A truly ‘HANDI’ resource

ALTERNATIVES TO DRUG THERAPY

GPs and patients have an increasing interest in the use of non-drug interventions to treat common conditions seen in primary care. Nearly half the thousands of clinical trials conducted each year are for evaluating non-drug treatments, such as diet, exercise, procedures, and devices. Advances in such treatments in the past few decades have been substantial and diverse — for example, exercise for heart failure and COPD, the Epley manoeuvre for benign paroxysmal positional vertigo, and CBT for depression. However, effective non-drug methods are less well known, less promoted, and less used than their pharmaceutical cousins.

There are well-established drugs/medications formularies such as the British National Formulary. However, no such formulary or resource for non-drug treatments (interventions) currently exists in the UK.

WHAT IS HANDI?

The Handbook of Non-Drug Interventions — HANDI — project was launched by the Royal Australian College of General Practitioners (RACGP) in 2013 to promote effective non-drug treatments. HANDI is an online formulary of non-drug interventions for use in primary care that have solid evidence of their effectiveness. The aim is to make ‘prescribing’ a non-drug therapy almost as easy as writing a prescription for a drug. Box 1 lists some common GP consultations and examples of HANDI resources that might help.

Box 1. Using HANDI in the GP consultation.

Common GP consultations	Examples of HANDI resources
Skin disorders	Sunscreen for skin cancer prevention Emollient therapy for infant atopic dermatitis Moisturiser for prevention of skin tears Wet combing for head lice Probiotics in pregnancy for infant atopic eczema
Musculoskeletal problems	Stretching exercises for plantar fasciitis Mindfulness and cognitive behavioural therapy (CBT) for chronic low back pain Exercise for acute lower back pain Exercise for knee osteoarthritis Exercise for preventing recurrent ankle sprain Exercises for falls prevention Exercise for preventing bone loss and reducing fracture risk
Upper respiratory and ear, nose, and throat conditions	Honey for coughs in children with URTI Autoinflation for glue ear Mother’s kiss for nasal foreign bodies The Epley manoeuvre for vertigo
Mental health problems	Bibliotherapy for depression Brief behavioural therapy for insomnia in adults Exercise for depression Internet-based or computerised CBT for depression and anxiety Music for insomnia in adults CBT for panic disorder CBT for chronic insomnia
Neurological problems	Graded exercise therapy for chronic fatigue syndrome Physical fitness training for stroke
Chronic respiratory disease	Mandibular devices for obstructive sleep apnoea Pulmonary rehabilitation for COPD
Women’s health issues	Antenatal perineal massage Pelvic floor muscle training for pelvic organ prolapse Pelvic floor muscle training for urinary incontinence
Diabetes	Exercise for type 2 diabetes
Gastrointestinal/nutritional problems	Dilute apple juice for children rehydration Low-FODMAP diets for irritable bowel syndrome Probiotics for acute infectious diarrhoea Egg allergy prevention Peanut allergy prevention

WHO CHOOSES WHAT GOES INTO HANDI?

The HANDI team collects possible topics from a variety of sources including online evidence summaries (for example, McMaster’s ACCESSSS update service [https://www.accessss.org] and the Cochrane databases), suggestions from the committee members, and suggestions posted to the HANDI website. The HANDI committee then considers two questions for assessing inclusion in the handbook:

• Is the evidence strong enough?

• Is the intervention relevant to and practical for GPs?

For inclusion in HANDI, interventions must be supported by at least two positive, good-quality randomised controlled trials (RCTs) with patient-relevant outcomes, or one RCT with strong supportive evidence for the causal connection under investigation. Criteria for inclusion in HANDI are high. Despite looking only at treatments with promising evidence, about half of the proposed interventions based on the criteria above are rejected: of 147 topics considered since 2012, 90 had sufficient evidence to be formally reviewed, and 60 were accepted for inclusion. If the evidence is strong and the intervention is relevant to general practice, the intervention is accepted for publication.

The format is similar to that of a drug formulary. It includes indications, contraindications, precautions, adverse effects, availability, and description of intervention. It also includes consumer resources and videos to demonstrate for GPs how non-drug interventions should be used as appropriate. Web access to HANDI has steadily increased, doubling each year since the launch and now resulting in around 10 000 unique page views and 2000 downloads per month. Several GP organisations have also commenced with inclusion of HANDI entries within clinical pathways.

HANDI AND THE RCGP

In an exciting new development, the Royal College of General Practitioners (RCGP) is partnering with the RACGP to provide access to HANDI for UK GPs. This is a free resource so why not take a look?¹ In addition, the RCGP will be contributing ideas for treatments to be included, helping with the review process, and linking RCGP resources to HANDI and creating UK-focused versions of HANDI advice.

We hope that you will make good use of this resource and please feel free to contact the RCGP at cpd@rcgp.org.uk if you have any good ideas for resources not currently included that could be considered by the HANDI panel.