Changes

October 2024 — reviewed. A literature search was conducted in September 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Assess and make a working diagnosis of people with suspected renal or ureteric colic.
• Ensure appropriate admission or referral to secondary care.
• Provide symptomatic relief.
• Give appropriate management, information, and advice to reduce the risk of recurrence.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

Renal and ureteric stones

• Adults with suspected renal colic have low-dose non-contrast CT within 24 hours of presentation.
• Adults, children, and young people with suspected renal colic receive a nonsteroidal anti-inflammatory drug as first-line treatment.
• Adults with ureteric stones and renal colic have surgical treatment within 48 hours of diagnosis or readmission, if pain is ongoing and not tolerated, or the stone is unlikely to pass.
• Adults with renal or ureteric stones have their serum calcium measured.
• Adults, children, and young people with renal or ureteric stones are given advice on diet and fluid intake.

[NICE, 2020]

What is it?

• Urolithiasis is the formation of stones anywhere in the urinary tract.
  • Most stones originate in the kidney, but they can also present in the ureter or bladder. 
• Renal or ureteric colic generally describes an acute and severe loin pain caused when a urinary stone moves from the kidney or obstructs the flow of urine through the ureter.

[BPAC NZ, 2014; PHE, 2018; BMJ Best Practice, 2022]

What causes it?

• Renal or ureteric colic is usually caused by a urinary stone. 
  • Urinary stones are often asymptomatic but may cause pain when they move or obstruct urine flow through the ureter [PHE, 2018].
  • Obstruction of urinary flow causes an increase in tension in the urinary tract wall. The increasing pressure stimulates the synthesis and release of prostaglandins, and subsequent vasodilatation induces a diuresis, which further increases pressure within the kidney [Masarani, 2007].
  • Pain from urinary stones can also be due to smooth muscle spasm (as a result of prostaglandins acting directly on the ureter), hyperperistalsis (due to the obstruction), oedema, and mucosal irritation [Masarani, 2007; BPAC NZ, 2014; BMJ Best Practice, 2022].
  • Urinary stones usually obstruct at one of three sites: the vesico-ureteric junction, in the mid-ureter where the ureter crosses the iliac vessels, or the pelvi-ureteric junction [Stewart, 2008; Eisner, 2009; Bultitude, 2012; Patti, 2024].
• Urinary stones form when the urine becomes excessively supersaturated with a mineral, leading to crystal formation. Once crystals are formed, they either pass out with the urine or are retained in the kidney, where they can grow and form stones [Khan, 2016; BMJ Best Practice, 2022].
  • Calcium stones make up about 80% of urinary stones and may be calcium oxalate stones (80% of cases) or calcium phosphate stones (20% of cases) [Khan, 2016; BMJ Best Practice, 2022; EAU, 2024].
    • Calcium oxalate stones are associated with low urine volume, hypercalciuria, hyperuricosuria, hyperoxaluria, and hypocitraturia.
    • Calcium phosphate stones (hydroxy apatite or brushite) are associated with low urine volume, hypercalciuria, hypocitraturia, high urine pH, and conditions such as primary hyperparathyroidism and renal tubular acidosis.
  • Uric acid stones make up about 10% of urinary stones and are associated with hyperuricosuria and a low urinary pH (less than 5.5).
  • Struvite stones (also known as infection stones) make up 1–5% of urinary stones and result from bacterial infection that hydrolyzes urea to ammonium and raises urine pH (greater than 7.2) [Morgan, 2016; BMJ Best Practice, 2022]. They consist of a mixture of magnesium, ammonium, and phosphate.
  • Cystine stones make up 1% of urinary stones and result from cystinuria, a genetic disorder that causes cystine to leak through the kidneys and into the urine.
  • Medication-induced stones represent about 1% of all urinary stones [Alelign, 2019]. They are formed by crystallized compounds of a drug or due to unfavourable changes in urine composition during drug treatment [EAU, 2024].
    • Drugs that impair urine composition include acetazolamide, allopurinol, aluminium magnesium hydroxide, ascorbic acid, calcium, furosemide, laxatives, vitamin D, and topiramate.
    • Drugs that crystallize in urine include allopurinol/oxypurinol, amoxicillin/ampicillin, ceftriaxone, quinolones, ephedrine, indinavir, magnesium trisilicate, sulphonamides, triamterene, and zonisamide.

What are the risk factors for stone formation?

• Risk factors for stone formation include: 
  • Age —  the incidence of urinary stones varies by age. Stone incidence peaks between the ages of 40 and 50 years, with lower incidence in children and elderly people. 
  • Sex — the risk of stone formation is higher in men than women (2-3:1 ratio of men to women), although the difference in incidence is narrowing.
  • Ethnicity — urinary stones are most common in white people, followed by Hispanic people, black people, and people of Asian family origin.
  • Diet — excessive dietary intake of oxalate, urate, sodium, and animal protein are associated with increased stone formation.
  • Chronic dehydration —  fluid intake is inversely proportional to the risk of stone formation. A low urine output can produce a higher concentration of urinary solutes, leading to stone formation.
  • Obesity — the prevalence and incident risk of kidney stones is directly correlated with higher weight and body mass index in both sexes, although the magnitude of the association seems to be greater in women than in men. Evidence linking obesity with low urine pH and uric acid stones and an association with hypercalciuria could account for an increased risk of uric acid and/or calcium stones in people with obesity.
  • Environmental factors — high ambient temperatures increase the risk of stone formation due to the impact of temperature on fluid status and urine volume. Chronic lead and cadmium exposure are also associated with stone formation.
  • Family history — a positive family history is associated with an increased risk of forming stones. A stone-former is twice as likely as a non-stone former to have a first-degree relative with a history of stones.
  • Medical history — certain conditions increase the risk of stone formation. These include:
    • Anatomical abnormalities of the urinary tract — horseshoe kidney, ureteral stricture, ureteropelvic junction obstruction, ureterocoele, caliceal diverticulum, caliceal cyst, or tubular ectasia (medullary sponge kidney), and vesico-uretero-renal reflux.
    • Gastrointestinal conditions — jejuno-ileal bypass, intestinal resection, Crohn’s disease, malabsorptive conditions, enteric hyperoxaluria after urinary diversion, and bariatric surgery.
    • Genetic conditions — cystinuria, primary hyperoxaluria, renal tubular acidosis, and cystic fibrosis.
    • Conditions which alter urinary volume, pH, and/or concentrations of certain ions — hyperparathyroidism, nephrocalcinosis, diabetes, hypertension, polycystic kidney disease, gout, sarcoidosis, spinal cord injury, neurogenic bladder, and increased levels of vitamin D.
  • Medication exposures — drug-induced stones represent about 1% of all urinary stones. See the section on Causes for more information.
• Risk factors for recurrent stone formation include:
  • Stone type — people with calcium-containing stones, uric acid and ammonium urate stones, and infection stones (such as struvite stones) are at higher risk of recurrent stone formation. 
  • Persisting or non-modifiable risk factors, such as an underlying metabolic abnormality or family history of stone formation — people with a family history have a higher incidence of multiple stones and early recurrence.
  • Previous stone formation — the rate of recurrence of urinary stones in first time stone-formers is 50% at 5 years and 80% at 10 years. 
  • Early onset of stone formation (especially during childhood or adolescence). 

[Khan, 2016; Shang, 2017; Sorokin, 2017; Aune, 2018,; Alelign, 2019; Howles, 2020; Wagner, 2021; BMJ Best Practice, 2022; EAU, 2024; Patti, 2024]

How common is it?

• Kidney stone disease affects up to 1 in every 10 people over their lifetime.
• Acute renal or ureteric colic is common.
  • The annual incidence is 1–2 cases per 1,000 people.
  • It is estimated that 12% of men and 6% of women will have one episode of renal colic during their lifetime.

[PHE, 2018; Wagner, 2021; Patti, 2024]

What is the prognosis?

• The chances of spontaneous stone expulsion decrease with increasing stone size. 
  
  • A systematic review of the natural history of stone expulsion (n = 6642) [Yallappa, 2018] reported that:
    • Overall, 64% of people passed their stones spontaneously: about 49% of upper ureteral stones, 58% of mid-ureteral stones, and 68% of distal ureteral stones.
    • Almost 75% of stones less than 5 mm and 62% of stones 5 mm or more passed spontaneously.
    • The average time to stone expulsion was about 17 days (range 6–29 days).
    • Around 5% of participants required rehospitalization due to a deterioration of their condition.
• Recurrence rates for acute renal or ureteric colic are high.
  • The rate of recurrence of urinary stones in first time stone-formers is 50% at 5 years and 80% at 10 years. 
  • About 50% of recurrent stone-formers have just one recurrence during their lifetime; highly recurrent disease is seen in more than 10% of all stone-formers. 
  • Around 66% of men have recurrent stones.

[BPAC NZ, 2014; PHE, 2018; BMJ Best Practice, 2022; EAU, 2024; Patti, 2024]

What are the complications?

• ​​​​​​The main complications of renal and ureteric stones are obstruction of urinary flow and infection.
  • Obstruction of urinary flow can decrease the glomerular filtration rate of the affected kidney (and increase renal excretion of the unaffected kidney). Persisting obstruction (for more than 48 hours) can lead to reduced renal blood flow and irreversible kidney damage [EAU, 2024; Patti, 2024].
  • The obstructed renal unit may become infected, causing obstructive pyelonephritis or pyonephrosis (a build-up of high-pressure pus behind the obstruction). If this occurs, the person is at risk of developing life-threatening sepsis [BPAC NZ, 2014; Sewell, 2017].
• Other possible complications include:
  • Renal carcinoma — a large cohort study on diet and cancer (n = 120,852) examined the association between kidney stones and renal cell carcinoma (RCC) and upper tract urothelial carcinoma (UTUC) risk in people aged 55–69 years [van de Pol, 2019]. After 20.3 years of cancer follow-up, 4352 subcohort members, 544 RCC cases, and 140 UTUC cases were eligible for case-cohort analysis. 
    • Kidney stones were associated with a statistically significant increased RCC risk (hazard ratio [HR] 1.39, 95% CI 1.05 to 1.84) compared with no kidney stones.
    • Kidney stones were associated with a statistically significant increased risk of papillary RCC (HR 3.08, 95% CI 1.55 to 6.11) but not clear-cell RCC (HR 1.14, 95% CI 0.79 to 1.65).
    • UTUC risk was increased for participants with kidney stones (HR 1.66, 95% CI 1.03 to 2.68). No heterogeneity of associations was found for UTUC in the ureter and renal pelvis.
    • An early kidney stone diagnosis (age 40 years or younger) was associated with an increased RCC and UTUC risk compared with later diagnosis.
  • Chronic kidney disease (CKD) — a meta-analysis (n = 2,810,233) compared the rates of CKD in people with a history of kidney stones [Shang, 2017].
    • Pooled results showed that a history of kidney stones was associated with a statistically significant increased risk of CKD (risk ratio [RR] 1.47, 95% CI 1.23 to 1.76). 
    • The association was observed in most of the subgroup analyses, but it was not statistically significant among sub-analyses of studies from Asian countries, where the mean age of participants was 50 years or older or included male participants only.
  • Coronary heart disease (CHD) — a meta-analysis (n = 3,658,360) assessed the potential relationship between kidney stones and CHD or stroke [Peng, 2017].
    • A history of kidney stones was associated with a statistically significant increased risk of CHD (relative risk [RR]  1.24, 95% CI 1.14 to 1.36).
    • Similar association with myocardial infarction was observed (RR 1.24, 95%CI 1.10 to 1.40). It was also reported that a history of kidney stones may be associated with an increased risk of stroke (RR 1.21, 95% CI 1.06 to 1.38).
    • In subgroup analysis, the risk of CHD was higher in men (RR  1.23, 95% CI 1.02 to 1.49), while the risk for stroke was higher in women (RR  1.12, 95% CI 1.03 to 1.21).
  • Rupture — rarely, spontaneous rupture of a renal calyx with the development of a urinoma (due to urine extravasation) may occur in people with urinary stones [Yanaral, 2017; Kheiri, 2018].

How should I assess a person with suspected renal or ureteric colic?

• Take a history. 
  • Ask about symptoms experienced, including the duration, severity, and any exacerbating or relieving factors. 
    • Renal or ureteric colic is characterized by an abrupt onset of severe unilateral abdominal pain originating in the loin or flank and radiating to the labia in women or to the groin or testicle in men.
    • The pain typically lasts minutes to hours and occurs in spasms (with intervals of no pain or dull ache). The pain is often accompanied by nausea, vomiting, and haematuria, and is usually described as the most severe pain experienced by the person — many women describe it as being more intense than the pain of childbirth.
    • The person may complain of dysuria, urinary frequency, and straining (due to the stone irritating the detrusor muscle when it reaches the vesico-ureteric junction).
  • Review the person's medical, drug, family history, and dietary habits to identify risk factors for stone formation. The person may have a history of previous episodes.
• Examine the person.
  • Perform a full and thorough abdominal examination to help exclude differential diagnoses, such as ruptured aortic aneurysm, appendicitis, diverticulitis, and peritonitis.
    • The person may be restless and unable to lie still (which helps to differentiate renal colic from peritonitis).
  • Look for signs which may indicate a complication, such as:
    • Hesitancy of micturition or an intermittent urinary stream — suggesting urinary tract obstruction.
    • Fever and sweats — suggesting coexisting urinary tract infection.
• Consider urine dipstick testing to support the diagnosis and to exclude infection.
  • Check for haematuria — the presence of haematuria can support the diagnosis of renal or ureteric colic. However, specificity and positive predictive values are poor, and the absence of haematuria does not exclude a diagnosis but should prompt consideration for other causes of pain.
  • Check for nitrite and leucocyte esterase — the presence of nitrite (with or without leucocyte esterase) in the urine suggests a urinary tract infection. See the CKS topics on Urinary tract infection (lower) - men and Urinary tract infection (lower) - women for more information.
• Consider the need for pregnancy testing in sexually active women, to rule out ectopic pregnancy. See the CKS topic on Ectopic pregnancy for more information.
• If there is suspicion for urinary stones based on the history, physical examination, and investigations, see the section on Management for more information.

What else might it be?

• Other cause of acute abdominal pain which may present similarly to renal or ureteric colic include:
  • Renal causes, such as:
    • Pyelonephritis. See the CKS topic on Pyelonephritis - acute for more information.
    • Obstruction of the ureter due to other causes (such as a blood clot, stricture, papillary necrosis, or urothelial tumour). See the CKS topic on Urological cancers - recognition and referral for more information.
    • Acute renal infarction.
    • Renal rupture.
    • Renal abscess (very rare).
  • Gynaecological causes, such as:
    • Ectopic pregnancy. See the CKS topic on Ectopic pregnancy for more information.
    • Endometriosis. See the CKS topic on Endometriosis for more information.
    • Ovarian cyst (rupture or torsion).
    • Pelvic inflammatory disease. See the CKS topic on Pelvic inflammatory disease for more information.
    • Salpingitis. See the CKS topic on Pelvic inflammatory disease for more information.
  • Gastrointestinal causes, such as:
    • Appendicitis. See the CKS topic on Appendicitis for more information.
    • Diverticulitis. See the CKS topic on Diverticular disease for more information.
    • Biliary colic. See the CKS topic on Gallstones for more information.
    • Bowel obstruction or ischaemia.
    • Constipation. See the CKS topic on Constipation for more information.
    • Crohn's disease. See the CKS topic on Crohn's disease for more information. 
  • Cardiovascular causes, such as:
    • Ruptured aortic aneurysm (particularly in men older than 50 years of age with a first presentation of suspected renal or ureteric colic) — can mimic left-sided ureteric colic.
    • Cardiac ischaemia. See the CKS topics on Angina and CVD risk assessment and management for more information.
  • Other causes, such as:
    • Musculoskeletal pain.
    • Shingles. See the CKS topic on Shingles for more information.
    • Pneumonia or pleurisy. See the CKS topic on Chest infections - adult for more information.
    • Radiculitis.
    • Rib pain, such as from fracture.
    • Testicular torsion. See the CKS topic on Scrotal pain and swelling for more information.
    • Factitious renal colic (for example, in people with drug dependence).

Scenario: Management of acute renal or ureteric colic

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of renal or ureteric colic.

Search dates

July 2019 - October 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 1st July 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases.

S6    S1 OR S2 OR S3 OR S4 OR S5 
S5    TI flank pain or loin pain 
S4    AB ( urolithiasis or nephrolithiasis or urinary lithiasis or ureterolithiasis ) OR TI ( urolithiasis or nephrolithiasis or urinary lithiasis or ureterolithiasis ) 
S3    AB ( ((renal* or kidney* or ureter* or urethra* or urinary) N1 (colic* or stone* or calcul*)) ) OR TI ( ((renal* or kidney* or ureter* or urethra* or urinary) N1 (colic* or stone* or calcul*)) ) 
S2    (MH "Urolithiasis+") 
S1    (MH "Renal Colic") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.