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GPs buried under trusts' workload dump

NICE rethinks pregabalin over cost

NICE has set a remarkable precedent by announcing it will review its recommendations on first-line drugs for neuropathic pain just eighteen months after they were published, over concerns about ‘the costs to the NHS'.

A consultation launched last week will look at changing NICE's recommendation, published in March 2010, that GPs should prescribe either pregabalin or amitriptyline as a first line treatment.

NICE said it was reviewing its economic modelling on pregabalin after it was made aware of ‘concerns about the associated costs that pregabalin may bring to the NHS'.

GPs issued 1.7 million prescriptions for pregabalin in 2010, at a net ingredient cost of just under £124 million. By contrast, even though 8.7 million prescriptions were issued in 2010 for amitriptyline, the net ingredient cost was just under £18 million.

A new draft guideline containing amended recommendations has been published, recommending that GPs use oral amitriptyline or gabapentin as a first-line treatment, although NICE stressed the current clinical guideline should be used ‘until any further announcement is made'.

A spokesperson said: ‘NICE's independent guideline development group originally recommended pregabalin as a first line treatment option for non-specialist settings because according to the draft economic modelling, it was more cost effective than other options.

‘NICE is proposing to make changes partly because of feedback, mainly from individual healthcare professionals, received after the guideline was published. As well as this, the economic modelling undertaken by Brunel University was peer-reviewed which resulted in some alterations to the model and the results.

Dr Mark Ritchie, a GP in Swansea and a member of the Primary Care Neurology Society steering committee, said the evidence for the two drugs from trial data was very similar. ‘NICE should always be open to review but for clinical excellence, not for a way to save money only. We all should be striving for best patient care.

‘From a primary care perspective it is easier to use pregabalin which requires fewer appointments to achieve a suitable dose. However primary care is not paid per appointment so these costs are not considered.

‘Amitriptyline and similar drugs are dirt cheap but they also cause dizziness, ataxia and very dry mouth and potentially in an elderly patient this could make them vulnerable. If pregabalin was the same price or lower this review would not be occurring.'

Dr Rubin Minhas, a GP and director on the BMJ clinical evidence centre, said the review could set a precedent for NICE to review more of its recommendations on cost grounds.

‘With changing evidence and costs it would be remiss of NICE not to reassess the basis for its decisions.'

New draft neuropathic pain recommendations

  • oral amitriptyline or gabapentin should be offered as first-line treatment, except for those with painful diabetic neuropathy who should be offered duloxetine.
  • GPs should consider imipramine or nortriptyline as alternatives if amitriptyline is effective but not tolerated
  • only consider pregabalin if gabapentin is effective but the patient has difficulty adhering to the dosage schedule or cannot tolerate the adverse effects.

Neuropathic pain - pharmacological management: guideline consultation, 12 Sep 2011

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