• 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
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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
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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
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