I'm sure everyone's been gripped by the NICE review and preliminary guidance on the NICE Technology Appraisal (TA 111), released yesterday. It goes on, at length, here. Reading the runes, it's likely to be refreshed from preliminary guidance into national NICE guidance in February 2011 which then has significant implications. Implementation and use of Technology Appraisals in clinical care has to be funded and can't be denied solely on cost grounds.
I'm rather relieved, therefore, that in my corner it isn't going to make a significant difference. Does the review of TA 111 matter, than? It was released in September 2007, updated in August 2009, now refreshed in October 2010 for update in February 2011. Does this document have any use or meaning? It will, helpfully, to a lot of other Trusts.
Microsoft Word tells me the preliminary guidance is 21 824 words. There's a lot of it.
I like it.
It's at variance with some folks' wishes who aren't keen on early diagnosis, since the guidance now invites treatment of mild dementia, rather than waiting 'til you're moderately demented before starting medication. This makes sense to me. The medication typically holds a person at their level of cognition for couple of years. Is is better to be held at a level where MMSE is 24/30 or where MMSE is 14/30? There're exceptions (where insight is a curse and distress blessedly diminishes as the ability to forget becomes more intense) but usually it's desirable (and desired by patients/carers) to keep someone at their best, rather than wait for a decline then keep them at that level.
This is what my colleagues and I've done for years. Our local Alzheimer's Society, PCT, Area Prescribing Committee, GPs and Trust Medicines Management Committee uncharacteristiclaly all agreed a care pwathway and funding such that folk with dementia access treatment on diagnosis, irrespective of severity/MMSE. All my patients with mild dementia have been having the drugs for years.
No changes there, then. Speaking with colleagues in other Trusts, it will open up a huge amount of work for them, with literally hundreds of people who've mild dementia who will be entitled to medication and aren't currently on it needing review and discussion and (often) medication initiated, titrated, reviewed then continued under Shared Care.
I don't prescribe a lot of memantine, using it with just a few patients, so the guidance there won't change my world. Opening up memantine so it can be used in the NHS (outside of clinical trials) isn't a change for me, since I am prescribing it already.
Over 20 000 words saying I can practice as I am.
That's the sort of guidance I can stand to receive!