EDITORIAL| VOLUME 392, ISSUE 10149, P712, SEPTEMBER 01, 2018 Does a spoonful of honey make the medicine go down?

https://doi.org/10.1016/S0140-6736(18)31986-X The National Institute for Health and Care Excellence's (NICE's) scientific rigour forms the basis of its credibility, and its guidance is a global benchmark for health-care provision. However, it is less well known that in their recommendations, when the evidence is weak, the NICE committees make judgements based on both the scientific and social values of the evidence. On Aug 23, NICE released draft guidance for treating acute cough associated with upper respiratory tract infection or acute bronchitis, which is open for consultation until Sept 20. This guidance sets itself apart due to its strong public health slant, aimed primarily towards limiting antibiotic use. The expert committee found that acute cough is usually a self-limiting infection that is often viral and that available evidence does not support the use of antibiotics in most cases. It recommends that doctors should clearly explain to their patients that acute cough symptoms should disappear on their own within 3–4 weeks of onset. The committee could have left their recommendations at that. However, presumably anticipating that patients would not be satisfied leaving the physician's office empty handed, NICE further recommended that doctors discuss options for self-care, including the herbal remedy pelargonium, cough medicines containing either guaifenesin or dextromethorphan, and honey. Interestingly, the quality of the evidence for the efficacy of these self-care remedies is described as moderate to very low. They further justify the choice of these remedies over others, such as ivy, primrose, or thyme, by excluding those that had similar quality evidence for efficacy but had no known safety data. Without strong evidence, the efficacy of these self-care remedies cannot be guaranteed, and they might be no more effective then a placebo. This approach likely will ensure better compliance to the course of action agreed with the physician and it has social value in a time where better antibiotic stewardship is urgently needed. However, in its guiding principles, NICE says that its “advisory bodies should avoid recommending interventions where evidence of their effectiveness is absent or too weak for reasonable conclusions to be drawn”. By privileging harm reduction over evidence quality, is NICE overreaching and jeopardising its raison d'être? Figure thumbnail fx1 Figure View Large Image Copyright © 2018 Arnd Wiegmann/Reuters Article Info Publication History Published: 01 September 2018 IDENTIFICATION DOI: 10.1016/S0140-6736(18)31986-X Copyright © 2018 Elsevier Ltd. All rights reserved. ScienceDirect Access this article on ScienceDirect Figures Figure thumbnail fx1 Figure Copyright © 2018 Arnd Wiegmann/Reuters