The Latest Guidance on Lynch Syndrome, Asthma, & COPD

Daily aspirin therapy for people with Lynch syndrome to help reduce the risk of colorectal cancer, and incentives for GPs for COPD and asthma management feature in this week's roundup of guidance from the National Institute for Health and Care Excellence (NICE).

Lynch Syndrome

Four in 5 people with inherited Lynch syndrome (LS) are estimated to have a lifetime risk of developing bowel cancer.

A previous update to guidance in 2017 recommended routine LS testing for anyone diagnosed with colorectal cancer.

Until now, the main management approach has been regular colonoscopy and polypectomy screening appointments to check for pre-cancerous cells.

Now, in a draft update to colorectal cancer guidelines issued for consultation, NICE is recommending daily aspirin taken for longer than 2 years to reduce colorectal cancer risk.

NICE wasn't able to recommend an ideal dose but said 150 mg or 300 mg is commonly used in current practice.

Asprin doesn't have marketing authorisation for bowel cancer prevention, so NICE is telling doctors to get informed patient consent for prescribing decisions, and to document the process.

The risk of side effects include internal bleeding, but NICE said the benefits for people with LS are likely to outweigh any harms.

In a statement, Dr Paul Chrisp, director of the Centre for Guidelines at NICE, said all available evidence had been reviewed before making the new recommendation: "While there are risks associated with long-term aspirin use, the committee agreed that the benefits are likely to outweigh any potential harms.

"It is important that clinicians and patients discuss the potential harms and benefits of long-term aspirin use so that an informed decision can be made."

The colorectal cancer guidance update also asks doctors to consider neoadjuvant chemotherapy for patients with the most severe form of colon cancer to help improve survival.

Asthma and COPD

Incentives for GPs feature in new indicators from NICE aimed at improving care for a range of conditions, including asthma and chronic obstructive pulmonary disease (COPD).

Quality and Outcomes Framework indicators will feature in negotiations between NHS England and the BMA over the General Medical Services contract.

Indicators include:

Asthma: An annual review to include a questionnaire on management, recording exacerbations, use of short-acting beta agonists, and a written action plan.

COPD: Objective testing to confirm COPD diagnosis, reducing misdiagnosis and overtreatment.

Heart failure: Reduced timeframe for echocardiogram or specialist assessment, ensuring correct diagnosis, timely treatment, leading to quality of life improvement and reduced premature mortality.

In a statement, Professor Gillian Leng, deputy chief executive and director of health and social care at NICE said: "There is currently no gold standard test for asthma which makes diagnosing a particularly difficult task for clinicians.

"It’s important that GPs take the appropriate steps to avoid misdiagnosing the condition, which can lead to overtreatment. These new indicators should increase the likelihood of improved outcomes and support the personalisation of care for people with asthma."

Preterm Labour and Birth

NICE also made some updates to guidance on preterm labour and birth, some following reviews of new evidence. Updates included:

A review of evidence on the effectiveness of prophylactic vaginal progesterone and prophylactic cervical cerclage for preterm labour and birth.
Updating licensing information for erythromycin and magnesium sulfate use during pregnancy.
The time period when corticosteroids are offered to women with suspected preterm labour have been updated.
For consistency, cervical length of 25 mm or less is indicative of a high-risk of preterm birth.

Unpaid Carers

There are around 6.5 million unpaid carers in the UK, with around 3 million people combining their work with caring for someone else, according to NICE.

This saves the UK's social care budgets around £132 billion a year, according to Carers UK. Most social care costs are the responsibility of local authorities in England rather than the NHS.

New draft guidance from NICE recommends measures that local authorities and social care practitioners can undertake to support carers.

First, it says unpaid carers need to be identified so they can be made aware of any financial, social, or emotional support they may be able to access.

Social care organisations should also consider appointing a 'carers' champion' to implement the NICE guidance and ensure other rights are delivered.

Replacement care should also be made available when necessary, as well as encouraging carer peer support groups.

For employers of unpaid carers, the guidance suggests offering flexible working and private spaces where phone calls about care can be taken.

Professor Leng said: "Many carers are not aware of the help available to them, therefore it’s important that health and social care practitioners are at the forefront of identifying and supporting them.

"Caring for a loved one can bring a whole host of responsibilities and worries. This guidance hopes to address those concerns and ensure that carers feel supported enough to provide the best possible care for those they look after."

Consultation on the draft guideline ends on 13th September 2019 with final guidance expected in January 2020.

Chronic Diabetic Macular Oedema

Fluocinolone acetonide intravitreal implant (Iluvien,

Alimera Sciences) is not recommended as a treatment option for chronic diabetic macular oedema in an appraisal consultation document.

NICE cited a lack of clinical evidence and uncertain cost-effectiveness estimates for its decision.

Cytomegalovirus

Letermovir (Prevymis, Merck, Sharpe & Dohme) is recommended as a treatment option for preventing cytomegalovirus (CMV) reactivation and disease after an allogeneic haematopoietic stem cell transplant in adults who are seropositive for CMV.

NICE said evidence showed letermovir is effective in reducing CMV infection and reduces the need for pre-emptive therapy.

The decision is dependent on a special commercial agreement with the manufacturer.

Major Cardiovascular Events

Rivaroxaban (Xarelto, Bayer) with aspirin is recommended as an option in some cases for prevention of atherothrombotic events in adults with coronary artery disease or symptomatic peripheral artery disease who are at high risk of ischaemic events.

NICE said there was evidence the treatment reduced the risk of ischaemic stroke, myocardial infarction, or death from cardiovascular disease. However, bleeding risk was increased.

Liothyronine for Hypothyroidism

NHS England clarified previous advice on prescribing and stopping liothyronine for hypothyroidism.

This followed reports of commissioners giving misleading advice to stop all prescriptions of the medication.

NHS England's revised guidance from the Regional Medicines Optimisation Committee issued in June states: "The prescribing of liothyronine is only supported if initiated by, or considered appropriate following a review by, an NHS consultant endocrinologist. The withdrawal or adjustment of liothyronine treatment should also only be undertaken by, or with the oversight of, an NHS consultant endocrinologist."

Saturated Fat

The Government's Scientific Advisory Committee on Nutrition (SACN) issued updated guidance recommending that a saturated fat intake should be no higher than 10% of dietary energy intake. SACN analysed evidence on the topic published since the last guidance in 1994 before making the recommendation for those aged 5 and over.

It reported "significant relationships between intake of saturated fats and cardiovascular disease (CVD) and coronary heart disease (CHD) events, but not CVD and CHD mortality." However, it noted that non-fatal CVD and CHD events still have a serious impact on a person's health and quality of life.

The report goes on to urge governments to support lowering saturated fat in people's diets.

Experts have commented on the findings via the Science Media Centre.

Prof Susan Jebb, professor of diet and population health at the University of Oxford, called the report "authoritative".

She said: "The outstanding challenge is how do we help people to make this change? And since people purchase and eat foods rather than nutrients, which foods should they eat less of?

"This is where the report is likely to be criticised because it has not considered the effects of specific types of saturated fatty acids; but this was not part of the scope of the report – which is already a huge piece of work."

She continued: "The fact is that if we are to succeed in reducing saturated fat intakes from current levels [of] around 13.5% to 10%, it is going to be extremely hard to do so without reducing saturated fat from dairy or meat."

Prof Naveed Sattar, professor of metabolic medicine at the University of Glasgow, noted that: "The saturated fat question continues to be debated and so it is nice to see an updated impartial and objective look at the best available evidence, including from randomised trials.

"That the evidence continues to suggest saturated fats increase cholesterol and the risk of heart disease remains clear, and there is no evidence for the opposite view. For this reason, their recommendation to maintain the current advice to cut saturated intake to under 10% of total energy seems entirely sensible."

He continued: "Whilst some complain that some specific types of saturated fats might not be as harmful as others, there is negligible evidence to support this point of view and such commentators should push for further trials to test their hypothesis. Without such evidence currently, the best advice to lessen health risks remains the same – cut intake of foods richer in saturated fats and replace with unsaturated foods or other healthier options."

Hair Dye Allergy test

The first hair dye allergy screening test patch has been approved for general sale after being moved from the prescription only medicine (POM) category by the Medicines and Healthcare products Regulatory Agency (MHRA).

The self-adhesive Colourstart Test kit has two patches, one with 65 micrograms of paraphenylenediamine (PPD) and a control patch. These are applied to the upper arm and indicate whether or not hair colourant should be used.

PPD is a common hair dye ingredient, and allergic reactions can result in itchy rashes, redness, and blisters, some needing emergency hospital treatment.

Jan MacDonald, MHRA group manager for access and information for medicines and standards (AIMS) in vigilance and risk management of medicines, said in a statement: "The move to make the Colourstart Test more widely accessible will make it easier for people to screen for allergy to hair colourant and to avoid suffering skin reactions if they are allergic to PPD.

"Wider availability of medicinal products and improved patient access and choice remain high on the health agenda. The MHRA is committed to improving access to medicinal products for self-care where it is safe to do so."

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