Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

NICE Guidance - June 2014 [updated]

The National Institute of Health and Care Excellence (NICE) has published new guidance for the month of June 2014. This month there is one clinical guideline and one technology appraisal that impacts upon primary care.

The Atrial fibrillation clinical guideline is an updated to guidance issued in June 2006 and it offers evidence-based advice on the care and treatment of people with atrial fibrillation. New recommendations have been added for a personalised package of care and information, referral for specialised management, stroke prevention, rate and rhythm control and the management of acute atrial fibrillation.

Additionally, this guideline recommends using CHA2DS2-VASc score to assess stroke risk and the HAS-BLED score to assess bleeding risk. Stroke prevention therapy is not recommended at low levels of stroke risk (CHA2DS2-VASc 0 for men and 1 for women).

Anticoagulation should be considered in men with a CHA2DS2-VASc risk score of 1 and offered to everyone with a risk score of 2 and above. Anticoagulation may be with apixaban, dabigatran and rivaroxaban or a vitamin K antagonist. Recommendations for the newer agents are adopted from existing technology appraisals. If a vitamin K antagonist is used, time in therapeutic range (TTR) should be calculated regularly and used with INR results to assess anticoagulation control. If control is poor and remains poor despite addressing factors that may contribute to poor control (cognitive function, adherence, illness, drug interactions, lifestyle) the risks and benefits of alternative stroke prevention strategies should be evaluated and discussed with the patient.

The Type 2 diabetes - Canagliflozin technology appraisal recommends this treatment as an option in dual therapy with metformin in patients who cannot take a sulphonylurea or is at risk of hypoglycaemia. It can also be used in triple therapy with metformin with a sulphonylurea or a glitazone. Finally, it can be used in combination with insulin, with or without antidiabetic drugs.

Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.

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