Feature / NICE update

Clinical guidelines

CG125 Peritoneal dialysis. This guideline is estimated to save up to £36.8m if all suitable patients were offered the choice of peritoneal dialysis. This is comprised of 9,700 patients at an average lower cost for peritoneal dialysis compared with haemodialysis of £3,800 per patient per year. However, it is recognised that this could require service reorganisation and training to achieve. Even modelling a modest increase from 15% to 20% of dialysis patients receiving peritoneal dialysis indicates a saving of £7.7m.

CG126 Organ donation Publication of this guidance has been delayed – it will be included in next month’s NICE update.

CG127 Hypertension (update) The main change from previous guidance is recommending ambulatory blood pressure monitoring to confirm diagnosis. This is considered to cost £5.1m to implement, but avoiding people incorrectly diagnosed could save £15.6m, so the net impact is a saving of £10.5m.

Technology appraisals

TA 228 Multiple myeloma (first line) - bortezomib and thalidomide. These drugs are recommended when intensive treatment with stem cell transplantation is not considered appropriate. Clinical opinion indicated guidance would result in a small increase in bortezomib prescribing at a cost of £2m. However, this is inconsistent with the recommendation that patients should initially receive thalidomide and only be considered for bortezomib where thalidomide is contra-indicated or intolerated.

TA229 Macular oedema (retinal vein occlusion) – dexamethasone. An estimated 15,900 patients per year may be eligible for dexamethasone at an additional cost of £32.2m. The benefit of this treatment is that it not only reduces the incidence of vision loss but has been shown to improve vision in affected patients; it was not possible to quantify this benefit, but blindness in the elderly is a leading cause of requiring residential care.                     

TA230 Myocardial infarction (persistent ST-segment elevation) – bivalirudin. This drug is anticipated to be suitable for up to 12,600 patients and could save £2.4m because it is a lower cost than the current standard treatment.            

TA231 Depression - agomelatine (terminated appraisal). No cost impact anticipated as NICE is unable to recommend due to no evidence submitted by the manufacturer

TA232 Epilepsy (partial) - retigabine (adjuvant). There are around 50,000 people who are using adjunctive or combination therapy for epilepsy refractory to treatment. We do not anticipate that the use of retigabine as an option for the adjunctive treatment will result in a significant impact on NHS resources. Retigabine represents a further adjunctive treatment option that is similarly priced to comparator anti epileptic drugs. Annual cost of existing drugs ranges from £1,236 to £2,591, compared with an annual cost for retigabine of £1,570.

TA233 Ankylosing spondylitis – golimumab This drug is recommended as an option for the same population and at a similar cost of other biologic drugs for ankylosing spondylitis. Therefore, no additional cost impact is anticipated. The commissioning and benchmarking tool can be used to review costs for all biologic drugs.

TA234 Rheumatoid arthritis – abatacept (2nd line) Abatacept has not been recommended for this indication, so no cost impact has been anticipated.

Medical technology

MTG5 MIST therapy system for the promotion of wound healing in chronic and acute wounds. Although there is some evidence that the MIST therapy system promotes wound healing, at the moment the quality of that evidence isn’t quite good enough to recommend its routine use in the NHS. NICE has recommended more research comparing the healing of wounds treated with the MIST therapy system and those treated with standard care. If the claimed patient benefits are substantiated by quality evidence in the future then significant cost savings may be possible.                  

MTG6 Ambulight photodynamic therapy for the treatment of non-melanoma skin cancer. Healthcare teams may want to use Ambulight PDT because it can be used to give photodynamic therapy in places other than hospitals, such as patients’ homes. It may also cause less pain than normal photodynamic therapy.  However, the evidence does not show that Ambulight PDT would make services more efficient, and there is not much evidence about how well it works. NHS organisations should take this into account, along with other features of Ambulight PDT, when deciding whether to use it.

NICE update was prepared by Jennifer Field, associate director (costing and commissioning) at NICE