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GPs advised to ignore ‘illogical’ NICE guidelines on TIAs

GPs have been advised that patients should be given the antiplatelet treatment clopidogrel after a transient ischaemic attack, even though it is not licensed for this indication and not recommended in NICE guidelines.

The advice comes in new guidance from the Royal College of Physicians that recommends the management of patients after stroke and a TIA should be the same.

They advised that GPs to ignore ‘illogical’ NICE guidelines from 2008 that recommends dipyridamole plus aspirin for people who have had a TIA, and clopidogrel after a stroke.

The RCP guidelines – published last month – said a ‘unified approach’ was needed in the treatment of TIA and stroke.

The RCP guide states: ‘Clinicians have tended to treat TIA and ischaemic stroke as different manifestations of the same disease and therefore it is illogical to have different treatment strategies for the two presentations.

‘Whilst clopidogrel does not have a license for use after TIA , as the more cost effective and better tolerated option, it was felt that the benefits of recommending this drug as a first-line outweigh any disadvantages.’

Professor Tony Rudd, professor of stroke medicine at Kings College London and co-author of the RCP guideline, said ‘The reason why we have deviated from NICE is because we consider stroke and TIA to be the same condition - just differing in severity - and therefore it is illogical to treat them differently.

‘The combination of aspirin and dipyridamole is certainly no better than clopidogrel alone and is often not well tolerated. It also has to be given twice a day rather than once a day.’

 ‘NICE are bound by their rules which say that they cannot recommend an unlicensed drug for a condition where there is a drug that has received a license.

‘The committee recognised that this might cause some difficulty with GPs but think that we are behaving rationally - compared to NICE.’

Dr Kathryn Griffith, a GPSI in cardiology in York, said she was thrilled with the RCP’s guidance.

She said: ‘Where a patient is discharged from hospital after a TIA we prescribe clopidogrel – its cheaper and its better tolerated , and it’s a once-a-day dose so you get better compliance.’

She added: ‘I am so happy that the RCP recommended clopidogrel rather than some expensive drug.’

A NICE spokesperson responded: ‘Unless the Department of Health specifically indicates otherwise, NICE will not publish guidance on the use of a technology for indications for which regulatory approval has not been granted in the UK (that is, off-licence use).

‘Because clopidogrel is not licensed for the treatment of transient ischaemic attack, no recommendations could be made in the 2010 NICE technology appraisal.’

What do the guidelines say?

For patients with ischaemic stroke or TIA in sinus rhythm, clopidogrel should be the standard antithrombotic treatment.

For patients unable to tolderate clopidogrel, offer aspirin 75mg daily in combination with modified release dipyridamole 200mg daily

Source: RCP guidelines, online Sept 2012