/quality-of-life-questionnaires/dermatology-life-quality-index  

UAS7 clinical tool:  

NICE CKS – Urticaria: 

NICE scenarios – Managing urticaria:  

BAD Urticaria guidelines (2007):  

PCDS guidance – Chronic spontaneous urticaria  

BSACI- Urticaria:  The EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis and management of urticaria - Zuberbier - 2021 – Allergy 

DermnetNZ – Urticaria   

Clinical Tips

  • Patients with urticaria have a higher incidence of thyroid receptor antibodies than the general population. 
  • Check C4 levels (complement) in patients with angioedema without urticaria. 
  • UAS7 can be a useful tool in estimating severity and response to treatment. 
  • Chronic spontaneous urticaria is rarely associated with food allergy, and patch testing is unhelpful and not recommended. 

Patient information resources

  1. BAD leaflet – Urticaria and angioedema
  2. Patient.info leaflet – Urticaria
  3. NHS Conditions- Hives
  4. Angioedema
  5. NHS Inform Scotland- Urticaria (Hives) 

ICD search category(s)

Inflammatory 

ICD11 code - EB00 

Editorial Information

Last reviewed: 11/04/2023

Next review date: 11/04/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society.

Approved By: Scottish Dermatological Society