Vol 13 - Sep 2025 Evidence for Primary Care
Evidence for Primary Care: the latest evidence from the Trip Database
A summary of some of the most important new documents for primary care that have recently been added to the Trip Database
From Skin to Sugar to Shoulders: This Month’s Surprising Connections
One of the joys of reading across specialties is seeing how conditions we think we know well can take on an entirely new dimension when examined from a different angle. Take psoriasis: usually the territory of dermatologists, yet this month we’re reminded it is far more than skin deep. The evidence continues to mount that psoriasis is a systemic inflammatory condition with real cardiovascular consequences. It’s a timely nudge for all of us to check lipids and blood pressure as carefully as we check plaques.
Meanwhile, in the world of diabetes care, continuous glucose monitoring (CGM) is no longer the preserve of insulin-treated patients. A fresh meta-analysis shows clear benefits in glycaemic control and patient experience even for those managed without insulin. If you thought CGM was a “nice-to-have,” the data suggest it’s becoming a “need-to-discuss.”
And then there are the shoulders—specifically, rotator cuff injuries. The new guideline reassures us that both physiotherapy and surgery improve outcomes for small to medium tears, though non-operative care carries the risk of gradual progression. The good news? No need to reach for routine acromioplasty—turns out that particular surgical flourish doesn’t add value.
So, from skin to sugar to shoulders, this month’s evidence reminds us of the breadth of medicine and the value of peeking into our neighbours’ specialties. After all, what happens under the skin, in the bloodstream, or within a joint rarely stays there.
In This Edition
- What are the benefits and harms of medications for adults with type 2 diabetes at different risks of cardiovascular and kidney complications?
- What is the evidence-based management of rotator cuff injuries?
- Does continuous glucose monitoring improve outcomes in people with noninsulin-treated type 2 diabetes?
- How should metabolic dysfunction–associated fatty liver disease be assessed in primary care?
- How should bipolar disorder be assessed and managed across the lifespan?
- Does exercise improve pain, function, or quality of life in people with fibromyalgia?
- How should irritable bowel syndrome and functional abdominal pain be treated in children and adolescents aged 4–18 years?
- What is the link between psoriasis and cardiovascular disease?
- Does home blood pressure monitoring improve outcomes for people with suspected or confirmed hypertension?
- How should chronic heart failure in adults be diagnosed and managed?
- Does Helicobacter pylori eradication prevent aspirin-associated peptic ulcer bleeding in older adults?
- How effective are beta-blockers and other first-line agents for essential tremor?
- How should osteoporosis be diagnosed and managed to reduce fracture risk?
- How should migraine be treated in adults to optimise care in primary care settings?
BMJ Rapid Reviews
What are the benefits and harms of medications for adults with type 2 diabetes at different risks of cardiovascular and kidney complications?
Clinical bottom line: In type 2 diabetes, SGLT-2 inhibitors and GLP-1 receptor agonists are strongly recommended for those at higher cardiovascular or kidney risk, considered with caution at moderate risk, and generally avoided at lower risk. Finerenone is an option for chronic kidney disease, while tirzepatide may be chosen for obesity given its weight-loss benefits but uncertain cardiovascular and kidney effects.
Summary: This BMJ living guideline provides risk-stratified recommendations for SGLT-2 inhibitors, GLP-1 receptor agonists, finerenone, and tirzepatide, based on updated evidence to July 2024. Recommendations weigh survival, cardiovascular, kidney, and weight outcomes against harms, treatment burden, and cost. The guidance is continuously updated in MAGICapp, with major updates reported in The BMJ.
View ArticleThe American Academy of Orthopaedic Surgeons
What is the evidence-based management of rotator cuff injuries?
Clinical bottom line: Both surgery and physical therapy improve outcomes for small to medium rotator cuff tears. Non-operative care can maintain good function in the short and medium term, but tears may enlarge and degeneration may progress over time. Surgical repair, when successful, yields superior functional outcomes compared with physical therapy or unhealed repairs. Routine acromioplasty offers no added benefit. Diagnosis is best made with combined clinical tests supported by imaging such as MRI or ultrasound.
Summary: This evidence-based clinical practice guideline reviews the management of rotator cuff injuries. High-quality evidence supports physical therapy and surgery as effective treatments for small to medium full-thickness tears, with long-term risks of tear progression in non-operative management. Surgical repair, when healed, provides better functional recovery than non-operative care. Acromioplasty is not recommended as a routine adjunct to repair. Clinical diagnosis is strengthened by using a cluster of physical tests, while imaging with MRI, MRA, CT, or ultrasound adds accuracy. Recommendations are based on high or moderate-quality evidence and are graded accordingly.
View ArticleDiabetes Obes Metab.
Does continuous glucose monitoring improve outcomes in people with noninsulin-treated type 2 diabetes?
Clinical bottom line: Continuous glucose monitoring (CGM) in adults with type 2 diabetes not treated with insulin improves glycaemic control, increases time in range, reduces time above range, and enhances patient experience. Evidence also suggests reduced healthcare utilisation and acceptable cost-effectiveness, supporting its broader use beyond insulin-treated populations.
Summary: This critical review and updated systematic review with meta-analysis examined observational studies and eight randomised controlled trials including 541 participants with noninsulin-treated type 2 diabetes. CGM use led to a mean HbA1c reduction of 0.37%, significantly increased time in range by almost 9%, and reduced time above range by over 8%, with consistent results across CGM types. Beyond glycaemic benefits, observational data indicate improvements in patient satisfaction, cost-effectiveness, and healthcare resource use. The findings strengthen the case for integrating CGM into the management of noninsulin-treated type 2 diabetes.
View ArticleMJA
How should metabolic dysfunction–associated fatty liver disease be assessed in primary care?
Clinical bottom line: In primary care, adults with type 2 diabetes, obesity, or multiple metabolic risk factors should be assessed for MAFLD. Ultrasound is recommended for hepatic steatosis, the FIB-4 index for fibrosis risk stratification, and comorbidities such as cardiovascular and kidney disease should be evaluated. A low FIB-4 (<1.3) reliably excludes advanced fibrosis and requires repeat testing every three years, while indeterminate or high scores warrant elastography, serum fibrosis testing, or referral to liver specialists.
Summary: This consensus statement outlines practical, evidence-based recommendations for the detection and monitoring of MAFLD in primary care. Screening is advised for individuals with type 2 diabetes, obesity, or two or more metabolic risk factors. Assessment includes ultrasound for steatosis, metabolic comorbidity evaluation, and exclusion of alternative causes such as alcohol misuse or viral hepatitis. The FIB-4 index is central to fibrosis risk stratification: low scores (<1.3) exclude advanced disease, indeterminate scores (1.3–2.7) require second-line testing or referral, and high scores (>2.7) or evidence of cirrhosis necessitate specialist assessment. Regular monitoring of weight, metabolic risk factors, and FIB-4 scores ensures timely detection of disease progression and guides referral pathways.
View ArticleNICE
How should bipolar disorder be assessed and managed across the lifespan?
Clinical bottom line: Bipolar disorder is best managed through early recognition, specialist referral when needed, a combination of psychological and pharmacological treatments, and close monitoring of both mental and physical health. Valproate use is tightly restricted due to safety concerns.
Summary: This NICE guideline outlines recognition, assessment, and management of bipolar disorder in children, young people, and adults. It emphasises early detection in primary care, urgent referral for mania or severe depression, and integrated care plans in secondary services. Treatment includes evidence-based psychological therapies and selected pharmacological options, with strong safety restrictions on valproate. Ongoing monitoring, crisis planning, and support for carers are central to improving outcomes.
View ArticleTools for Practice
Does exercise improve pain, function, or quality of life in people with fibromyalgia?
Clinical bottom line: Exercise provides small improvements in pain, function, and fatigue in fibromyalgia, but the changes are often below clinically meaningful thresholds and the overall evidence is limited. Despite this, exercise remains safe and offers broader health benefits, making it a reasonable part of management.
Summary: This review of systematic reviews and randomized trials assessed aerobic, aquatic, resistance, and combined exercise in fibromyalgia. Across modalities, exercise led to modest improvements in pain and Fibromyalgia Impact Scale scores compared with control, though effects rarely reached clinically significant levels and no responder analyses were reported. Evidence is limited by small trials, variable interventions, and inconsistent reporting, but exercise is safe, rarely associated with adverse events, and provides additional benefits such as reduced cardiovascular risk and improved mental health.
View ArticleESPGHAN/NASPGHAN
How should irritable bowel syndrome and functional abdominal pain be treated in children and adolescents aged 4–18 years?
Clinical bottom line: Gut–brain psychotherapies, particularly hypnotherapy and cognitive behavioural therapy, have the strongest evidence for benefit in children with IBS or functional abdominal pain. Some dietary and pharmacological options, including soluble fibre, selected probiotics, peppermint oil, and certain medications, may be considered, but overall evidence is limited. Education, reassurance, and cautious use of treatments within a supportive, holistic care plan are central to management.
Summary: This ESPGHAN/NASPGHAN guideline synthesises evidence from 86 randomised controlled trials to provide 25 graded recommendations and 10 best practice statements for managing IBS and functional abdominal pain in children. Strong recommendations support hypnotherapy and CBT, while conditional recommendations support PENFS, soluble fibre, Lactobacillus rhamnosus GG, peppermint oil, probiotics, and selected medications such as amitriptyline or cyproheptadine. Several treatments, including buspirone, mebeverine, drotaverine, citalopram, and yoga, are not recommended. The guideline emphasises education about the gut–brain interaction, careful dietary use to avoid restrictive patterns, and avoidance of unnecessary surgery. It highlights major evidence gaps and calls for large, high-quality paediatric trials.
View ArticleClinical Correlations
What is the link between psoriasis and cardiovascular disease?
Clinical bottom line: Psoriasis is not only a skin condition but a systemic inflammatory disease that increases the risk of cardiovascular events, particularly in younger patients with severe disease. Clinicians should routinely screen for and manage cardiovascular risk factors in patients with psoriasis, as interventions such as lifestyle modification and possibly statin therapy may reduce both cardiovascular risk and psoriasis severity.
Summary: This review highlights the strong association between psoriasis and cardiovascular disease, driven by systemic inflammation and overlapping metabolic dysfunction. Severe or early-onset psoriasis increases the risk of myocardial infarction and stroke, partly mediated by obesity, diabetes, dyslipidaemia, and hypertension. Evidence from animal studies, cohort data, and clinical trials suggests that systemic inflammation links psoriasis to accelerated atherosclerosis. Lifestyle interventions and statins may improve psoriasis severity and reduce systemic inflammation, though more research is needed. Current guidelines recognise psoriasis as a cardiovascular risk enhancer, supporting aggressive risk factor management in affected patients.
View ArticleScottish Health Technologies Group
Does home blood pressure monitoring improve outcomes for people with suspected or confirmed hypertension?
Clinical bottom line: Home blood pressure monitoring (HBPM), especially when combined with telemonitoring or professional support, modestly improves blood pressure control, supports medication adherence, and empowers patients, with no evidence of increased adverse events. It is at least as effective as clinic-based monitoring for predicting cardiovascular outcomes and may be cost-saving for healthcare systems.
Summary: Evidence from multiple systematic reviews and large cohort studies shows that HBPM reduces systolic and diastolic blood pressure compared with routine care, particularly when paired with eHealth or pharmacist support. HBPM and ambulatory monitoring predict cardiovascular risk better than clinic measurements, though direct evidence of reduced morbidity and mortality is limited. HBPM can encourage medication initiation and adherence but may also cause confusion or stress without adequate clinician feedback. Patients report increased autonomy and accuracy compared to clinic readings, while health services may benefit from reduced appointment times and lower costs. Overall, HBPM is a safe, effective, and cost-efficient strategy for managing hypertension in primary care.
View ArticleNICE
How should chronic heart failure in adults be diagnosed and managed?
Clinical bottom line: Diagnose promptly with NT-proBNP triage and echocardiography, then manage through a specialist heart-failure MDT working closely with primary care. For HFrEF, initiate the four foundational therapies—ACE inhibitor (or ARNI/ARB when indicated), beta-blocker, MRA, and an SGLT2 inhibitor—then switch ACE inhibitor to an ARNI if symptoms persist. Consider IV iron for iron deficiency, ivabradine or hydralazine–nitrate in selected cases, and avoid non-dihydropyridine calcium-channel blockers. For HFmrEF, consider the same four drug classes; for HFpEF, consider MRA plus an SGLT2 inhibitor. Titrate with close renal/electrolyte and BP monitoring, adjust doses in CKD, and provide a written care plan with regular primary-care reviews.
Summary: This NICE guideline (NG106, updated 2025) mandates MDT-led care, shared care with primary care, and early discharge to community follow-up once stable. NT-proBNP thresholds trigger urgent (≥2000 ng/L within 2 weeks) or soon (400–2000 ng/L within 6 weeks) specialist assessment and echocardiography; <400 ng/L makes heart failure less likely but clinical judgment remains essential. HFrEF treatment centres on rapid initiation and up-titration of ACE inhibitor/ARNI, beta-blocker, MRA, and SGLT2 inhibitor, with ARNI substitution when maximally treated yet symptomatic; HFmrEF and HFpEF receive class-specific recommendations (MRA and SGLT2 inhibitor for HFpEF). The guideline details IV iron criteria, add-on/specialist drugs, CKD-specific dosing and liaison, and a structured monitoring schedule for renal function, potassium, and blood pressure, all embedded in personalised care planning, rehabilitation access, and regular six-monthly reviews.
View ArticleNIHR
Does Helicobacter pylori eradication prevent aspirin-associated peptic ulcer bleeding in older adults?
Clinical bottom line: In adults ≥65 years taking aspirin, H. pylori eradication reduces the risk of peptic ulcer bleeding during the first 2.5 years after treatment, but the benefit is not sustained long-term and proactive population-wide screening is not cost-effective. Selective use in high-risk patients may still be valuable.
Summary: The HEAT RCT enrolled over 5,300 H. pylori-positive adults ≥60 years on aspirin and randomised them to eradication therapy (clarithromycin, metronidazole, lansoprazole) or placebo. Over 5 years, eradication significantly reduced ulcer bleeding risk in the first 2.5 years (HR 0.35, NNT ~238) but not thereafter. Overall, there was no long-term difference in peptic ulcer bleeding or mortality, though fewer deaths occurred in the eradication group (mainly due to lower malignancy rates, not GI bleeding). Economic modelling showed routine screening and eradication was not cost-effective at the population level. Future studies may need to focus on patients starting aspirin, when bleeding risk is highest.
View ArticleTools for Practice
How effective are beta-blockers and other first-line agents for essential tremor?
Clinical bottom line: Propranolol remains the best-supported first-line treatment, producing clear short-term improvements in tremor severity and patient-reported benefit. Primidone and topiramate also show clinically meaningful benefit in limited trials, while other beta-blockers are less effective.
Summary: Evidence from small, older RCTs shows propranolol (90–240 mg/day) consistently improves tremor severity by about 2 points on 10–15 point scales, with most patients reporting clear benefit compared to placebo. Primidone improves functional outcomes in small studies, and topiramate demonstrates meaningful benefit in a larger trial. Other beta-blockers (e.g., metoprolol, atenolol) show no advantage over placebo, and metoprolol is inferior to propranolol. Overall, propranolol, primidone, and topiramate remain first-line options, but the evidence base is limited by small sample sizes, short follow-up, and variable outcome measures.
View ArticleACE Clinical Guidance
How should osteoporosis be diagnosed and managed to reduce fracture risk?
Clinical bottom line: Osteoporosis diagnosis is based on fragility fracture history or a DXA T-score ≤ –2.5. All postmenopausal women and men ≥65 years should be assessed for fracture risk. Lifestyle optimisation (adequate calcium/vitamin D, exercise, smoking and alcohol moderation, fall prevention) is recommended for all. Oral bisphosphonates are first-line, with zoledronate or denosumab as alternatives. Very high-risk patients may benefit from anabolic agents. Treatment should be guided by overall fracture risk, not bone density alone, with periodic reassessment and specialist referral for complex cases.
Summary: The 2025 ACE Clinical Guidance (Singapore) emphasises early identification and treatment of osteoporosis to reduce fragility fractures, which remain a significant health burden. Risk assessment tools such as OSTA and FRAX® support screening in primary care. Pharmacological therapy is indicated for patients with fragility fractures or T-scores ≤ –2.5, and may be considered in osteopenia when fracture risk is high. Bisphosphonates remain the mainstay of therapy, while denosumab and anabolic agents are options in selected patients. Non-pharmacological strategies complement drug treatment, and ongoing monitoring, drug holidays (for bisphosphonates), and specialist referral ensure safe, effective long-term management.
View ArticleINESSS
How should migraine be treated in adults to optimise care in primary care settings?
Clinical bottom line: Effective migraine care requires structured treatment pathways, informed shared decision-making, and clear criteria for treatment success or failure. First-line management includes evidence-based pharmacological options supported by lifestyle advice and monitoring, while specialist referral is reserved for complex or refractory cases.
Summary: This INESSS guidance synthesises best practices for adult migraine management in Quebec, aiming to support primary care clinicians. It provides an algorithm for sequencing acute and preventive pharmacological treatments, highlights drugs with proven benefit, and stresses the need for informed shared decision-making with patients. Lifestyle modification and headache diaries are encouraged to aid diagnosis and follow-up. The tool clarifies when primary care can continue management and when specialist input is warranted, helping reduce unnecessary referrals while ensuring timely escalation for refractory or complex migraine.
View Article
