Nice.org.uk

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL
EXCELLENCE
Optimal Practice Review (OPR)
Tetracyclines for acne vulgaris
1 Introduction
The Chief Executive is asked to consider the following does not proceed as a technology appraisal does not proceed as an OPR developed using short clinical guideline is referred back through the topic selection process for development as a clinical guideline. If referred, the OPR aspect would be dealt with by an economic section focussing on the cost effectiveness of tetracyclines in the treatment of acne vulgaris. 2 Background
Tetracyclines are antibiotics that are commonly used for acne vulgaris. A number of systematic reviews have failed to find any difference in efficacy between the tetracyclines despite differences in acquisition cost. There is potential for a different adverse effect profile but this has not been fully explored. Similarly, although there are differences in the recommended regimens, the implications have not been evaluated. The original OPR paper to the Department of Health considered the tetracyclines for acne to be a potential candidate for the OPR work stream. The purpose of considering it would not be to stop the prescription of tetracyclines, but to consider their most cost effective A draft scope and evidence table were consulted on and a workshop held in 2007 to discuss the issues raised from consultation and to decide which programme of work would be the most appropriate to Issues discussed at scoping workshop
All stakeholders agreed that this topic was important and should proceed through the Institute’s work programmes. The focus should be on the use of tetracyclines in general, rather than Comparisons between tetracyclines would be a valid approach. However because there are many treatment options, including the use of oral and topical treatments in combination, a technology appraisal approach would not be able to take into account the existing complexities and uncertainties surrounding treatment. The impact of the different treatment regimens were considered to be important (e.g. treatment dosage, adherence and duration of treatment) and it was felt they could only be fully explored within a The scope should not include acne rosacea. Teenagers should be considered as a separate sub-group. Gram negative folliculitis patients should be excluded as a sub-group. There are other important subgroups that could only be fully explored in a guideline (i.e. patients who have previously failed to respond to other treatments, patients for whom acne vulgaris is either chronic or Options for progress
Consultees considered that a technology appraisal would answer an important question. However key parameters that needed to be taken into account were safety, dosage, treatment regimens and adherence to treatment. However, due to the many treatment pathways and sub- groups it would be very complex project that would not easily be able to accommodate the many parameters that ultimately impact on the clinical and cost-effectiveness. There were also restricted options for recommendations and the original OPR remit might not be fulfilled. Initially, Consultees had only been give a choice between the OPR being carried out as either a technology appraisal or as a “short clinical guideline” and consultation responses favoured a “short clinical guideline”. During the workshop, it became apparent that it would be difficult to limit the scope to just 3 or 4 questions and many of the uncertainties surrounding the management of acne would not be resolved. It was, therefore, considered not appropriate to use the short There are no existing UK guidelines on the management of acne, although a guideline from the British Association of Dermatologists is anticipated in 2008. A clinical guideline would be able to consider the full care pathway for this important disease, address appropriate questions for health economic assessment and also take into account the chronic nature of acne and the complexity around its treatment. Consultees, however, acknowledged that such a guideline would be larger and longer in development than either a technology appraisal or an OPR developed using the short clinical guideline process. It should also be noted that although a clinical guideline on the management of acne vulgaris has been considered for referral to Issues for consideration
There is widespread variation in the management of acne and guidance from NICE would optimise current practice and explore the The proposed topic is not suitable for development as a technology appraisal due to the complexities and uncertainties surrounding the It is unlikely that a short clinical guideline (i.e. limited to 3 or 4 questions) would be able to take all of the necessary issues into account. It is also unlikely that this topic would meet the criteria for referral by the DH as a ‘short clinical guideline’. It is not clear what the costs associated with the comparators are and therefore whether the outcome will result in increased costs, be cost- The Short Clinical Guideline process is currently committed and further discussion is required as to whether this topic should be prioritised or further resources committed. 6 Recommendation
Following consultation it is considered by both the Appraisals and Guidelines teams that a standard guideline is necessary and should Dr Sarah Garner, Associate Director, R&D, CPHD March 2008

Source: http://www.nice.org.uk/media/685/35/OPRScopingWorkshopReportAcne.pdf