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

Editor – I read with great interest the regional audit on anti-TNF therapy in ankylosing spondylitis patients carried out in the Midlands (Clin Med Aug 2012 pp 324–327). We are presently undertaking a similar audit in the north-west, looking at NICE compliance with anti-TNF therapy in patients with psoriatic arthritis. My question was relating to the data on ‘reasons for switching anti-TNF agents’. As per NICE guidance, unless one applies for special funding from the PCT, one cannot switch anti-TNF therapy if the patient has shown either an inadequate initial response or a secondary loss of effect. Patients can only be switched to another agent if they develop side effects to the first anti-TNF treatment. With this in mind, were the study group able to determine whether PCT funding had been officially requested in the 15 patients who were switched to another anti-TNF agent because of inadequate or secondary loss of effect? If funding had not been applied for in these cases then the team should have highlighted this in their discussion as it would be another recommendation to make for closure of the audit loop in the future.
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.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2012 Royal College of Physicians
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2012 Royal College of Physicians
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