BC Guidelines

 

BC Guidelines are clinical practice guidelines and protocols that provide recommendations to B.C. practitioners on delivering high quality, appropriate care to patients with specific clinical conditions or diseases. These “Made in BC” clinical practice guidelines are developed by the Guidelines and Protocol Advisory Committee (GPAC), an advisory committee to the Medical Services Commission. The primary audience for BC Guidelines is BC physicians, nurse practitioners, and medical students. However, other audiences such as health educators, health authorities, allied health organizations, pharmacists, and nurses may also find them to be a useful resource.

There are several ways to find the guidelines you are looking for.

What's New

For information on COVID-19, visit the BC Centre for Disease Control website.

 

REVISED: Diabetes care 

Diabetes Care (2021) describes the care objectives for the prevention, diagnosis, and management of diabetes mellitus (diabetes or DM in this guideline) in adults aged ≥ 19 years. It focuses on the approaches and systems that are ideally in place to improve care for the majority of people, the majority of the time. Diabetes in pregnancy (including gestational diabetes) is outside the scope of this guideline, although statements about pre-conception care for people with diabetes are included

Key Recommendations include:

  • Diabetes care should be holistic and centred around the person living with diabetes. Include an individualized management plan developed by the person with diabetes and their primary care provider(s).
  • Goals include reducing microvascular and cardiovascular complication, reducing hyperglycemia and its symptoms, reducing risk and occurrence of hypoglycemia, and improving quality of life.
  • The 5 Rs describe the key components to consider when organizing diabetes care in the office or clinic: Recognize, Register, Resource, Relay, and Recall.
  • People ≥ 40 years of age and those younger than 40 with risk factors should be screened for diabetes.
  • Glycosylated hemoglobin (A1C), fasting plasma glucose (FPG) or rarely 2-hour plasma glucose (2hPG) as part of a 75g oral glucose tolerance test (OGTT) can be used for diagnosis and screening.
  • Individualized glycemic targets are based on age, duration of diabetes, risk of hypoglycemia, cardiovascular disease presence, and life expectancy.
  • Measure A1C every 3 months to assess if glycemic goals are met. Consider testing every 6 months if targets are consistently met, and treatment and lifestyle are stable.

Management of Type 2 diabetes:

  •  A systematic approach to cardiovascular management is recommended, including healthy behaviour choices, glycemic and blood pressure control, and pharmacological interventions.
  • Metformin is recommended as initial pharmacotherapy. 
  • NEW: Choose antihyperglycemic agents (AHA’s) with cardiorenal protection for those with Atherosclerotic Cardiovascular Disease (ASCVD/CVS), Chronic Kidney Disease (CKD), Heart Failure (HF) or ≥ age 60 with CVS risk factors. These agents should be used even if A1C is at target.
  • Achieve glycemic goal (A1C target) in 3-6 months. Adjust therapy if glycemic targets are not reached or if there is a change in clinical status.
  • If frailty, cognitive decline, or limited life expectancy are present, target an A1C of 7.1 to 8.5. Prioritize use of agents with low risk of hypoglycemia. 
 

NEW: Infectious Diarrhea guideline: Open for External Review until February 23rd, 2022

This guideline provides guidance for primary care practitioners regarding adults and children greater than 2 months of age on appropriate testing for suspected community onset infectious diarrhea, including Clostridioides difficile infection. This guideline does not apply to outbreak situations, or patients with hospital onset diarrhea. The Infectious Diarrhea Panel (IDP) is a new stool test that combines stool cultures, ova & parasites (O&P) and C. difficile within a single specimen. It functionally replaces stool cultures and O&P, however standalone C. difficile tests are still available. This guideline serves to describe the most appropriate use of IDP, and the use and interpretation of C. difficile tests. The Infectious Diarrhea Panel (IDP) is not yet implemented in BC. Please do not order the test until the guideline is published and the laboratories have announced that the test is available. Peer review is a critical component of guideline development. Please visit our External Review page to download the draft guideline and submit your feedback via our new online questionnaire.

 

NEW: Colorectal Cancer guideline: Open for External Review until February 16th, 2022

Part 1 of the guideline provides recommendations for the detection of colorectal cancer (CRC) and precancerous lesions in asymptomatic adults, including those with hereditary syndromes. Part 2 of the guideline provides follow up recommendations for patients after curative resection of CRC or colorectal precancerous lesions (previously referred to as polyps). Peer review is a critical component of guideline development. Please visit our External Review page to download the draft guideline and submit your feedback via our new online questionnaire.

 

NEW:  High Ferritin and Iron Overload – Investigation and Management Guideline

The High Ferritin and Iron Overload – Investigation and Management (2021) guideline is directed to primary care practitioners who encounter an unexplained finding of high ferritin in an adult outpatient aged >19 years. It provides recommendations for the investigation of high ferritin levels (hyperferritinemia), outlines common causes of hyperferritinemia and gives practitioners guidance on when to investigate for and treat hereditary hemochromatosis. The guideline is not for screening for iron overload. Hemochromatosis caused by mutations in iron-related genes other than HFE is outside the scope of this guideline. HFE (high Fe) is the gene most commonly associated with hemochromatosis. Because the non-HFE hereditary hemochromatosis causes of hyperferritinemia are so diverse, their management is out of scope. They should be managed according to the underlying condition.

Key recommendations include:

  • Ferritin is an acute phase reactant released by activated macrophages and damaged hepatocytes.  
  • High ferritin levels are most commonly caused by inflammation, infection, liver disease (particularly non-alcoholic steatohepatitis (NASH)/fatty liver), renal disease, alcohol excess, metabolic syndrome or malignancy. In these cases, a high ferritin level does not accurately reflect iron stores.
  • The first-line investigations for a patient with a raised serum ferritin are:
    • History taking: alcohol intake and other risk factors for liver disease, type 2 diabetes mellitus, obesity, hypertension, signs and symptoms of an underlying inflammatory or malignant disorder, transfusion history, and family history of iron overload.
    • Lab tests: repeat serum ferritin, transferrin saturation (TSAT), complete blood count, serum creatinine, liver enzymes (ALT and GGT) with consideration of viral hepatitis screening and abdominal ultrasonography (if suspected liver disease or elevated liver enzymes). Check blood glucose and lipid studies if not recently performed.
  • Hereditary hemochromatosis is an uncommon cause of hyperferritinemia and testing for HFE-HH is not recommended in patients of non-European ancestry because its prevalence is very rare.
  • Individuals of East Asian descent have ferritin values 1.5-2x higher than the upper limit of normal reported.
  • Iron overload can generally be excluded when TSAT
 

NEW: Obstructive Sleep Apnea: Assessment and Management in Adults 

Obstructive Sleep Apnea: Assessment and Management in Adults (2021) guideline applies to adult patients 19 and older with suspected obstructive sleep apnea (OSA) and provides testing, referral and management recommendations. While sleep apnea may occur in 1-4% of children, pediatric diagnosis and management is beyond the scope of this guideline.

Key Recommendations include:

  • History
    • If OSA is suspected, conduct a detailed history and a physical examination, focused on the upper airway. 
    • The STOP-Bang questionnaire can be used to help determine if a patient is at increased risk of moderate to severe OSA. 
    • While the most common symptom of OSA is excessive daytime sleepiness, the clinical presentation can vary. Completion of the Epworth Sleepiness Scale is recommended. 
    • Patients with untreated OSA may have increased perioperative morbidity. Consider appropriate screening when referring patients for potential surgery (e.g. STOP-Bang Questionnaire). See also the BC Surgical Rehabilitation Toolkit for further information. [Expert opinion]
  • Testing and Referral 
    • Home Sleep Apnea Test (HSAT) should not be used to screen asymptomatic patients. HSAT is only recommended for the diagnosis of OSA in symptomatic patients who are determined to be at an increased risk of moderate-to-severe OSA, and who have no exclusion criteria (see Requisition). 
    • A negative or equivocal HSAT does not exclude OSA. If an HSAT is negative, inconclusive or technically inadequate, and OSA is suspected, polysomnography is recommended. 
    • BC now has a Standard Requisition for HSAT that referring practitioners are required to use. 
    • Symptomatic patients for which the HSAT is not the appropriate diagnostic test should be referred for a sleep disorder consultation for polysomnography. [Expert Opinion]
  • Management and Follow-up
    • When assessing whether a patient should be treated, it is important to consider the severity of the symptoms, presence and severity of any comorbid disease, presence of any safety-critical occupation and the results of all sleep studies. 
    • OSA is a serious chronic disease that warrants regular follow-up, short-term to ensure initial compliance and response to treatment and long-term to confirm continued effectiveness. 
    • Patients with OSA may be prone to drowsiness while driving. Physicians caring for these patients should be familiar with BC’s Driver Medical Fitness Information for Medical Professionals. [Expert Opinion] 
    • Surgery for OSA, including minimally invasive techniques to reduce tissue volume, incurs typical surgical risks. Since there may be effective medical alternatives to surgery, prior referral to a sleep disorder physician is recommended.
 

NEW: Fall Prevention - Risk Assessment and Management for Community-Dwelling Older Adults Guidelines

The scope of the Fall Prevention: Risk Assessment and Management for Community-Dwelling Older Adults guideline (2021) is to address the identification and management of older adults aged ≥ 65 years living in the community with risk factors for falls, and is intended for primary care practitioners. The guideline facilitates individualized assessment and provides a framework and tools to manage risk factors for falls and fall-related injuries. Hospital, facility-based care settings and acute fall management are outside the scope of this guideline, although some of the principles in this guideline may be useful in those settings.

Key recommendations include:

• Annually, or with a significant change in clinical status, ask patients ≥ 65 years about their fall risk using simple one-minute screening tools to identify people at risk of falls:

o Three question approach and/or

o Staying Independent checklist

• Recommend exercise to improve strength and balance and safe mobility. This is the most effective fall prevention intervention. See Exercise Prescription and Programs section.

• For those evaluated as “at risk” or who have had a fall, a multifactorial risk assessment is recommended over multiple visits to review (see Multifactorial Risk Assessment, Fall History and Intervention section):

o Medications

o Medical conditions (including review of common geriatric conditions)

o Mobility (endurance, strength, balance and flexibility)

o An assessment of the home environment

o Osteoporosis risk assessment and management (increases risk of fracture from fall)

• After a fall, interdisciplinary assessment and care planning can reduce the risk of future falls. A team-based approach, when available, is recommended (see Referral Options section).

 

REVISED: Cataract – Treatment of Adults

The scope of the Cataract – Treatment of Adults guideline is to provide recommendations for primary care providers in the prevention, diagnosis, management and postoperative care of cataracts for adults (age 19 and older).

Key recommendations include:

  • The following are recommended to delay the onset and progression of cataracts: smoking cessation, reduced ultraviolet (UV) -B exposure (hats, sunglasses with UV-B protection), and safety eyeglasses during high-risk activities at work or recreation to avoid eye trauma.
  • Patients who are long-term users of corticosteroids (by any route) should be informed of the increased risk of cataract formation.
  • Indications for cataract surgery are not limited to Snellen visual acuity alone and referral for cataract surgery consultation is indicated in the setting of glare, monocular diplopia or other non-visual functional impairment.
  • Cataract surgery may be indicated in other ocular diseases for reasons independent of vision rehabilitation.
  • When a cataract lens is surgically removed, it is replaced with a synthetic intraocular lens (IOL). There are many types of IOL’s available. IOL technologies and choices continuously evolve as does MSP coverage of IOLs. Patients can be reassured that MSP-covered monofocal lenses provide fully satisfactory visual correction in the vast majority of patients. Glasses are usually required after surgery for near and sometimes also distance vision. Non-MSP covered lenses may lessen dependency on glasses post-surgery, but may not be appropriate for all patients due to individual suitability or side effects. IOL selection evolves out of a comprehensive discussion with the surgeon.
  • Primary care practitioners should be aware of postoperative “red flags”. Post-operative patients should be urgently assessed (within 24 hours) by their surgeon or an on-call ophthalmologist with increasing eye redness, pain or decrease in vision (see Table 4 for more details).

The scope of the Viral Hepatitis Testing (2021) guideline is to outline the use of laboratory tests to diagnose acute and chronic viral hepatitis in adults (≥ 19 years) in the primary care setting. Testing related to children or perinatally acquired viral hepatitis infection, or treatment information is outside the scope of this guideline.

Key recommendations include:

HAV

  • There are very few acute HAV infections in BC. Cases relate to travel, contaminated food products or close contact with those who are infected.
  • Self-limited disease not requiring ongoing serological follow-up. Post-vaccination testing is not recommended.

HBV

  • Although there is currently no cure, treatment is available for chronic HBV infection. Patients with chronic HBV infection should be engaged into comprehensive specialist care. Consultation or referral is strongly recommended.
  • In the absence of risk factors, routine HBV testing is not needed for those born in Canada.
  • One-time HBV testing for immigrants from endemic areas is recommended.
  • Vaccinate individuals susceptible to HBV infection when risk factors are present.
  • Individuals being treated for HCV who are getting worked-up for HIV pre-exposure prophylaxis (PrEP), are immunosuppressed, or who are about to start immunosuppressive therapy, should be evaluated for prior HBV infection to assess the potential risk for reactivation of HBV.

HCV

  • Curative treatments (> 95 % effective) are available for those who have HCV infection.
  • Patients known to have HCV infection, but who have not been previously treated and cured, should be recalled and engaged into care for HCV treatment.
  • One-time HCV testing for the birth cohort 1945-1965 can be considered.
  • One-time HCV testing for immigrants from endemic areas is recommended.
  • Annual HCV testing for susceptible individuals with ongoing risks for HCV infection or reinfection is indicated.
  • Treatment providers must establish a respectful, trust-based relationship with all patients, and need to consider HCV treatment within a holistic wellness framework.
  • Where appropriate, many individuals with HCV infection could benefit from further supports and enrolment into comprehensive care (e.g., opioid agonist therapy, mental health and addiction services, alcohol reduction).
  • As of 2018, an estimated 28,607 people in BC living with hepatitis C infection (diagnosed and undiagnosed) remain untreated.

 

BC Guidelines Mobile App Now Available at BCGuidelinesApp.ca

We are pleased to announce the release of our new BC Guidelines Mobile App for Android and Apple devices.

BC Guidelines has partnered with Dr. Matthew Toom, a Family Physician and experienced computer programmer, to create the new BC Guidelines Mobile App. The free and redesigned mobile app works even without Internet connectivity so busy practitioners can instantly access BC Guidelines on any Apple or Android mobile device no matter where they are working.

To learn more about BC Guidelines see our video below

BC Guidelines Overview