8 September 2010
NICE has updated its clinical guidelines for chronic heart failure and chronic obstructive pulmonary disease (COPD). It has also issued technology appraisals on the use of various biologics (including tociluzimab▼) in rheumatoid arthritis (RA) after failure of a TNF inhibitor; and on dronedarone▼ for treating atrial fibrillation.
Chronic heart failure
This guidance (CG108) was published in August 2010. There are significant changes from the previous 2003 guidance in relation to:
- Diagnosis, including referral for transthoracic Doppler echocardiography in people with suspected heart failure and previous myocardial infarction (MI), and measurement of serum natriuretic peptides in people without previous MI
- Pharmacological management of heart failure (see below)
The guidance recommends that ACE inhibitors and beta-blockers licensed for heart failure should be considered as first-line treatments in patients with heart failure due to left ventricular systolic dysfunction, using clinical judgement to decide which drug to start first. The guidance also advises switching stable patients who are already taking a beta-blocker for a co-morbidity to one which is licensed in heart failure. There are also changes to the guidance on second line drug therapy, which should be started only after specialist advice. For an overview of the recommendations see the quick reference guide, and for more detailed information see the guideline. More information on heart failure can also be found on the heart failure floor of NPC, which will be updated to reflect the changes outlined in the new NICE guidance in early 2011.
Management of COPD
Updated NICE guidance was published in June 2010 (CG 101). There are significant changes from the previous 2004 guidance on:
- Diagnosis, with the introduction of post-bronchodilator spirometry
- Assessment of severity: NICE classification now follows the GOLD classification, and the guidance now includes the use of the BODE index
- Inhaled therapy (see below)
There are also additions and modifications to the guidance on oral therapy and pulmonary rehabilitation. The guidance on inhaled therapy is substantially different from the previous guidance: see the quick reference guide. For more detail of the recommendations, see the guideline. We are currently in the process of reviewing our materials on COPD on the NPC website, which will be updated in early 2011.
Biologics for RA after failure of a TNF inhibitor
NICE has reviewed its guidance on management of patients with RA who have had an inadequate response to, or have not tolerated, other DMARDs, including at least one TNF inhibitor. Previously, only rituximab (with methotrexate) was recommended in this situation, although other TNF inhibitors recommended by NICE (adalimumab▼, etanercept▼ and infliximab) could be used if the first TNF inhibitor used was not tolerated (TA130).
NICE continues to recommend rituximab plus methotrexate as first choice in such people. However, in patients with severe active RA, if rituximab is contraindicated or not tolerated, adalimumab, etanercept, infliximab, or abatacept, each in combination with methotrexate, are now recommended as treatment options. In addition, if rituximab therapy cannot be given because methotrexate is contraindicated or not tolerated, adalimumab or etanercept monotherapy is now recommended as an option (see TA195). In patients with moderate to severe active RA, tocilizumab▼ in combination with methotrexate is also a treatment option if rituximab is contraindicated, not tolerated or has not produced an adequate response (see TA198).
Dronedarone▼ for the treatment of non-permanent atrial fibrillation
Dronedarone is recommended as an option for the treatment of non-permanent atrial fibrillation(AF) for new patients only in people who meet all of the following criteria:
- Their AF is not controlled by first-line therapy (usually including beta-blockers)
- They do not have unstable NYHA class III or IV heart failure
- They have at least one of the following cardiovascular risk factors:
- Hypertension being treated with at least two different classes of drugs
- Diabetes mellitus
- Previous transient ischaemic attack, stroke or systemic embolism
- Left atrial diameter of 50 mm or greater
- Left ventricular ejection fraction (LVEF) less than 40%
- Age 70 years or older
Note that the SmPC does not recommend dronedarone for stable patients with recent (1 to 3 months) NYHA class III heart failure or LVEF less than 35% because of limited experience of using it in this group. Further information and guidance on the use of dronerdarone for non-permanent AF is available from NICE TA 197. More information on AF can also be found on the atrial fibrillation atrial fibrillationfloor of NPC.
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