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“URINARY INCONTINENCE IN WOMEN 2013” NICE guidelines implementation in Primary Care

“URINARY INCONTINENCE IN WOMEN 2013” NICE guidelines implementation in Primary Care. Tony Smith Urogynaecologist St Mary’s Hospital Anson Medical Centre Manchester Manchester. Relevance of NICE to GPs. NICE provides the evidence base for Quality and Outcomes Framework (QOF).

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“URINARY INCONTINENCE IN WOMEN 2013” NICE guidelines implementation in Primary Care

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  1. “URINARY INCONTINENCE IN WOMEN 2013”NICE guidelines implementation in Primary Care Tony Smith Urogynaecologist St Mary’s Hospital Anson Medical Centre ManchesterManchester

  2. Relevance of NICE to GPs • NICE provides the evidence base for Quality and Outcomes Framework (QOF)

  3. Relevance of NICE to GPs • NICE provides the evidence base for Quality and Outcomes Framework (QOF) • NICE pathways define appropriate transfer of care from GP to specialist care

  4. Relevance of NICE to GPs • NICE provides the evidence base for Quality and Outcomes Framework (QOF) • NICE pathways define appropriate transfer of care from GP to specialist care • NICE quality standards should form the basis for assessing the quality of the new GP commissioners

  5. Key recommendations • Antimuscarinic drugs • Mirabegron

  6. NICE Key recommendations • “At the initial assessment, the woman’s UI should be categorised as stress UI, mixed UI, or urge UI / OAB. Initial treatment should be started on this basis. In mixed UI, treatment should be directed towards the predominant symptom.” • “expert opinion concludes that symptomatic categorisation of UI based on reports from the woman and history taking is sufficiently reliable to inform initial, non-invasive treatment decisions”

  7. Who takes the best history? Prim Care Sec Care Patient Q KHQ Stress only 25 15 7 2 Mixed 15 32 41 45 OAB 2 0 0 1 Not Classified 7 - - -

  8. History taking • More detailed history may be more accurate

  9. e-PAQ

  10. EPAQ • Comprehensive, validated questionnaire • Provides a database of patient details • Outcome analysis • Potential for online use • Referral from primary to secondary care • Care integration • triage

  11. NICE Key recommendations Management of OAB • Lifestyle advice / behavioural therapy • Pelvic floor physiotherapy • Drug therapies • PTNS • Botox • SNS

  12. NICE Guideline 2006 • Drug therapies 1st IR oxybutinin (if training ineffective) 2nd solifenacin, tolterodine, darifenacin etc or transdermal oxybutinin

  13. NICE Guideline 2013 Problems with the literature on anti-muscarinic drugs • Most studies compare drug to placebo

  14. NICE Guideline 2013 Problems with the literature on anti-muscarinic drugs • Most studies compare drug to placebo • Outcome measures vary with different trials

  15. NICE Guideline 2013 Problems with the literature on anti-muscarinic drugs • Most studies compare drug to placebo • Outcome measures vary with different trials • Head to head comparison difficult

  16. NICE Guideline 2013 Problems with the literature on anti-muscarinic drugs • Most studies compare drug to placebo • Outcome measures vary with different trials • Head to head comparison difficult • Compliance in trials vs real life

  17. NICE Guideline 2013 Network Metanalysis of drugs Drug B vs placebo Drug A vs placebo Drug C vs placebo

  18. NICE Guideline 2013 Network Metanalysis of drugs Robust outcome measures Similar regimes Adverse event / compliance Incontinence Higher dose 12 weeks

  19. NICE Guideline 2013 Anti-muscarinic drugs Conclusions Incontinent /dry only robust outcome All drugs are of similar efficacy Compliance varies from 20% to 35% at 12 months Cost

  20. Anti-muscarinic drugs • Is the additional cost of the better tolerated drugs worth paying for?

  21. MirabegronBetmiga • B adrenergic agonist • First in class • Similar efficacy to tolterodine • Adverse events

  22. MirabegronBetmiga • B adrenergic agonist • First in class • Similar efficacy to tolterodine • Adverse events “treatment-emergent adverse events (TEAEs) were similar between the mirabegron 50 mg (26.2%) and tolterodine groups (27.6%), the incidence of treatment related serious adverse events (SAEs) was 1.2% in the mirabegron 50 mg group and 0.6% in the tolterodine group and the incidence of treatment-related TEAEs leading to study drug discontinuation was 4.3% in the mirabegron 50 mg group and 3.8% in the tolterodine group.”

  23. NICE guidelines for urinary incontinence in primary care Conclusions • Pathways and standards are important • Commissioning • Treatment choices are difficult • GP input to NICE GDG

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