NICE
 
The new NICE guidelines were published in June 2010. They are extensive, and cover diagnosis, smoking cessation, inhaled therapy, pulmonary rehab, exacerbations and non-invasive ventilation. In this section we will concentrate on the inhaled therapies.

At the heart of the new NICE guidelines is the focus on person-centred care. Good communication supported by evidenced based information allows people to reach informed decisions about their care.

There is still no evidence for a beneficial effect of treatment in asymptomatic individuals, with or without risk factors for airflow obstruction, to prevent future respiratory symptoms or reduce subsequent decline in lung function.

Stable COPD

In patients with mild symptoms who do not experience exacerbations the use of short acting bronchodilators is recommended. The choice is between salbutamol or ipratropium bromide. We use salbutamol first line because of its lack of anti-cholinergic side effects.

Persistent Symptoms

Always choose drugs based on the persons symptomatic response and preference, the drugs side effects and potential to reduce exacerbations.

For the first time NICE has confirmed a preference for combined inhalers (if choosing ICS & LABA) at this stage – the two currently licensed are the Symbicort Turbohaler (400/12 one puff BD) and the Seretide 500 Accuhaler (one puff BD). Fostair is currently unlicensed but has evidence of parity to the Symbicort Turbohaler in terms of bronchodilation, but it has no reliable exacerbation data.

Patients at this stage of the algorithm are divided according to FEV1 into >50% and <50% predicted. In milder patients (FEV1>50%) who experience exacerbation we recommend the use of Tiotropium or Indacaterol first line; but for patients with more severe disease who are exacerbating (FEV1<50%) we recommend using one of the ICS LABA combinations first.

If patients are still symptomatic on these therapies then the use of triple therapy (Tiotropium and the ICS/LABA combination) is recommended.

Our own interpretation of the NICE algorithm is shown below.


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