September's free article
NICE guidelines on complementary/alternative medicine: more
consistency and rigour are needed
Recent NICE guidelines have recommended that patients suffering
from persistent, non-specific low back pain should be offered ‘one
of the following treatment options, taking into account patient
preference: an exercise programme, a course of manual therapy, or a
course of acupuncture’.1 No previous document by NICE
has been so explicitly positive about complementary/alternative
medicine (CAM). This, it seems, is a good occasion to review the
totality of the recommendations from NICE guidelines in respect to
CAM.
As of July 2009, NICE have published 88 clinical
guidelines.2 We have reviewed 83 of these (five have
been replaced and were no longer available). The majority of these
documents make no mention of CAM at all, often, it seems, for good
reason; there are many conditions for which there is no
evidence-based CAM option. Several guidelines refer to ‘holistic’
care, nutrition, vitamin therapy, and exercise, which some might
view as CAM. For example, those relating to chronic and/or
degenerative conditions explicitly recognise the need for holistic
patient care and management, or focus on dietary and lifestyle
interventions. A small number of the guidelines recognise various
forms of CAM as an effective treatment. For instance, the
depression guidelines state that St John’s Wort is more effective
than placebo. Yet the use of St John’s wort is not recommended
‘because of uncertainty about appropriate doses, variation in the
nature of the preparations, and potential serious interactions with
other drugs’.1
Many of the guidelines which do incorporate CAM state or imply
that patients themselves should determine the value of CAM by trial
and error, or make statements such as ‘some patients may find CAM
useful’. The majority of these documents refer to CAM with the
assertion that ‘further research is needed’ or that ‘evidence is
insufficient for firm recommendations’. In a number of
instances (for example, guidelines relating to anxiety, type 2
diabetes, hypertension, and stroke) the impression is given that
there is little evidence to indicate that CAM approaches may be
valuable, while reasonably sound data do exist.3 In
other instances, the evidence for CAM is hopeful but the NICE
verdict is discouraging. For example, the osteoarthritis guidelines
state that ‘results from acupuncture studies are mixed’. Yet
several systematic reviews of acupuncture for osteoarthritis have
drawn positive overall conclusions.4–6 Acupuncturists
have therefore argued that this NICE guideline ‘gives the reader a
distinctly negative impression of acupuncture. This could be
against patients’ best interests …’.7 The opposite
scenario could be true for the recent back pain
guidelines.1 It has been argued that they over-estimated
the effectiveness and under-estimated the risks of spinal
manipulation.8
In conclusion, our analysis shows that many NICE guidelines have
evaluated CAM. But there is a substantial degree of inconsistency:
some are comprehensive, while others are not. The decision of
whether or not to consider CAM for any given topic appears to be
somewhat arbitrary. Generally speaking, this inconsistency seems to
be at odds with NICE’s excellent track record of evaluating
conventional treatments, by utilising a transparent and rigid
hierarchy of evidence for its recommendations. We therefore suggest
that, in future, NICE should evaluate CAM by the same standards as
conventional medicine.
Edzard Ernst and Rohini Terry
References
1. Savigny P, Watson P,
Underwood M. Early management of persistent non-specific low back
pain: summary of NICE guidance. BMJ 2009; 338: 1441–1442.
2. National Institute for Health and Clinical Excellence
(NICE). Our guidance. http://www.nice.org.uk/guidance/index.jsp
(accessed 14 Aug 2009).
3. Ernst E, Pittler MH, Wider B, Boddy K. The desktop guide
to complementary and alternative medicine. 2nd edn. Edinburgh:
Elsevier Mosby, 2006.
4. Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral
joint osteoarthritis: a systematic review and meta-analysis.
Rheumatology (Oxford) 2006; 45: 1331–1337.
5. Ezzo J, Hadhazy V, Birch S, et al. Acupuncture for
osteoarthritis of the knee: a systematic review. Arthritis Rheum
2001; 44(4): 819–825.
6. White A, Foster NE, Cummings M, Barlas P. Acupuncture
treatment for chronic knee pain: a systematic review. Rheumatology
(Oxford) 2007; 46(3): 384–390.
7. White A. NICE guideline on osteoarthritis: is it fair to
acupuncture? No. Acupunct Med 2009; 27(2): 70–72.
8. Ernst E. Spinal manipulation for the early management of
persistent non-specific low back-pain — a critique of the recent
NICE guidelines. Int J Clin Pract 2009: in press.
DOI: 10.3399/bjgp09X454232
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