Select Committee on Health Minutes of Evidence


BNF and advice issued by the National Institute of Clinical Excellence

Relevant NICE adviceWhat NICE advice says Comments from BNFWhat the BNF says

Technology Appraisal Guidance
No. 3:
Guidance on the Use of Taxanes for Ovarian Cancer (May 2000)
Paclitaxel in combination with a platinum therapy (cisplatin or carboplatin) should be the standard initial therapy for patients with ovarian cancer following surgery. The Joint Formulary Committee received the following advice:

"Paclitaxel and a platinum compound are entirely appropriate for inoperable patients (it could be rgued that this group needs Taxol more as they are more likely to have resistant disease which will not respond to platinum alone. There is a trial looking at interval surgery after chemotherapy (3 or 4 cycles) hence the NICE guidance is unfortunate! Some patients become operable after this combination chemotherapy."

"Paclitaxel is certainly still regarded as the treatment of choice regardless of whether surgery can be performed"
BNF 42 section 8.1.5 (p 415) states:

NICE guidance (ovarian cancer).

The National Institute for Clinical Excellence has recommended that pacitaxel in combination with a platinum compound (cisplatin or carboplatin) should be the standard initial thereapy for ovarian cancer following surgery [but see notes above].

The "notes above" state:

There is increasing evidence that paclitaxel given with carboplatin or cisplating is the treatment of choice for ovarian cancer (see NICE guidance below); the combination is also considered appropriate for women whose ovarian cancer is initially considered inoperable.

Technology Appraisal Guidance
No 7:
Guidance on the Use of Proton Pump Inhibitors in the Treatment of Dyspepsia (July 2000)
For patients with a documented non steroidal anti-inflammatory drug (NSAID)—induced ulcer, who must unavoidably continue with NSAID therapy (eg those with severe rheumatoid arthritis), an acid suppressor, usually a proton pump inhibitor (PPI) should be prescribed. After the ulcer has healed, the patient, where possible, should be stepped down to a maintenance dose of the acid suppressor. The Joint Formulary Committee received the following advice:

"The guidance under 1.2 is wrong (and irresponsible). Whereas reflux patients know treatment is failing because they get symptoms, patients with PPIs for NSAID ulcer prophylaxis do not (because these lesions are silent). Step down will therefore take them to ineffective treatment and they won't know it until they come in with a life-threatening bleed!"

The expression "maintenance dose of the acid suppressor" is ambiguous. Is this meant to cover acid suppressors other than proton pump inhibitors?

Furthermore, produce licences of proton pump inhibitors do not mention dose reduction for continuing treatment
BNF 42 section 1.3.5 (p 42) states:

NICE advice (proton pump inhibitors)

The National Institute for Clinical Excellence has provided guidance on the use of proton pump inhibitors for the following indications:
  • Gastro-oesophageal reflux disease .  . .  (full does should be maintained);

  • NSAID—associated ulceration in patients who need to continue NSAID treatment—on healing of the ulcer a lower dose of proton pump inhibitor may be used [but see notes above].

The "notes above" state:

in patients who need to continue NSAID treatment after an ulcer has healed, the dose of proton pump inhibitor should normally not be reduced because asymptomatic ulcer deterioration may occur.

Clinical Guideline A:
prophylaxis for patients who have experienced a myocardial infarction (April 2001) [Summary Table]

Drug treatment
If not initiated in hospital, Primary Care should initiate ASAP

Statins: measure initial serum cholesterol to exclude familial lipid disorders and identify levels <4mmol/l (do not need to treat)

Beta-blockers: BNF recommends hospital supervision for initiation

Calcium channel blockers, nitrates, and potassium channel activators should only be used in patients intolerant of beta-blockers and ACE inhibitors
Drug treatment should ideally be initiated in hospital; initiation in primary care is too late. There is less likelihood of initiating drugs in primary care if they have not been initiated in hospital.

Does not specify whether this value refers to total cholesterol concentration or LDL-cholesterol concentration.

Lifestyle and dietary measures should be considered before initiating lipid-lowering therapy if total cholesterol concentration is less than 6 mmol/litre

BNF does not recommend hospital supervision; it recommends specialist supervision

Are nitrates of proven value in post-myocardial infarction management in patients without angina?
BNF advice has not been amended to fall in line with this NICE Clinical Guideline and no mention of the guideline is made in the BNF

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Prepared 8 July 2002