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.

 

NEW (2022):  Managing Patients with Pain in Primary Care – Part 1 and Part 2

This guideline comprises of two parts:

1. Pain Assessment and Management Approaches

2. Pain Management – Pharmacological and Procedural

Within scope of this guideline:

  • Practical recommendations within the primary care setting for a graded, multimodal approach to supporting adult patients (≥ 19 years) with pain on a continuum from acute, subacute to chronic pain. A multimodal approach is one where patients with pain receive multiple interventions and supports, both concurrently and sequentially.
  • General approaches to treating patients with pain and links to supportive resources.

Key Recommendations:

  • Patients with moderate to severe acute injury should receive adequate pain control and consideration of early referral to specialized services, where indicated and available.
  • Consider improving function and reducing disability, rather than elimination of pain, as the goal of pain management strategies, especially when pain progresses into the chronic pain continuum.
  • A supportive longitudinal therapeutic relationship is a foundation of pain management. Given the changing face of primary care with team-based care, walk-in care, and virtual care, use of databases like Electronic Medical Records (EMRs), PharmaNet, and CareConnect is increasingly important.
  • Throughout the pain continuum, especially in subacute and chronic phases, assess for biopsychosocial factors (yellow flags) and co-morbid conditions. Be alert to addressing risk factors for developing chronic pain. •
  • Complex Regional Pain Syndrome (CRPS) is often considered a pain emergency and warrants urgent referral or consultation by a pain specialist and consideration of early intervention with steroids.
  • Consider all forms of interventions, including non-pharmacological and pharmacological, as a ‘trial’ to be reassessed for effectiveness on a regular basis.
  • For people with chronic pain not already on opioid therapy, optimize non-pharmacotherapy and non-opioid pharmacotherapy first before considering a trial of opioid therapy.
  • For all medication, aim for the optimal dose and be aware of the recommended maximal dose with fewest side effects and do regular, recurrent evaluation to assess for meaningful improvement in pain and function. See Managing Pain in Primary Care – Part 2: Pharmacological Management.
 

REVISED: Cardiovascular Disease - Primary Prevention (2021) 

Cardiovascular Disease – Primary Prevention (2021) guideline provides recommendations on the primary prevention of atherosclerotic cardiovascular disease (ASCVD/CVD) in adults aged ≥19 years without clinical CVD. It does not apply to patients with a known history of CVD or who currently have signs or symptoms of CVD, as this would require treatment and secondary prevention. The recommendations include how to assess a patient’s risk of CVD and how to manage their CVD risk factors.

Familial hypercholesterolemia (FH) and other genetic dyslipidaemias are out of scope of this guideline. Practitioners are recommended to access Canadian Cardiovascular Society guidelines that address this condition. For updated guidance on secondary prevention practitioners are recommended to access the 2021 Canadian Cardiovascular Society guidelines.

Key Recommendations

  • Assess CVD risk in all asymptomatic adults ≥40 years of age [Strong Recommendation, Strong Evidence].
  • Health behaviour change (e.g., smoking cessation, healthy diet) is recommended as the first-line intervention for all risk groups in CVD primary prevention. Pharmacological management is recommended for high risk groups [Strong Recommendation, Strong Evidence].
  • Initiate statin therapy only after objectively evaluating the person’s individual risks, benefits and preferences, and by having an individualized discussion with the patient. Initiate pharmaceutical management after considering the patient’s overall individual risk. Treatment with a statin is expected to result in a significant reduction (30 - 50%) in the elevated baseline lipid levels [Strong Recommendation, Strong Evidence].
  • Reducing LDL-C using statin and/or non-pharmacological management is recommended as each 1 mmol/L decrease in LDL-C results in a 20-22% relative risk reduction of major vascular events [Strong Recommendation, Strong Evidence].
  • The use of aspirin to reduce risk of morbidity or mortality may only be beneficial to certain individuals. [Strong Recommendation, Strong Evidence].
  • Recommendation against the use of over-the-counter omega-3 PUFA to reduce CVD risk. [Strong Recommendation, Strong Evidence].
 

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:  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.

 

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