Tocilizumab for treating giant cell arteritis [TA 518]

New: Technology appraisal guidance


Tocilizumab for treating giant cell arteritis


Evidence-based recommendations on tocilizumab (RoActemra) for treating giant cell arteritis in adults.


https://www.nice.org.uk/guidance/ta518

New NICE guideline NG89: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism

Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism


This guideline covers assessing and reducing the risk of venous thromboembolism (VTE or blood clots) and deep vein thrombosis (DVT) in people aged 16 and over in hospital. It aims to help healthcare professionals identify people most at risk and describes treatments and interventions that can be used to reduce the risk of VTE.


Published  March 2018
Next Review 2020


Full guidance available at https://www.nice.org.uk/guidance/ng89

Vascular surgery: GIRFT Programme National Specialty Report.

Vascular surgery: GIRFT Programme National Specialty Report.

This report provides a detailed picture of vascular procedures and how they are delivered. It is intended to enable clinicians and managers to consider how best to configure their vascular services as part of a 'hub and spoke' model for the benefit of their patients.

Get full details and the report at http://gettingitrightfirsttime.co.uk/vascular-surgery-report/

Crenolanib for advanced or metastatic gastrointestinal stromal tumours (GISTs) with the D842V mutation in the PDGFRA gene

GISTs with D842V mutation in PDGFRA are usually resistant to the currently available targeted cancer drugs. Crenolanib is a medicine that specifically blocks the PDGFRA pathway involved in the production of blood vessels that supply the cancer cells, thereby preventing the cancer cells from growing and multiplying. It is being developed for the treatment of advanced or metastatic GISTs with D842V mutation in the PDGFRA gene. This drug is given by mouth. If licensed, crenolanib will offer an additional treatment option for this patient group, particularly those that do not respond to other treatments.


From the NIHR Innovation Observatory

Lenvatinib with everolimus for previously treated advanced renal cell carcinoma [TA 498]

New:  Technology appraisal guidance




Lenvatinib plus everolimus is recommended as an option for treating advanced renal cell carcinoma in adults who have had 1 previous vascular endothelial growth factor (VEGF)-targeted therapy, only if:

• their Eastern Cooperative Oncology Group (ECOG) performance status score is 0 or 1 and
• the company provides lenvatinib with the discount agreed in the patient access scheme.

1.2 This recommendation is not intended to affect treatment with lenvatinib plus everolimus that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.

Subcutaneous Tocilizumab (RoACTEMRA) With or Without Methotrexate for the Treatment of Inadequate Responders in Systemic Juvenile Idiopathic Arthritis

Tocilizumab is a drug that targets and blocks the IL-6 pathway and is currently used for the treatment of many diseases, including sJIA, rheumatoid arthritis and Giant Cell Arteritis (GCA). It is now being developed for patients with sJIA that may have been treated with, and have not responded to another drug called methotrexate. It is being developed to be administered as an injection under the skin (subcutaneous) as opposed to the usual intravenous infusion preparation and this has the potential to reduce patient inconvenience and clinical burden.

From NIHR Innovation Observatory

Ultrasonography of occipital arteries to diagnose giant cell arteritis: a case series and literature review

Clin Rheumatol. 2017 Dec 12. doi: 10.1007/s10067-017-3946-5. [Epub ahead of print]

We describe four cases of giant cell arteritis (GCA) that presented with occipital headache in the last 6 months. Typical ultrasound features of GCA were found in the occipital arteries which helped to confirm the diagnosis. One patient had already suffered significant visual loss by the time the diagnosis was made, reflecting the similarity in prognosis to the more typical GCA patients. These cases prompted a review of the literature to evaluate the evidence regarding the use of occipital artery ultrasonography in the investigation of GCA. We searched PubMed, Google Scholar and Web of Science and identified 17 papers but only four of these were relevant studies. The studies available show that typical features of GCA can be detected in the occipital arteries using ultrasonography. They also suggest that ultrasonography can detect changes in the occipital arteries when temporal arteries are not involved. However, occipital artery abnormalities were less common than temporal artery abnormalities in GCA. We advocate maintaining a high index of suspicion for GCA in patients presenting with atypical features, such as occipital headache. Ultrasonography has a vital role to play in the diagnosis of these patients. We recommend priority imaging of the affected area to facilitate prompt and accurate diagnosis of GCA, especially when atypical vessels are involved.

UHCW Research: Pinnell J, Tiivas C, Perkins P, Blake T, Saravana S and Dubey S.

Rivaroxaban (Xarelto) in Combination with Aspirin for Prevention of Major Cardiovascular Events in Coronary or Peripheral Artery Disease

Rivaroxaban and aspirin are drugs that reduce blood clots in blood vessels and are currently being given to some patients with CAD and PAD. The combination of rivaroxaban with aspirin is being developed as a more effective treatment. If licensed, this combination will offer a new option for the prevention of major cardiovascular events.

From the NIHR Innovation Observatory

National Vascular Registry 2017 annual report

The number of patients who die in hospital following an operation to repair an abdominal aortic aneurysm (AAA) continues to fall according to the National Vascular Registry 2017 annual report published by the Vascular Society of Great Britain and Ireland (VSGBI) and the Royal College of Surgeons (RCS). 

Of the just over 13,000 patients who had a planned operation to repair an aneurysm between 2014 and 2016, the proportion who died in hospital after surgery was 1.4%, which represents approximately 130 patients lives saved each year compared to figures published in 2012.

Rexmyelocel-T for critical limb ischaemia in patients with diabetes mellitus

The treatment, rexmyelocel-T, is being developed to relieve leg pain at rest and heal leg ulcers. The treatment uses cells from bone marrow which are injected into the damaged blood vessel, where they restore existing blood vessels and create new blood vessels. By improving the blood flow in the limb, this treatment aims to improve the patient’s condition so that they do not require amputation.

From the NIHR Innovation Observatory

Extracranial to intracranial bypass for intracranial atherosclerosis [IPG596]

New interventional procedures guidance from NICE:

Evidence-based recommendations on extracranial to intracranial bypass for intracranial atherosclerosis. This involves joining a blood vessel from outside the skull to one inside the skull to bypass a narrowed or partially blocked vessel.

Current evidence on the safety and efficacy of extracranial to intracranial bypass for intracranial atherosclerosis shows that there is no benefit to the patient from the intervention. There are major concerns around its safety, therefore this procedure should not be used to treat this condition.

Canakinumab (ILARIS®) for Cardiovascular risk reduction – Add on therapy

Cardiovascular disease (CVD) is a general term that refers to all conditions affecting the heart and blood vessels (circulation). These include angina, heart attack (also known as myocardial infarction), heart failure, stroke, and a number of diseases that affect the blood vessels.
CVD is usually associated with a build-up of fatty deposits inside the blood vessels (arteries) which make the vessels become narrowed (atherosclerosis). The body also reacts to the fatty deposits by sending white blood cells to the blood vessels; this process is called inflammation. The fatty deposits along with the inflammation lead to reduction of the blood supply to the heart and significantly increase the risks of heart attack and other types of cardiovascular diseases.
Canakinumab is a medicine being developed to target inflammation. It is the first and only agent which has shown that by selectively targeting some specific biomarkers of inflammation, it significantly reduces cardiovascular risks. Canakinumab is currently being developed to be used as an add-on therapy for patients who have had a prior heart attack and have a higher risk of further cardiovascular disease.


From the NIHR Innovation Observatory

Changes to the National Patient Reported Outcomes Measures programme

NHS England undertook a consultation on the national Patient Reported Outcomes Measures (PROMs) programme in 2016. As a result of the findings of that consultation, NHS England has now taken the decision to discontinue the mandatory varicose vein surgery and groin-hernia surgery national PROM collections.

NHS England will continue with hip and knee surgery PROM collections and are working with NHS Digital to make the national data on them easier to use and to provide a range of automated outputs that are tailored to the needs of trusts, CCGs and other users.

Major vascular injuries during lumbar disc surgery

The Association of Anaesthetists of Great Britain and Ireland (AAGBI) is passing on important information following the death of a patient:

There is a 1:4000 risk of abdominal vessel injury during lumbar spine discectomy. Teams delivering such surgery should know about this rare but life-threatening complication and be prepared and able to manage the situation.

The Society of British Neurological Surgeons (SBNS) and the Royal College of Anaesthetists (RCoA) received instruction from the Coroner to act to prevent future death. Teams delivering this service are asked to address matters of consent, education, continuing professional development as well as the organisation of timely and safe supportive services.

Mechanical clot removal for stroke reduces disability at two years

Timely mechanical removal of the blood clots from inside vessels in the brain after a stroke reduces disability and improves quality of life at two years compared with usual care.

Over a third of those in the thrombectomy group had good functional outcome compared with less than a quarter of the standard care group who received clot busting drugs. This was similar to the results at 90 days and was associated with improved quality of life in terms of self-care and mobility. Findings came from a trial of almost 400 people followed up over two years in the Netherlands.

From the NIHR Dissemination Centre

Endovascular management of iliac artery dissection during renal transplantation

CIRSE 2017 - P-670

We present a renal failure patient who received a donor kidney complicated with flow-limiting external iliac dissection.We demonstrate through our case that this rare complication can be
successfully managed with endovascular techniques that salvage a failing donor kidney.

UHCW Research: M.J. Maddock and J. Harding

Successful endovascular treatment of external iliac artery dissection causing renal allograft dysfunction

CIRSE 2017 P-639

We describe the diagnosis and endovascular treatment of external iliac artery dissection shortly following renal transplantation; this is a rare complication. This case emphasizes the high level of clinical suspicion needed to diagnose rare postoperative vascular complications and the importance of early interventional radiology involvement.

UHCW Research: R.S. Sagoo1, C. Imray, F. Lam and J. Harding

A staged, endovascular approach to treat a ruptured external iliac artery mycotic pseudoaneurysm in an intravenous drug user: A case report

Int J Surg Case Rep. 2017 Aug 5;39:115-118. doi: 10.1016/j.ijscr.2017.07.054. [Epub ahead of print]

We have shown a successful outcome in managing a challenging patient using endovascular techniques as a bridge to definitive arterial reconstruction. This circumvents traditional approaches including primary arterial ligation, which carry a risk of limb-loss.

UHCW Research: Ahmad M, Poh YW and Imray CHE

Biopatch for venous or arterial catheter sites

Medt ech innovation briefing on Biopatch for venous or arterial catheter sites.

The technology described in this briefing is Biopatch. It is a hydrophilic foam dressing impregnated with chlorhexidine gluconate (CHG), and is used for covering central venous or arterial catheter sites.

The innovative aspects are that it releases CHG to reduce the risk of catheter-related bloodstream infections (CRBSIs), while the absorbent foam draws discharge away from the catheter site.

Ultrasound could help diagnose giant cell arteritis

Ultrasound may aid diagnosis of giant cell arteritis in people referred from the community. It is less invasive than biopsy and might provide quicker results than a biopsy, but its role and place in the diagnostic pathway remain unclear.

From the NIHR Dissemination Centre