BC Guidelines

The Ischemic Stroke and Transient Ischemic Attack (TIA) - Diagnosis and Acute Management guideline [link the guideline title to the guideline webpage once it has been created] provides recommendations for the early recognition, assessment and acute management of ischemic stroke and transient ischemic attack (TIA) in adults ≥19 years old. Primary prevention, cerebral venous thrombosis, and hemorrhagic, pediatric, and pregnancy-related strokes are out of scope.

Key Recommendations

• NEW Treat suspected TIA or minor stroke presenting <48 hr as a medical emergency because stroke recurrence and/or progression is highest within this period.
• NEW Perform neuroimaging (non-contrast CT brain and non-invasive CTA arch to vertex) in all patients with suspected stroke/TIA, regardless of timing or persistence/resolution of symptoms.
• NEW Triage patients based on type of symptoms and time since onset (woke up with symptoms, <6 hr, 6–48 hr, >48 hr–2 weeks, >2 weeks) to determine the urgency of transport, neuroimaging, and specialist referral. Imaging is essential for assessing eligibility for reperfusion therapy (generally feasible within first 24 hr), and risk stratification.
• NEW Direct all patients with symptom onset <48 hr to a neuroimaging-capable ED, even if symptoms have resolved.
  • If symptoms are ongoing and onset <24 hr, contact 911 to activate stroke protocols to expedite imaging and assess eligibility for reperfusion therapy.
  • If symptoms have fully resolved OR onset is 24–48 hr, personal transport to nearest ED is an option. Alert ED about incoming patient. Patients should not drive themselves.
• NEW Consult with a stroke specialist (on-site or via Patient Transport Network) for urgent diagnostic and management decisions, including eligibility for reperfusion therapy (thrombolysis and/or endovascular therapy) and/or antithrombotic therapy (antiplatelet therapy [APT] or oral anticoagulant).
• NEW Initiate single APT prior to outpatient imaging in patients whose symptoms occurred >2 weeks ago and have now resolved. Consult with stroke specialist first if there is concern for high risk of intracranial hemorrhage.
• NEW Assess the risk of stroke within first week after a TIA by using the Canadian TIA Score.
• Urgently refer patients with symptomatic extracranial carotid artery stenosis (50–99% stenosis) to stroke prevention clinic and vascular surgery for potential carotid revascularization (surgery or stenting) to be performed ideally within 14 days.
• NEW Aim to admit patients to an acute stroke unit (i.e., a specialized, geographically defined hospital unit dedicated to the management of patients with stroke).

The Chronic Kidney Disease – Diagnosis and Management guideline provides recommendations for the investigation, evaluation, and management of adults at risk of/or with known chronic kidney disease (CKD).

Key Recommendations

• Screen high-risk patients (e.g., diabetes, hypertension, cardiovascular disease, family history, and those with a history of acute kidney injury) using estimated Glomerular Filtration Rate (eGFR) and urine Albumin-Creatinine Ratio (ACR). Confirm abnormal test results with a repeat measurement and obtain urinalysis (microscopic).
• Determine likely cause of kidney disease where possible. This has important implications for determining risk of End Stage Kidney Disease (ESKD)/Kidney Failure and other complications.
• Use disease modifying drugs to control hypertension and proteinuria that prevent or postpone kidney function decline.
• All patients with CKD: Initiate an ACE inhibitor (ACE-I) or angiotensin receptor blocker (ARB).
• [NEW] Patients with CKD and uACR ≥20 mg/mmol: In addition to ACE-I/ARB, start a sodium-glucose cotransporter 2 inhibitor (SGLT2i), unless contraindicated.
• [NEW] Patients with CKD and heart failure: In addition to ACE-I/ARB, start a SGLT2i, unless contraindicated.
• [NEW] Patients with CKD and type 2 diabetes: In addition to ACE-I/ARB and SGLT2i, include a non-steroidal mineralocorticoid receptor antagonist (ns-MRA) and a glucagon-like peptide-1 receptor agonist (GLP-1 RA) to optimize renal and cardiovascular outcomes.
• Prescribe statins for CKD patients ≥ 50 yrs and for those 18-49 yrs with cardiovascular risk factors.
• Hold ACE-I, ARB, SGLT2i, and diuretics if patient has acute illness with dehydration, with a plan to restart.
• To assist in determining the need for and timing of referral, obtain advice from local internists, nephrologists or RACE.

Revisions to the Cervical Cancer Prevention and Screening Guideline to reflect changes in the BC Cancer screening program as well as HPV9 vaccine dose schedule recommendations and Immunize BC program eligibility.

Minor revisions to the Chronic Obstructive Pulmonary Disease (COPD) guideline to reflect new PharmaCare regular benefit coverage for Tiotropium.

The Tobacco Use Disorder (TUD) guideline provides evidence-based recommendations for primary care practitioners on managing tobacco use disorder (TUD). This guideline also addresses vaping. While the guideline focuses on TUD in adults (ages ≥ 19), there are some recommendations addressing the youth population (ages 12-18).

• Tobacco use disorder (TUD) (defined in the DSM-5-TR), like other substance use disorders, is a chronic and often relapsing condition. Document smoking history by number of years spent smoking (now considered a better risk indicator than “pack years”). Ask regularly about smoking status and document tobacco use in the patient medical record, including number of cessation attempts.
• Acknowledge that relapse is common and can be expected. If a patient has resumed tobacco use, offer education and review and adjust their smoking cessation plan.
• Continue to provide brief interventions (BI), which are effective when routinely repeated. Consider a motivational interviewing (MI) approach with all patients, including those not yet ready to stop smoking.
• The most effective way to stop smoking is a combination of both pharmacotherapy and counselling. Treatment plans should be individually and collaboratively tailored.
  • Medications: Encourage first-line pharmacotherapy, including nicotine replacement therapy (NRT), varenicline, and bupropion.
  • Counselling: Smoking cessation programs provide support to those who plan to quit smoking. Encourage patients to connect with QuitNow or to the FNHA’s Talk Tobacco Program.
• Ask regularly about and document vaping use (including youth). Advise and support efforts to quit vaping.