The Latest Guidance and Quality Standards From NICE

Peter Russell

August 09, 2018

Announcements from the National Institute for Health and Care Excellence (NICE) this week (ending 9th August 2018) included quality standards for endometriosis and intermediate care, and treatment guidance for lung cancer and leukaemia in England and Wales.

Managing Endometriosis

A quality standard described improvements in care for diagnosing and managing endometriosis, including in those women aged 17 and younger.

It recommended that:

  • Women with suspected endometriosis should have an abdominal and, if appropriate, a pelvic examination. A physical examination of the abdomen, and the pelvis if appropriate, could identify signs of endometriosis such as abdominal or pelvic masses, reduced organ mobility or organ enlargement, points of tenderness, or visible vaginal endometriotic lesions.

  • Women should be referred to a gynaecology service if initial hormonal treatment for endometriosis is not effective, not tolerated, or contraindicated. Referral would allow further investigation and treatment options to be explored and would reduce the possibility of women experiencing significant, prolonged ill health and distress, and improve their quality of life.

  • Women with suspected or confirmed deep endometriosis involving the bowel, bladder or ureter should be referred to a specialist endometriosis service. Referral would help ensure that patients with deep endometriosis receive the appropriate treatment, including surgery carried out by a specialist if needed.

Treatment of Thyroid Cancer

Lenvatinib (Lenvima, Eisai) and sorafenib (Nexavar, Bayer) were recommended as options for treating progressive, locally advanced or metastatic differentiated thyroid cancer in adults whose disease does not respond to radioactive iodine.

Final guidance said that both medications were only recommended for patients who had not had a tyrosine kinase inhibitor before or had stopped taking a tyrosine kinase inhibitor within 3 months of starting it because of toxicity.

Both lenvatinib and sorafenib were recognised by NICE as the only available treatment options for delaying disease progression but because of their high price could only be recommended if the manufacturers provided them at a discount.

Psoriatic Arthritis

An appraisal recommended ixekizumab (Taltz, Eli Lilly) either alone, or with methotrexate, as an option for treating active psoriatic arthritis in adults. Treatment should be dependent on certain conditions:

  • It was used as described in NICE's technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis, or

  • The patient had a tumour necrosis factor (TNF)-alpha inhibitor but their disease has not responded within the first 12 weeks or has stopped responding after the first 12 weeks, or

  • TNF-alpha inhibitors were contraindicated but would otherwise be considered (as described in NICE's technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis)

The final guidance pointed to clinical evidence to show that ixekizumab was more effective than placebo at treating joint and skin symptoms.

It said ixekizumab was only recommended for NHS use if the manufacturer provided it at a discounted price.

Non-Small-Cell Lung Cancer

NICE recommended alectinib (Alecensa, Roche) as an option for untreated anaplastic lymphoma kinase (ALK)-positive advanced non-small-cell lung cancer (NSCLC) in adults.

The appraisal committee said that patients with the condition were usually offered crizotinib (Xalkori, Pfizer) but that evidence from an ongoing clinical trial suggested that alectinib was more effective in delaying disease progression.

The final draft appraisal recommendation depended on the manufacturer supplying the medication at a discounted price, NICE said.

Intermediate Care

A new quality standard covered referral and assessment for intermediate care, and how to deliver those services, aimed at helping patients regain independence. It recommended that:

  • Healthcare professionals in hospitals or the community who were assessing people for intermediate care should have a discussion, provide information and ensure that the person – and their carer or family – understood the nature of intermediate care and what it could and could not achieve. This would ensure that people were involved in making decisions about their care.

  • Adults accepted for bed-based intermediate care should start the service within 2 days of referral to reduce the risk of further deterioration and the likelihood of hospital admission or residential care.

  • Adults who start intermediate care should discuss and agree personal goals to encourage them to be engaged in their care and to promote independence. The goals should be reviewed regularly.

  • Adults who use intermediate care services should agree a transition plan for when their support ends.

Lymphoblastic Leukaemia

Inotuzumab ozogamicin (Besponsa, Pfizer) was recommended as an option for treating relapsed or refractory CD22-positive B-cell precursor acute lymphoblastic leukaemia in adults.

Approximately 114 of the 650 people diagnosed each year in the UK would be eligible for treatment, NICE said.

In final draft guidance, the appraisal committee said it had reversed an earlier decision not to recommend the medication for NHS use after the manufacturer provided more evidence and agreed a discounted price.

Adult patients with Philadelphia-chromosome-positive acute lymphoblastic leukaemia must have failed treatment with a tyrosine kinase inhibitor before they could be offered the new treatment, NICE said.

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