Important notice:
From 15th May 2012, the team delivering the work of the NPC will form the NICE Medicines and Prescribing Centre and will sit alongside the Clinical Guidelines team within the Centre for Clinical Practice.
As part of NICE, all future Medicines and prescribing outputs will be published on the NICE website and signposted from the Medicines and prescribing home page.
No 38 May 2011
MeReC Monthlies are correct at the time of publication. Have you checked for updates?
See our MeReC Rapid reviews and e-learning materials, or search for further information on NHS Evidence.
NICE updates Anxiety Guideline
Inhaled corticosteroids as rescue therapy in children with mild asthma
Antibiotics with hormonal contraception – key changes to advice
Updated information on uptake of NICE-approved medicines
NICE updates Anxiety Guideline
NICE has published an updated clinical guideline for management of generalised anxiety disorder (GAD) and panic disorder (with or without agoraphobia) in adults (clinical guideline 113).1 The recommendations relating to GAD have been updated. Those relating to panic disorder are unchanged from the previous guideline.
ActionHealthcare professionals involved in the care and treatment of people with GAD or panic disorder should familiarise themselves with this guideline and base their management on this.
The guidelines recommend a stepwise approach to the management of GAD:
Step 1: All known and suspected presentations of GAD:
- Identification and assessment, education and active monitoring
Step 2: Diagnosed GAD that has not improved after step 1 interventions:
- Low-intensity psychological interventions
Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions:
- Offer either an individual high-intensity psychological intervention (cognitive behavioural therapy [CBT] or applied relaxation) or drug treatment.
- If drug treatment is chosen at step 3, an SSRI should be offered first. Although sertraline is not licensed for GAD, NICE advises, with some caveats, to consider using sertraline as it is the most cost-effective drug.
Step 4: Complex, treatment-refractory GAD and very marked functional impairment or high risk of self-harm:
- Specialist care
Note that:
- drug treatment is not recommended at steps 1 or 2
- benzodiazepines should not be offered for treatment of GAD in primary or secondary care except as a short-term measure during crises (and following BNF advice)
- antipsychotics should not be offered for treatment of GAD in primary care.
For more details of this guidance see MeReC Rapid Review No. 2682. More information can be found within the anxiety NPC elearning materials; there are also some useful implementation resources for this guideline on the NICE website.
Inhaled corticosteroids as rescue therapy in children with mild asthma
A randomised controlled trial suggests that an inhaled corticosteroid (ICS) plus salbutamol as reliever therapy might be an effective step-down strategy for children (>5 years of age) with well-controlled mild asthma on regular ICS.1 However, the study had a number of limitations (including being small, underpowered and a large number of children being excluded during the run-in phase) and this option is not currently recommended in the British asthma guideline.
Action
Health professionals should continue to follow the British asthma guideline to manage asthma in children. Regular ICS should be used as first-choice preventer therapy (Step 2) in children with persistent asthma, at a dose appropriate to the severity of the disease and the age of the child. The lowest possible effective maintenance ICS dose should be used to try and prevent systemic side effects.
In some children with mild persistent asthma, who remain well controlled on a low dose of ICS, the guideline allows for stepping down of the ICS dose, where appropriate, with rescue salbutamol being used alone to control symptoms (Step 1).
What did this study show?
The study did not show any significant difference in the primary outcome measure of time to first exacerbation that required oral corticosteroids. The probability of an exacerbation during the trial period was 35% (95% confidence interval [CI] 24 to 47) with as-needed beclometasone and salbutamol and 28% (95%CI 18 to 40) with regular twice daily beclometasone. However, it did find that using as-needed beclometasone and salbutamol significantly reduced treatment failure (the requirement for two courses of prednisone within six months), compared to salbutamol alone (8.5% vs. 23%, P=0.024, number needed to treat (NNT) (NNT) =7).
This study suggests an alternative means of stepping down the ICS dose, by use of as-needed ICS in addition to salbutamol for symptom relief. This might be considered as an alternative step-down option for some children with very intermittent symptoms, especially where there are problems with adherence to regular ICS dosing. However, this option is not currently recommended in the British asthma guideline, and more studies are required before this can be considered routinely.
For more information on this study and its limitations see MeReC Rapid Review No. 2664. More information on asthma can be found within the NPC respiratory elearning materials.
Antibiotics with hormonal contraception – key changes to advice
New guidance was published in January 2011 by the Faculty of Sexual & Reproductive Healthcare on drug interactions with hormonal contraception.1 A key change is that women taking combined oral contraceptives no longer require additional contraceptive precautions during or after a course of antibacterials, with the exception of rifabutin and rifampicin.
Action
Health professionals involved in prescribing or issuing combined oral contraceptives (COCs) should familiarise themselves with the full guidance .
Overall, the evidence does not generally support the possibility that non-enzyme-inducing antibacterials reduce COC efficacy. In line with WHO and US guidance, additional contraceptive precautions are now recommended only when prescribing:
- rifampicin and rifabutin (as these induce liver enzymes)
- other antibacterials if diarrhoea and vomiting occur, either as a result of the antibacterial, or the illness itself.
Patient information leaflets (and summaries of product characteristics, SPCs) may not have been updated to reflect the new guidance, so this should be explained clearly to patients when prescribing or dispensing COCs, or when prescribing an antibacterial for a patient who is using a COC.
For more information on these guidelines see MeReC Rapid Review No. 2586. More information on hormonal contraception can be found within the contraception NPC elearning materials.
Updated information on uptake of NICE-approved medicines
A report from the NHS Information Centre has assessed the variation in the use, by the NHS in England in 2009, of 18 groups of medicines considered by NICE in 29 technology appraisals.1 In the 12 groups where a comparison could be made, observed use was higher than predicted use for eight and lower for three. In one case it was lower on one set of assumptions and higher on the alternative. The report demonstrates considerable variation and, by implication, implementation of NICE guidance, across individual primary care trusts. This variation may be due to a number of factors, including natural variation within different populations, variation in presentation to the NHS by affected populations, inaccuracies in disease modelling, inaccuracies in disease coding, and estimation of drug use, as well as variation in clinical practice.
Action
Although the information in this report is ‘experimental’ in status owing to limitations in the data, medicines managers and commissioning organisations should familiarise themselves with the report. It may stimulate local debate, and highlight areas where careful examination of local usage of NICE-approved medicines and implementation of NICE guidance is appropriate. Feedback on the report is encouraged.
For a summary of the report see MeReC Rapid Review No. 2564.
The National Prescribing Centre (NPC) is responsible for helping the NHS to optimise its use of medicines. NPC is part of the National Institute for Health and Clinical Excellence (NICE), an independent organisation providing national guidance on promoting good health and preventing and treating ill health.
© National Institute for Health and Clinical Excellence, 2011. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE.
Email: copyright@npc.nhs.uk Copyright 2011
