The National Institute for Clinical Excellence has recommended the use of
glycoprotein IIb/IIIa inhibitors for patients with acute coronary syndromes.
In guidance issued on September 29, the NICE says that the drugs, which are
administered intravenously to reduce blood clotting, “should be given to
high-risk patients who have either a minor heart attack, unstable angina or
who are undergoing a balloon angioplasty”. Specifically, the NICE recommends
their use in patients with unstable angina, non-Q-wave myocardial infarction,
acute myocardial infarction with ST segment elevations and Q-wave development,
and in patients having an emergency or planned percutaneous coronary intervention
(angioplasty). High-risk patients are defined as those with any of the following:
The guidance states that intravenous glycoprotein IIb/IIIa inhibitors should
be combined with aspirin and low (adjusted) doses of unfractionated heparin.
No evidence was found to support the use of oral glycoprotein IIb/IIIa inhibitors
(none is licensed for oral use in the UK).
The NICE says that it is not possible to comment on the relative effectiveness
of the three glycoprotein IIb/IIIa inhibitors currently available in the UK
and says that no “head to head” trials of intravenous use of these
drugs have been reported. It recommends the use of all three glycoprotein IIb/IIIa
inhibitors within their current UK licences. According to the British National
Formulary (No 40), tirofiban (Aggrastat) and eptifibatide (Integrilin) are indicated
for the prevention of early myocardial infarction in patients with unstable
angina or non-Q-wave myocardial infarction, and abciximab (Reopro) is indicated
as an adjuvant to percutaneous coronary intervention and for prevention of myocardial
infarction prior to percutaneous coronary intervention.
The NICE says that treating patients with angina or non-Q-wave myocardial infarction
with glycoprotein IIb/IIIa inhibitors will cost an additional £14.5m to
£16m a year. This figure is based on an average cost of £450 per
case and an estimate that 5 to 10 per cent of this group of patients currently
receive treatment. Similarly, based on a cost per case of £840, the additional
cost of treating patients undergoing percutaneous coronary intervention with
glycoprotein IIb/IIIa inhibitors will be £15m.
In guidance issued at the same time, the NICE has also recommended that implantable
cardioverter defibrillators used to control heart rate, should be routinely
considered for patients with specific types of cardiac disease. The full guidance
is available on the NICE website (www.nice.org.uk).