Long-acting reversible contraception

Amendment to implementation of 2017 surveillance report (March 2019)

Background

The NICE guideline on long-acting reversible contraception (LARC), was published in 2005 with surveillance reviews in 2008, 2011, 2013 and 2017. The 2017 review did not identify any evidence that impacted on the guideline and no update was proposed. However, feedback from stakeholders at consultation suggested that there had been significant changes in how contraceptive services are commissioned and provided in England, and the recommendations in the guideline no longer fitted with current practice. In addition, many new LARC products had become available. Therefore, the 2017 surveillance report proposed the following amendments to the guideline which were presented to NICE's Guidance Executive in September 2017 and approved for implementation:

• A medicines prescribing briefing will be produced to provide evidence based information for the different types of LARCs. The outdated recommendations in the guideline will be stood down and replaced with a cross reference to the briefing as well as a link to the British National Formulary (BNF).
• NICE will produce a resource (icon array or options grid) that health professionals can use with patients during consultations to support shared decisions.
• Appendix A and B of the guideline will be updated to incorporate newly available products.
• A cross reference will be made in recommendations 1.1.1 to 1.1.6 to NICE's guideline on contraceptive services for under 25s and NICE's local government briefing on contraceptive services.

Further consideration

The medicines prescribing team (MPT) have worked with guidance information services to undertake a literature review of evidence published since the NICE guideline was updated. They concluded that producing a medicines and prescribing briefing would require extensive time and resource, and it would be more efficient to make use of existing guidance and tools, particularly those that have been accredited/endorsed by NICE and are already widely accepted and used in practice.

Medicines and prescribing briefing for LARC preparations

Features of the LARC methods to discuss with women (appendix A of the guideline), discusses a number of issues including mode of action, efficacy, effect on periods, duration of use and major risks for the major groups of LARC types. This fits with sections 1.2 to 1.5 of the main guideline and is also reflected in the information for patients section. During their review, the MPT did not find any additional LARC methods that do not fit into these general categories. Some of the newer preparations do have nuanced differences but these are already covered either by the products’ summary of product characteristics (SmPC), the BNF or NICE accredited guidance from the Faculty of Sexual and Reproductive Healthcare (FSRH) of the Royal College of Obstetricians and Gynaecologists. The MPT also noted that any evidence review of effectiveness of LARCs is unlikely to make any material change to the current recommendations in the NICE guideline as the evidence around effectiveness would be unlikely to change and that choice is most often influenced by patient factors such as convenience, likely tolerability, individual risk factors and the resource implications.

Therefore, the MPT concluded that a medicines and prescribing briefing would offer little additional useful information to users of the guideline.

Resource to support shared decision making

The NICE process for preparing a patient decision aid in an option-grid style format would require evidence for all available LARC products. However, as discussed above, this supporting evidence is not available from the guideline. However, the Family Planning Association (FPA) have already produced up to date patient information and decision aids on contraceptive choice that are widely used by family planning professionals to assist decision making. It is unlikely that NICE could improve or replace these as the preferred choice of decision aids for professionals or the public. Therefore, discussions with the NICE endorsement team identified the Contraception at a Glance tool as providing a simple and structured guide to all methods of contraception and suitable for endorsement.

Proposed changes to implementation plans

Based on the considerations above, the MPT propose the following alternative approaches to support implementation which will meet the requirements of the surveillance review and address the concerns of stakeholders in the most efficient way:

• Produce an implementation resource summary that will accompany the guideline (and appendix A) and direct users to up to date information available from guidance produced by the FSRH, the SmPC and the BNF. The outdated recommendations in the guideline will be stood down and appendix A will be amended.
• The Contraception at a Glance tool produced by the FPA will be reviewed for endorsement by NICE (with appropriate support from the MPT and the endorsement team). The tool will be linked to from the guideline homepage.

Both actions will be completed by 30 April 2019.

The 2 other actions from the 2017 surveillance review remain unchanged.

However, it should be noted that NICE's local government briefing on contraceptive services was removed from the NICE website in March 2018.