Compliance with NICE guidance on the use of anti-TNF agents in ankylosing spondylitis

Thank you for your interest in our article. The 2008 NICE Technology Appraisal 143 states that prescription of an alternative TNF a inhibitor is not recommended in patients who have either not achieved an adequate initial response to treatment with adalimumab or etanercept, or who experience loss of the initially adequate response to treatment. However, as these are guidelines (rather than strict protocols), PCTs interpret the NICE guidance with varying degrees of rigidity with some strictly allocating funding according to the guidance and others being more liberal in their interpretation.

Of the 15 patients in the Midlands audit who switched due to an inadequate response: one received anti-TNF under the care of the dermatologists for psoriasis before treatment was started for their ankylosing spondylitis; one received their first treatment as part of a clinical trial; three were switched from infliximab (started prior to the 2008 guideline publication) and one received a different anti-TNF after a prolonged period off any biologic treatment. Each of these cases can be seen to require a degree of interpretation when applying the guidelines. Unfortunately, because a question regarding PCT funding was not included in the audit proforma, no further information was available on the remaining nine patients.

We can only speculate, but these remaining patients may have switched prior to publication of the NICE guidance, or the Trusts involved may have interpreted the guidance on an individual basis which may or may not have involved applying for external funding.

We agree that including a question exploring PCT funding streams for patients switching anti-TNF therapy in any future re-audit would provide useful additional information.

• © 2012 Royal College of Physicians