HHE Respiratory 2019 | Page 19

• A&E attendance • quality of life • change in breathlessness • exercise capacity • inappropriate non-invasive ventilation. Guideline implications The new guideline encourages holistic treatment and will impact current practice; an increase in numbers of counselling/consultation episodes (including time taken) may result. Professionals are expected to be qualified to provide high- quality spirometry and interpretation for appropriate diagnosis and earlier management. Prescribing will change, replacing single long- acting inhaled agents with dual (increasing LABA/ LAMA prescribing) and reducing inappropriate ambulatory and short-burst oxygen prescribing. Smoking cessation intervention should increase. Close communication will be required across sectors to ensure continued prescribing, monitoring and review of medications, especially for macrolides and oxygen. There is an expected increase in referrals for LVR interventions. Increased monitoring and pharmacovigilance will be necessary to minimise and manage medication adverse effects. Greater patient empowerment and increased self-management plans are expected (tailoring therapy for maximal benefit and reducing hospitalisation). For patients exhibiting asthmatic features, dual therapy should be initiated with ICS/LABA rather than LABA/ LAMA Conclusions The NICE guideline has been long overdue; it conflicts with the most recent 2019 GOLD COPD guidance on prevention, diagnosis and management, which might cause clinicians some confusion as to which guideline to use. GOLD provides pragmatic guidance such as acknowledging the potential role of eosinophils to inform ICS prescribing and is used globally; hence all suggestions might not be applicable/ available to UK patients. NICE has a robust development process, leading to evidence-based recommendations for the most cost-effective interventions to provide maximal societal value benefit. It reiterates the importance of non-pharmacological measures to References 1 Department of Health. COPD commissioning toolkit, a resource for commissioners. Department of Health, England, August 2012. www.gov.uk/ government/uploads/system/ uploads/attachment_data/ file/212876/chronic-obstructive- pulmonary-disease-COPD- commissioning-toolkit.pdf (accessed May 2019). 2 National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guideline [NG115] Published date: December 2018. www.nice.org. uk/guidance/ng115 (accessed May 2019). 3 Global Strategy for Prevention, Diagnosis and Management of COPD. 2019 report – Global initiative for chronic obstructive lung disease. https:// goldcopd.org/wp-content/ uploads/2018/11/GOLD-2019- v1.7-FINAL-14Nov2018-WMS.pdf (accessed May 2019). 4 Chen WC et al. Long-acting beta2-agonists versus long-acting muscarinic antagonists in patients with stable COPD: A systematic review and meta-analysis of randomized controlled trials. Respirology 2017;22:1313–19. 5 Vogelmeier C et al; POET-COPD Investigators. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med 2011;364:1093–103. 6 National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2019 update). In development [GID-NG10128]. www.nice.org.uk/guidance/ gid-ng10128/documents/draft- guideline (accessed May 2019). 7 National Institute for Health and Care Excellence. Depression in adults: recognition and management Clinical guideline [CG90] Published date: October 2009. Last updated: April 2018. www.nice.org.uk/guidance/cg90 (accessed May 2019). 8 National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. Clinical guideline [CG91] Published date: October 2009. www.nice.org. uk/guidance/cg91 (accessed May 2019). 9 Luckett T et al. Contributions of a hand-held fan to self-management of chronic breathlessness. Eur Resp J 2017;50:1700262; DOI: 10.1183/13993003.00262-2017 10 National Institute for Health and Care Excellence. Stop smoking interventions and services NICE guideline [NG92] Published date: March 2018. www.nice.org.uk/guidance/ng92 (accessed May 2019). 11 Bauld L et al. The effectiveness of NHS smoking cessation services: a systematic review. J Publ Health 2009:1–12. 12 Hoogendoorn M et al. Long-term effectiveness and cost effectiveness of smoking cessation interventions in patients with COPD. Thorax 2010;65:711–18. 13 Public Health England. Immunisation against infectious disease — ‘The Green Book’. 14 British National Formulary. 19 HHE 2019 | hospitalhealthcare.com underpin the overall holistic treatment approach before escalating therapy. It acknowledges the need for appropriately skilled healthcare professionals to be able to diagnose, monitor and review patients with COPD throughout their disease trajectory. This should empower multidisciplinary staff (such as physiotherapists and pharmacists) to expand current roles, enabling patients’ greater access for review, support and consistent messages of disease management. The new guidance takes a more considered approach to ICS use. Fixed dose triple inhalers are now available and the role of inhaled triple therapy is becoming clearer; further guidance on this is due in Summer 2019. The guidelines encourage more cost effective, responsible prescribing overall including improving medication adherence and a reduction in waste, which can be the basis for further quality improvement work. The effect of long-term macrolide antibiotic use is unknown, both in terms of safety and clinical effect, there are no studies beyond one year to inform this. There is also concern of increased antimicrobial resistance as a result. It is expected that this intervention will have little cost implication but may reduce exacerbations and associated costs of health resource utilisation. Patients will need to be monitored closely with increased counselling, pharmacovigilance and ‘yellow card’ reporting to the Medicines Health Regulatory Authority (https://yellowcard.mhra. gov.uk/). The guidance addresses many current clinically relevant issues in the diagnosis and management of patients with COPD but acknowledges that evidence is still lacking or unclear in some areas, leading to recommendations for research. COPD has no cure but if guidance is applied, in conjunction with the quality standards, premature mortality can be prevented. Patients can have better healthcare experiences, co-create their care decisions for an improved quality of life and palliation. See the full guideline for detailed guidance and recommendations on the above. Number 76. September 2018 – March 2019. British Medical Journal Group and Royal Pharmaceutical Society (Great Britain). 15 Barnes H et al. Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Systematic Review - Intervention Version published: 31 March 2016. www.cochranelibrary.com/ cdsr/doi/10.1002/14651858. CD011008.pub2/full#CD011008- abs-0002 (accessed May 2019). 16 National Institute for Health and Care Excellence. Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence Clinical guideline [CG76] Published date: January 2009. www.nice.org.uk/ Guidance/CG76 (accessed May 2019). 17 National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes NICE guideline [NG5] Published date: March 2015. www.nice.org.uk/guidance/ng5 (accessed May 2019). 18 National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management NICE guideline [NG56] Published date: September 2016. www. nice.org.uk/guidance/ng56 (accessed May 2019). 19 National Institute for Health and Care Excellence. End of life care for adults. Quality standard [QS13]. Published date: November 2011. Last updated: March 2017. www.nice.org.uk/ guidance/qs13/chapter/List-of- statements (accessed May 2019). 20 National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in adults. Quality standard [QS10]. Published date: July 2011. Last updated: February 2016. www.nice.org.uk/ guidance/qs10 (accessed May 2019).