175221_Leaflet.

qxd:Coeliac QRG v5 15/5/09 14:51 Page 1

Coeliac disease Patient-centred care Coeliac disease Further information

This is a quick reference guide that summarises the recommendations NICE has made to the NHS Further information
in ‘Coeliac disease: recognition and assessment of coeliac disease’ (NICE clinical guideline 86).
Ordering information Implementation tools
You can download the following documents NICE has developed tools to help
from www.nice.org.uk/CG86 organisations implement this guidance
Introduction ● The NICE guideline – all the
(see www.nice.org.uk/CG86).

Coeliac disease is an autoimmune disorder that involves a heightened immunological response to recommendations.
ingested gluten in genetically susceptible people. It was believed to be uncommon but population- Related NICE guidance
● A quick reference guide (this document) –
based studies show that it is much more prevalent than previously thought. For information about NICE guidance that
a summary of the recommendations for
has been issued or is in development,
Although people with coeliac disease often have gastrointestinal symptoms, other symptoms are healthcare professionals.
see www.nice.org.uk
increasingly being recognised and some people have no symptoms at all. ● ‘Understanding NICE guidance’ – a summary
● Irritable bowel syndrome in adults. NICE
Coeliac disease often coexists with other conditions. for patients and carers.
clinical guideline 61 (2008). Available from:
● The full guideline – all the recommendations, www.nice.org.uk/CG61
details of how they were developed, and
reviews of the evidence they were based on.
● Chronic fatigue syndrome/myalgic Quick reference guide
Patient-centred care encephalomyelitis (or encephalopathy).
Treatment and care, including recognition and diagnosis, should take into account patients’ For printed copies of the quick reference NICE clinical guideline 53 (2007). Available
individual needs and preferences. Good communication is essential, supported by evidence-based guide or ‘Understanding NICE guidance’, from: www.nice.org.uk/CG53
information, to allow patients to reach informed decisions about their care. Follow Department of phone NICE publications on 0845 003 7783 or
email publications@nice.org.uk and quote:
● Type 1 diabetes. NICE clinical guideline 15 Issue date: May 2009
Health advice on seeking consent if needed. If the patient agrees, families and carers should have (2004). Available from:
the opportunity to be involved in decisions about treatment and care. If caring for young people ● N1859 (quick reference guide) www.nice.org.uk/CG15
in transition between paediatric and adult services refer to ‘Transition: getting it right for young
●
Coeliac disease
N1860 (‘Understanding NICE guidance’).
people’ (available from www.dh.gov.uk). Updating the guideline
This guideline will be updated as needed, Recognition and assessment of coeliac disease
and information about the progress of
Key to terms any update will be available at
www.nice.org.uk/CG86
AGA: anti-gliadin antibodies HLA DQ2/DQ8: human IgG: immunoglobulin G
EMA: anti-endomysial leukocyte antigen DQ2/DQ8 tTGA: anti tissue
antibodies IgA: immunoglobulin A transglutaminase antibodies

NICE clinical guidelines are recommendations about the treatment and care of people with specific
diseases and conditions in the NHS in England and Wales.
This guidance represents the view of NICE, which was arrived at after careful consideration of National Institute for
the evidence available. Healthcare professionals are expected to take it fully into account when
Health and Clinical Excellence
exercising their clinical judgement. However, the guidance does not override the individual
responsibility of healthcare professionals to make decisions appropriate to the circumstances of MidCity Place
the individual patient, in consultation with the patient and/or guardian or carer, and informed 71 High Holborn © National Institute for Health and
by the summary of product characteristics of any drugs they are considering. London Clinical Excellence, 2009. All rights
Implementation of this guidance is the responsibility of local commissioners and/or providers. reserved. This material may be freely
WC1V 6NA
Commissioners and providers are reminded that it is their responsibility to implement the guidance, reproduced for educational and not-for-
in their local context, in light of their duties to avoid unlawful discrimination and to have regard to profit purposes. No reproduction by or for
www.nice.org.uk commercial organisations, or for commercial
promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that
would be inconsistent with compliance with those duties. purposes, is allowed without the express
N1859 1P 60k May 09
written permission of NICE. NICE clinical guideline 86
ISBN 1-84629-960-8 Developed by the Centre for Clinical Practice at NICE
Coeliac disease Patient-centred care

This is a quick reference guide that summarises the recommendations NICE has made to the NHS
in ‘Coeliac disease: recognition and assessment of coeliac disease’ (NICE clinical guideline 86).

Introduction
Coeliac disease is an autoimmune disorder that involves a heightened immunological response to
ingested gluten in genetically susceptible people. It was believed to be uncommon but population-
based studies show that it is much more prevalent than previously thought.
Although people with coeliac disease often have gastrointestinal symptoms, other symptoms are
increasingly being recognised and some people have no symptoms at all.
Coeliac disease often coexists with other conditions.

Patient-centred care
Treatment and care, including recognition and diagnosis, should take into account patients’
individual needs and preferences. Good communication is essential, supported by evidence-based
information, to allow patients to reach informed decisions about their care. Follow Department of
Health advice on seeking consent if needed. If the patient agrees, families and carers should have
the opportunity to be involved in decisions about treatment and care. If caring for young people
in transition between paediatric and adult services refer to ‘Transition: getting it right for young
people’ (available from www.dh.gov.uk).

Key to terms
AGA: anti-gliadin antibodies HLA DQ2/DQ8: human IgG: immunoglobulin G
EMA: anti-endomysial leukocyte antigen DQ2/DQ8 tTGA: anti tissue
antibodies IgA: immunoglobulin A transglutaminase antibodies

NICE clinical guidelines are recommendations about the treatment and care of people with specific
diseases and conditions in the NHS in England and Wales.
This guidance represents the view of NICE, which was arrived at after careful consideration of
the evidence available. Healthcare professionals are expected to take it fully into account when
exercising their clinical judgement. However, the guidance does not override the individual
responsibility of healthcare professionals to make decisions appropriate to the circumstances of
the individual patient, in consultation with the patient and/or guardian or carer, and informed
by the summary of product characteristics of any drugs they are considering.
Implementation of this guidance is the responsibility of local commissioners and/or providers.
Commissioners and providers are reminded that it is their responsibility to implement the guidance,
in their local context, in light of their duties to avoid unlawful discrimination and to have regard to
promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that
would be inconsistent with compliance with those duties.
 Signs, symptoms and Care pathway
conditions associated
with coeliac disease Important: Do not use serological testing for coeliac disease in infants before
gluten has been introduced to the diet
Coeliac disease

Box A. Offer serological

175221_Leaflet.qxd:Coeliac QRG v5

testing to children and

NICE clinical guideline 86

adults with any of
Person is unlikely to need
the following signs, Does the person have
15/5/09

testing for coeliac disease at

any of the signs,
symptoms and conditions No this point, unless there is a
symptoms or conditions
Signs and symptoms continuing medical problem
listed in box A or box B?
14:51

● Chronic or intermittent diarrhoea or clinical suspicion

● Failure to thrive or faltering
growth (in children)
Page 2

Yes
● Persistent or unexplained
gastrointestinal symptoms
including nausea and vomiting Is the person
Is the person willing/
● Prolonged fatigue (‘tired all the time’)
on a gluten- able to
No No
● Recurrent abdominal pain, containing reintroduce
cramping or distension diet? gluten to
Recognition and assessment

● Sudden or unexpected weight loss their diet?

● Unexplained iron-deficiency
anaemia, or other unspecified
anaemia Yes

Conditions
● Autoimmune thyroid disease Refer them to a
Care pathway

● Dermatitis herpetiformis Offer serological testing gastrointestinal specialist and

if the person has any of inform them that it may be
● Irritable bowel syndrome the signs, symptoms or difficult to confirm a diagnosis
● Type 1 diabetes conditions in box A of coeliac disease on intestinal
Consider offering biopsy, and that this may have
● First-degree relatives (parents,
serological testing if the implications for their ability
siblings or children) with coeliac
person has any of the to access prescribed
disease
conditions in box B gluten-free foods

Box B. Consider offering Dietary Other information before serological

serological testing to considerations
children and adults with before serological
any of the following testing
● Addison’s disease Inform people (and their
● amenorrhoea parents or carers as
appropriate) that:
● aphthous stomatitis (mouth ulcers)
● testing (serology and
● autoimmune liver conditions
biopsy if required) is
● autoimmune myocarditis accurate only if they
follow a gluten-
● chronic thrombocytopenia purpura
containing diet
● dental enamel defects ● when following a
● depression or bipolar disorder gluten-containing diet
they should eat some
● Down’s syndrome gluten in more than
testing
● Inform people who are considering, or who have
undertaken, self-testing for coeliac disease that any
result from self-testing needs to be discussed with
a healthcare professional and confirmed by
laboratory-based tests
● Before seeking consent to take blood for serological
tests, explain:
– what coeliac disease is
– that serological tests do not diagnose coeliac disease,
but indicate whether further testing is needed
– the implications of a positive test (including referral
for intestinal biopsy and implications for other
family members)
– the implications of a negative test (that coeliac disease
Information needs

is unlikely but it could be present or arise in the future)

● epilepsy one meal every day for
● Inform people (and their parents or carers as
●
at least 6 weeks
low-trauma fracture appropriate) that a delayed diagnosis of coeliac disease,
before testing
● lymphoma or undiagnosed coeliac disease, can result in:
● they should not start a – continuing ill health
● metabolic bone disease gluten-free diet until – long-term complications, including osteoporosis and
(such as rickets or osteomalacia) diagnosis is confirmed increased fracture risk, unfavourable pregnancy
● microscopic colitis by intestinal biopsy outcomes and a modest increased risk of
(even if a self-test or intestinal malignancy
● persistent or unexplained other serological test – growth failure, delayed puberty and dental problems
constipation is positive) (in children)
● persistently raised liver enzymes
with unknown cause
● polyneuropathy
Important:
● recurrent miscarriage ● All tests should be undertaken in laboratories with clinical pathology

● reduced bone mineral density accreditation (CPA)

● Do not use IgA or IgG anti-gliadin antibody (AGA) tests in the diagnosis of
● sarcoidosis
coeliac disease
● Sjögren’s syndrome
● Do not use HLA DQ2/DQ8 testing in the initial diagnosis of coeliac disease
● Turner syndrome (However, its high negative predictive value may be of use to gastrointestinal
● unexplained alopecia specialists in specific clinical situations)
● ● Do not use self-tests and/or point of care tests for coeliac disease as a substitute for
unexplained subfertility
laboratory-based testing

● Use serological testing for IgA

tissue transglutaminase (tTGA) as a Negative
first-choice test Negative Check for IgA result but
result deficiencya continuing
● Use IgA endomysial antibodies clinical
(EMA) testing if the result of the suspicion
tTGA test is equivocal
Coeliac disease

Positive Negative
result result, no
further
Serology testing and after

reason to
suspect
Positive Offer IgG tTGA tests coeliac
result and/or IgG EMA tests disease

Unlikely
to have
coeliac
disease
No need
to repeat
Refer to a Positive Negative result tests
gastrointestinal result but continuing
specialist for clinical
intestinal biopsy suspicion
to confirm or
exclude coeliac
disease
Care pathway

a
Quick reference guide

Investigation for IgA deficiency should be done if the laboratory detects a low or very low optical density on IgA tTGA test or low background on IgA EMA test.
 Signs, symptoms and Care pathway
conditions associated
with coeliac disease Important: Do not use serological testing for coeliac disease in infants before
gluten has been introduced to the diet
Coeliac disease

Box A. Offer serological

175221_Leaflet.qxd:Coeliac QRG v5

testing to children and

NICE clinical guideline 86

adults with any of
Person is unlikely to need
the following signs, Does the person have
15/5/09

testing for coeliac disease at

any of the signs,
symptoms and conditions No this point, unless there is a
symptoms or conditions
Signs and symptoms continuing medical problem
listed in box A or box B?
14:51

● Chronic or intermittent diarrhoea or clinical suspicion

● Failure to thrive or faltering
growth (in children)
Page 2

Yes
● Persistent or unexplained
gastrointestinal symptoms
including nausea and vomiting Is the person
Is the person willing/
● Prolonged fatigue (‘tired all the time’)
on a gluten- able to
No No
● Recurrent abdominal pain, containing reintroduce
cramping or distension diet? gluten to
Recognition and assessment

● Sudden or unexpected weight loss their diet?

● Unexplained iron-deficiency
anaemia, or other unspecified
anaemia Yes

Conditions
● Autoimmune thyroid disease Refer them to a
Care pathway

● Dermatitis herpetiformis Offer serological testing gastrointestinal specialist and

if the person has any of inform them that it may be
● Irritable bowel syndrome the signs, symptoms or difficult to confirm a diagnosis
● Type 1 diabetes conditions in box A of coeliac disease on intestinal
Consider offering biopsy, and that this may have
● First-degree relatives (parents,
serological testing if the implications for their ability
siblings or children) with coeliac
person has any of the to access prescribed
disease
conditions in box B gluten-free foods

Box B. Consider offering Dietary Other information before serological

serological testing to considerations
children and adults with before serological
any of the following testing
● Addison’s disease Inform people (and their
● amenorrhoea parents or carers as
appropriate) that:
● aphthous stomatitis (mouth ulcers)
● testing (serology and
● autoimmune liver conditions
biopsy if required) is
● autoimmune myocarditis accurate only if they
follow a gluten-
● chronic thrombocytopenia purpura
containing diet
● dental enamel defects ● when following a
● depression or bipolar disorder gluten-containing diet
they should eat some
● Down’s syndrome gluten in more than
testing
● Inform people who are considering, or who have
undertaken, self-testing for coeliac disease that any
result from self-testing needs to be discussed with
a healthcare professional and confirmed by
laboratory-based tests
● Before seeking consent to take blood for serological
tests, explain:
– what coeliac disease is
– that serological tests do not diagnose coeliac disease,
but indicate whether further testing is needed
– the implications of a positive test (including referral
for intestinal biopsy and implications for other
family members)
– the implications of a negative test (that coeliac disease
Information needs

is unlikely but it could be present or arise in the future)

● epilepsy one meal every day for
● Inform people (and their parents or carers as
●
at least 6 weeks
low-trauma fracture appropriate) that a delayed diagnosis of coeliac disease,
before testing
● lymphoma or undiagnosed coeliac disease, can result in:
● they should not start a – continuing ill health
● metabolic bone disease gluten-free diet until – long-term complications, including osteoporosis and
(such as rickets or osteomalacia) diagnosis is confirmed increased fracture risk, unfavourable pregnancy
● microscopic colitis by intestinal biopsy outcomes and a modest increased risk of
(even if a self-test or intestinal malignancy
● persistent or unexplained other serological test – growth failure, delayed puberty and dental problems
constipation is positive) (in children)
● persistently raised liver enzymes
with unknown cause
● polyneuropathy
Important:
● recurrent miscarriage ● All tests should be undertaken in laboratories with clinical pathology

● reduced bone mineral density accreditation (CPA)

● Do not use IgA or IgG anti-gliadin antibody (AGA) tests in the diagnosis of
● sarcoidosis
coeliac disease
● Sjögren’s syndrome
● Do not use HLA DQ2/DQ8 testing in the initial diagnosis of coeliac disease
● Turner syndrome (However, its high negative predictive value may be of use to gastrointestinal
● unexplained alopecia specialists in specific clinical situations)
● ● Do not use self-tests and/or point of care tests for coeliac disease as a substitute for
unexplained subfertility
laboratory-based testing

● Use serological testing for IgA

tissue transglutaminase (tTGA) as a Negative
first-choice test Negative Check for IgA result but
result deficiencya continuing
● Use IgA endomysial antibodies clinical
(EMA) testing if the result of the suspicion
tTGA test is equivocal
Coeliac disease

Positive Negative
result result, no
further
Serology testing and after

reason to
suspect
Positive Offer IgG tTGA tests coeliac
result and/or IgG EMA tests disease

Unlikely
to have
coeliac
disease
No need
to repeat
Refer to a Positive Negative result tests
gastrointestinal result but continuing
specialist for clinical
intestinal biopsy suspicion
to confirm or
exclude coeliac
disease
Care pathway

a
Quick reference guide

Investigation for IgA deficiency should be done if the laboratory detects a low or very low optical density on IgA tTGA test or low background on IgA EMA test.
 Signs, symptoms and Care pathway
conditions associated
with coeliac disease Important: Do not use serological testing for coeliac disease in infants before
gluten has been introduced to the diet
Coeliac disease

Box A. Offer serological

175221_Leaflet.qxd:Coeliac QRG v5

testing to children and

NICE clinical guideline 86

adults with any of
Person is unlikely to need
the following signs, Does the person have
15/5/09

testing for coeliac disease at

any of the signs,
symptoms and conditions No this point, unless there is a
symptoms or conditions
Signs and symptoms continuing medical problem
listed in box A or box B?
14:51

● Chronic or intermittent diarrhoea or clinical suspicion

● Failure to thrive or faltering
growth (in children)
Page 2

Yes
● Persistent or unexplained
gastrointestinal symptoms
including nausea and vomiting Is the person
Is the person willing/
● Prolonged fatigue (‘tired all the time’)
on a gluten- able to
No No
● Recurrent abdominal pain, containing reintroduce
cramping or distension diet? gluten to
Recognition and assessment

● Sudden or unexpected weight loss their diet?

● Unexplained iron-deficiency
anaemia, or other unspecified
anaemia Yes

Conditions
● Autoimmune thyroid disease Refer them to a
Care pathway

● Dermatitis herpetiformis Offer serological testing gastrointestinal specialist and

if the person has any of inform them that it may be
● Irritable bowel syndrome the signs, symptoms or difficult to confirm a diagnosis
● Type 1 diabetes conditions in box A of coeliac disease on intestinal
Consider offering biopsy, and that this may have
● First-degree relatives (parents,
serological testing if the implications for their ability
siblings or children) with coeliac
person has any of the to access prescribed
disease
conditions in box B gluten-free foods

Box B. Consider offering Dietary Other information before serological

serological testing to considerations
children and adults with before serological
any of the following testing
● Addison’s disease Inform people (and their
● amenorrhoea parents or carers as
appropriate) that:
● aphthous stomatitis (mouth ulcers)
● testing (serology and
● autoimmune liver conditions
biopsy if required) is
● autoimmune myocarditis accurate only if they
follow a gluten-
● chronic thrombocytopenia purpura
containing diet
● dental enamel defects ● when following a
● depression or bipolar disorder gluten-containing diet
they should eat some
● Down’s syndrome gluten in more than
testing
● Inform people who are considering, or who have
undertaken, self-testing for coeliac disease that any
result from self-testing needs to be discussed with
a healthcare professional and confirmed by
laboratory-based tests
● Before seeking consent to take blood for serological
tests, explain:
– what coeliac disease is
– that serological tests do not diagnose coeliac disease,
but indicate whether further testing is needed
– the implications of a positive test (including referral
for intestinal biopsy and implications for other
family members)
– the implications of a negative test (that coeliac disease
Information needs

is unlikely but it could be present or arise in the future)

● epilepsy one meal every day for
● Inform people (and their parents or carers as
●
at least 6 weeks
low-trauma fracture appropriate) that a delayed diagnosis of coeliac disease,
before testing
● lymphoma or undiagnosed coeliac disease, can result in:
● they should not start a – continuing ill health
● metabolic bone disease gluten-free diet until – long-term complications, including osteoporosis and
(such as rickets or osteomalacia) diagnosis is confirmed increased fracture risk, unfavourable pregnancy
● microscopic colitis by intestinal biopsy outcomes and a modest increased risk of
(even if a self-test or intestinal malignancy
● persistent or unexplained other serological test – growth failure, delayed puberty and dental problems
constipation is positive) (in children)
● persistently raised liver enzymes
with unknown cause
● polyneuropathy
Important:
● recurrent miscarriage ● All tests should be undertaken in laboratories with clinical pathology

● reduced bone mineral density accreditation (CPA)

● Do not use IgA or IgG anti-gliadin antibody (AGA) tests in the diagnosis of
● sarcoidosis
coeliac disease
● Sjögren’s syndrome
● Do not use HLA DQ2/DQ8 testing in the initial diagnosis of coeliac disease
● Turner syndrome (However, its high negative predictive value may be of use to gastrointestinal
● unexplained alopecia specialists in specific clinical situations)
● ● Do not use self-tests and/or point of care tests for coeliac disease as a substitute for
unexplained subfertility
laboratory-based testing

● Use serological testing for IgA

tissue transglutaminase (tTGA) as a Negative
first-choice test Negative Check for IgA result but
result deficiencya continuing
● Use IgA endomysial antibodies clinical
(EMA) testing if the result of the suspicion
tTGA test is equivocal
Coeliac disease

Positive Negative
result result, no
further
Serology testing and after

reason to
suspect
Positive Offer IgG tTGA tests coeliac
result and/or IgG EMA tests disease

Unlikely
to have
coeliac
disease
No need
to repeat
Refer to a Positive Negative result tests
gastrointestinal result but continuing
specialist for clinical
intestinal biopsy suspicion
to confirm or
exclude coeliac
disease
Care pathway

a
Quick reference guide

Investigation for IgA deficiency should be done if the laboratory detects a low or very low optical density on IgA tTGA test or low background on IgA EMA test.
175221_Leaflet.qxd:Coeliac QRG v5 15/5/09 14:51 Page 1

Coeliac disease Patient-centred care Coeliac disease Further information

This is a quick reference guide that summarises the recommendations NICE has made to the NHS Further information
in ‘Coeliac disease: recognition and assessment of coeliac disease’ (NICE clinical guideline 86).
Ordering information Implementation tools
You can download the following documents NICE has developed tools to help
from www.nice.org.uk/CG86 organisations implement this guidance
Introduction ● The NICE guideline – all the
(see www.nice.org.uk/CG86).

Coeliac disease is an autoimmune disorder that involves a heightened immunological response to recommendations.
ingested gluten in genetically susceptible people. It was believed to be uncommon but population- Related NICE guidance
● A quick reference guide (this document) –
based studies show that it is much more prevalent than previously thought. For information about NICE guidance that
a summary of the recommendations for
has been issued or is in development,
Although people with coeliac disease often have gastrointestinal symptoms, other symptoms are healthcare professionals.
see www.nice.org.uk
increasingly being recognised and some people have no symptoms at all. ● ‘Understanding NICE guidance’ – a summary
● Irritable bowel syndrome in adults. NICE
Coeliac disease often coexists with other conditions. for patients and carers.
clinical guideline 61 (2008). Available from:
● The full guideline – all the recommendations, www.nice.org.uk/CG61
details of how they were developed, and
reviews of the evidence they were based on.
● Chronic fatigue syndrome/myalgic Quick reference guide
Patient-centred care encephalomyelitis (or encephalopathy).
Treatment and care, including recognition and diagnosis, should take into account patients’ For printed copies of the quick reference NICE clinical guideline 53 (2007). Available
individual needs and preferences. Good communication is essential, supported by evidence-based guide or ‘Understanding NICE guidance’, from: www.nice.org.uk/CG53
information, to allow patients to reach informed decisions about their care. Follow Department of phone NICE publications on 0845 003 7783 or
email publications@nice.org.uk and quote:
● Type 1 diabetes. NICE clinical guideline 15 Issue date: May 2009
Health advice on seeking consent if needed. If the patient agrees, families and carers should have (2004). Available from:
the opportunity to be involved in decisions about treatment and care. If caring for young people ● N1859 (quick reference guide) www.nice.org.uk/CG15
in transition between paediatric and adult services refer to ‘Transition: getting it right for young
●
Coeliac disease
N1860 (‘Understanding NICE guidance’).
people’ (available from www.dh.gov.uk). Updating the guideline
This guideline will be updated as needed, Recognition and assessment of coeliac disease
and information about the progress of
Key to terms any update will be available at
www.nice.org.uk/CG86
AGA: anti-gliadin antibodies HLA DQ2/DQ8: human IgG: immunoglobulin G
EMA: anti-endomysial leukocyte antigen DQ2/DQ8 tTGA: anti tissue
antibodies IgA: immunoglobulin A transglutaminase antibodies

NICE clinical guidelines are recommendations about the treatment and care of people with specific
diseases and conditions in the NHS in England and Wales.
This guidance represents the view of NICE, which was arrived at after careful consideration of National Institute for
the evidence available. Healthcare professionals are expected to take it fully into account when
Health and Clinical Excellence
exercising their clinical judgement. However, the guidance does not override the individual
responsibility of healthcare professionals to make decisions appropriate to the circumstances of MidCity Place
the individual patient, in consultation with the patient and/or guardian or carer, and informed 71 High Holborn © National Institute for Health and
by the summary of product characteristics of any drugs they are considering. London Clinical Excellence, 2009. All rights
Implementation of this guidance is the responsibility of local commissioners and/or providers. reserved. This material may be freely
WC1V 6NA
Commissioners and providers are reminded that it is their responsibility to implement the guidance, reproduced for educational and not-for-
in their local context, in light of their duties to avoid unlawful discrimination and to have regard to profit purposes. No reproduction by or for
www.nice.org.uk commercial organisations, or for commercial
promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that
would be inconsistent with compliance with those duties. purposes, is allowed without the express
N1859 1P 60k May 09
written permission of NICE. NICE clinical guideline 86
ISBN 1-84629-960-8 Developed by the Centre for Clinical Practice at NICE