They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see:

Transcription

1 bring together everything NICE says on a topic in an interactive flowchart. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see: NICE Pathway last updated: 12 July 2018 This document contains a single flowchart and uses numbering to link the boxes to the associated recommendations. Page 1 of 10

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3 1 Person over 16 with stable COPD No additional information 2 Corticosteroids Maintenance use of oral corticosteroid therapy in COPD is not normally recommended. Some patients with advanced COPD may require maintenance oral corticosteroids when these cannot be withdrawn following an exacerbation. In these cases, the dose of oral corticosteroids should be kept as low as possible. Patients treated with long-term oral corticosteroid therapy should be monitored for the development of osteoporosis and given appropriate prophylaxis. Patients over the age of 65 should be started on prophylactic treatment, without monitoring. For further information, see NICE's recommendations on osteoporosis. 3 Mucolytics Mucolytic drug therapy should be considered in patients with a chronic cough productive of sputum. Mucolytic therapy should be continued if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production). Do not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD. 4 Roflumilast The following recommendations are from NICE technology appraisal guidance on roflumilast for the management of severe chronic obstructive pulmonary disease. Roflumilast, as an add-on to bronchodilator therapy, is recommended as an option for treating severe chronic obstructive pulmonary disease in adults with chronic bronchitis, only if: the disease is severe, defined as a forced expiratory volume in 1 second (FEV 1 ) after a bronchodilator of less than 50% of predicted normal, and Page 3 of 10

4 the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid. Treatment with roflumilast should be started by a specialist in respiratory medicine. These recommendations are not intended to affect treatment with roflumilast that was started in the NHS before this guidance was published. People having treatment outside these recommendations may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop. NICE has written information for the public on roflumilast. 5 Theophylline Theophylline should only be used after a trial of short-acting bronchodilators and long-acting bronchodilators, or in patients who are unable to use inhaled therapy, as there is a need to monitor plasma levels and interactions. Particular caution needs to be taken with the use of theophylline in older people because of differences in pharmacokinetics, the increased likelihood of comorbidities and the use of other medications. The effectiveness of the treatment with theophylline should be assessed by improvements in symptoms, activities of daily living, exercise capacity and lung function. The dose of theophylline prescribed should be reduced at the time of an exacerbation if macrolide or fluroquinolone antibiotics (or other drugs known to interact) are prescribed. 6 Drugs not recommended Antibiotics There is insufficient evidence to recommend prophylactic antibiotic therapy in the management of stable COPD. Page 4 of 10

5 Antioxidants Treatment with alpha-tocopherol and beta-carotene supplements, alone or in combination, is not recommended. Antitussives Antitussive therapy should not be used in the management of stable COPD. 7 Back to managing stable COPD See / Managing stable COPD Page 5 of 10

6 ASA American Society of Anesthesiologists ATS American Thoracic Society BODE body mass index, airflow obstruction, dyspnoea and exercise capacity BTS British Thoracic Society CEN Comité Européen de Normalisation (European Committee for Standardisation) COPD chronic obstructive pulmonary disease cor pulmonale in the context of this guidance, the term 'cor pulmonale' has been adopted to define a clinical condition that is identified and managed on the basis of clinical features; this clinical syndrome of cor pulmonale includes patients who have right heart failure secondary to lung disease and those in whom the primary pathology is retention of salt and water, leading to the development of peripheral oedema ECG electrocardiogram ERS European Respiratory Society Page 6 of 10

7 FEV1 forced expiratory volume in 1 second FVC forced vital capacity GOLD global initiative for chronic obstructive lung disease ICS inhaled corticosteroid LABA long-acting beta 2 agonist LAMA long-acting muscarinic antagonist LTOT long-term oxygen therapy MRC Medical Research Council NIV non-invasive ventilation PaO2 partial pressure of oxygen in arterial blood Page 7 of 10

8 PaCO2 partial pressure of carbon dioxide in arterial blood PEF peak expiratory flow SABA short-acting beta 2 agonist SAMA short-acting muscarinic antagonist SaO2 oxygen saturation of arterial blood TLCO carbon monoxide lung transfer factor Sources in over 16s: diagnosis and management (2010) NICE guideline CG101 Roflumilast for treating chronic obstructive pulmonary disease (2017) NICE technology appraisal guidance 461 Page 8 of 10

9 Your responsibility Guidelines The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Technology appraisals The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to Page 9 of 10

10 have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Medical technologies guidance, diagnostics guidance and interventional procedures guidance The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Page 10 of 10