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NICE’s recommendations for thromboembolism are not evidence based

BMJ 2011; 343 doi: (Published 07 December 2011) Cite this as: BMJ 2011;343:d6452

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Re: NICE’s recommendations for thromboembolism are not evidence based

Mark Welfare's review of the evidence for what has become ritualistic behaviour in most hospitals is timely. I work within a specialty (Stroke Medicine) that does not routinely use low molecular weight heparin or compression stockings precisely because the evidence does not favour their use. In fact the most recent Cochrane review of anticoagulation in acute stroke shows any benefit in prevention of VTE was offset by harm associated with haemorrhage(1). Two recent randomized controlled trials have found that the use of compression stockings is not associated with clinical benefit(2,3).

The current status quo, whereby the majority of hospitalized patients are treated with either anitcoagulants and/or compression stockings is a very lucrative one for ‘Big Pharma’. This is perhaps why Boehringer Ingelhem is amongst sponsors contributing to Lifeblood, whose accounts for the year to Jan 2011* showed £75K in corporate donations. In its capacity as a stakeholder organization, a representative of Anticoagulation Europe (another charity dedicated to the prevention of thrombosis) championed Dabigitran Etexilate in its submission to NICE during the early appraisal process†. Anticoagulation Europe receives funding from Boehringer Ingelheim amongst others. Its accounts show that it received total sponsorship, subscriptions excluded, in excess of £123K to year end 2010‡.

The good intentions of these charitable organizations is not in question. However we now seem to be living in an era when decision makers within the NHS are increasingly required to give almost equal weighting to clinical evidence and ‘stakeholder’ opinion. ‘Big Pharma’ has correctly deduced that supporting patient groups and charitable organizations is a neat way to sidestep the regulations prohibiting direct-to-patient marketing. In this setting it is vital that clinicians keep their critical faculties honed, and do not conflate enthusiastic advocacy with evidence.

*Accessed Dec 2011 at

†Accessed Dec 2011 at

‡Accessed Dec 2011 at

1. Sandercock P, Counsell C, Kamal AK. Anticoagulants for Acute Ischemic Stroke. Stroke. 2009 Jun. 29;40(7):e483–e484.
2. Collaboration TCT. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. The Lancet. 2009 Jun. 6;373(9679):1958–1965.
3. CLOTS (Clots in Legs Or sTockings after Stroke) Trial Collaboration. Thigh-length versus below-knee stockings for deep venous thrombosis prophylaxis after stroke: a randomized trial. Ann Intern Med. 2010 Nov. 2;153(9):553–562.

Competing interests: No competing interests

12 December 2011
James B Scott
Consultant Stroke Physician