Working with NICE

Implementing the NICE Guideline and Quality Standard for Spondyloarthritis

We are continuing to develop our excellent relationship with NICE as we work towards a series of regional workshops for commissioners and healthcare professionals, as part of our Every Patient Every Time campaign in 2019 and 2020. The workshops aim to cover:

• What the NICE Guideline and Quality Standard entail
• Examples of good practice in implementing
• The positive impact good implementation can have on the NHS

NICE Spondyloarthritis Guideline

The Spondyloarthritis Guideline was published in February 2017 and covers both axial SpA (AS) and peripheral spondyloarthritis.

The CEO of NASS was a member of the Guideline Development Group working with NICE for over two years, particularly giving the patients’ perspective. NASS are working hard to promote the guideline and to ensure the recommendations are taken on board.

The guideline includes recommendations on:

• Recognition and referral
• Diagnosing spondyloarthritis in specialist care
• Managing spondyloarthritis
• Information and support

You can read the guideline in full on the NICE website.

NICE Quality Standard for Spondyloarthritis

In June 2018, following on from the publication of the NICE Spondyloarthritis Guideline, NICE published a Quality Standard for Spondyloarthritis.

A Quality Standard sets out the priority areas for quality improvement in health and social care. They cover areas where there is variation in care. Each standard gives:

• A set of statements to help improve quality
• Information on how to measure progress

The NICE Quality Standard for Spondyloarthritis covers four areas

1. Adults with suspected axial or peripheral spondyloarthritis are referred to a rheumatologist.
2. Adults with suspected axial spondyloarthritis and an X-ray that does not show sacroiliitis have an MRI using an inflammatory back pain protocol.
3. Adults with axial spondyloarthritis are referred to a specialist physiotherapist for a structured exercise programme.
4. Adults with spondyloarthritis are given information about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them.

Read the full NICE Quality Standard

If the Quality Standard is implemented effectively, it could help reduce the current 8.5 year delay to diagnosis, ensure people see a physiotherapist and make sure people diagnosed with AS get the help and support they need. NASS are working on plans to ensure that these standards are implemented.

NICE anti TNF guidance for axial SpA (AS)

NASS worked with NICE on the appraisal for the anti TNF drugs back in 2008. This gave people with AS access to adalimumab (Humira) and etanercept (Enbrel). We worked with NICE again in 2011 when another anti TNF golimumab (Simponi) was approved for AS. In 2014 The Department of Health asked the National Institute for Health and Care Excellence (NICE) to produce guidance on using anti TNF therapy for AS and non radiographic axial spondyloarthritis.

Under the current NICE anti TNF guidance:

All the available anti TNF therapies are recommended as options for treating ankylosing spondylitis (AS)

This means you and your rheumatologist can choose any of the anti TNF therapies on the market, including infliximab (cheapest version). Previously infliximab was not available to people with AS on the grounds of cost.

NICE recommend the choice of treatment should be made after discussion between the rheumatologist and the patient about the advantages and disadvantages of the treatments available.

Adalimumab (Humira), certolizumab pegol (Cimzia) and etanercept (Enbrel) are recommended, as options for treating severe non-radiographic axial spondyloarthritis

This means that anti TNF therapy can now be used earlier. The previous guidance specified that people needed a diagnosis of ankylosing spondylitis (AS), where changes to the sacroilliac joints and /or the spine could be seen on x-ray. This left some people living in pain as they had all the symptoms, but did not have changes on x-ray.

Now the guidance includes people with non-radiographic axial spondyloarthritis which is where no changes are yet visible on x-ray.

Treatment with another anti TNF is recommended for people who cannot tolerate, or whose disease has not responded to, treatment with the first TNF-alpha inhibitor, or whose disease has stopped responding after an initial response

Until now, NICE guidance only allowed people to try one anti TNF, unless they had side effects in the first 12 weeks. If the first anti TNF didn’t work or if effectiveness wore off over time, NICE did not recommend trying another anti TNF.

Now your rheumatologist can think about trying you on another anti TNF if your first anti TNF didn’t work or if the effect has worn off over time.

Secukinumab (Cosentyx) recommended by NICE for ankylosing spondylitis (AS)