Updating clinical guidelines

What do national and international guideline methods handbooks say about updating clinical guidelines?

A 2014 systematic review (SR) addressed this question. It included 35 handbooks, mainly from Europe, North America, Australia and New Zealand. Of most relevance for the UK are the NICE and SIGN handbooks.

Updating clinical guidance is not described as rigorously as for developing guidelines

This was the main conclusion of the 2014 SR and a later (2016) review. From the SR,

  • Few handbooks gave guidance on updating search strategies, selecting evidence, assessment, synthesis, or external review of the updating process.
  • Only a third of the handbooks specified the people who should be involved in updating the guideline.
  • Time between updates ranged from less than one year up to five years.
  • Methods for identifying new evidence included carrying out limited searches or collecting alerts, or were not specified. Seventeen guidebooks covered how to carry out the literature search, of which half (8) covered how to modify the original strategy and six suggested using the original strategy.
  • Only a few guidebooks had information on publicising the update or highlighting changes to recommendations.
  • Another problem was variation in use of terminology for ‘living’ or ‘dynamic’ guidelines – the review authors recommend avoiding these terms.

What do NICE and SIGN say in 2021?

The 2020 version of the NICE handbook covers updating guidelines in Section 14.

Although this is only several pages long, there are many links to procedural descriptions elsewhere in the handbook. It covers the different types of guideline update; the general approach for procedures (other than when simply refreshing recommendations) is to follow the same processes as for the original guideline.

The 2019 SIGN Guidance devotes Section 9 to updating, but this only covers 3 pages and gives an outline rather than full details.


An updated systematic review on the topic would be useful; in the meantime, NICE gives a clear description of the updating process, which tends towards replication of the original development process.


Kredo T, Bernhardsson S, Machingaidze S et al. Guide to clinical practice guidelines: the current state of play. International Journal for Quality in Health Care. 2016;28(1):122-8.

NICE. Developing NICE guidelines: the manual [PMG20]. London: National Institute for Health and Care Excellence (2014, updated 2020).

SIGN. SIGN 50: a guideline developer’s handbook. Edinburgh: Scottish Intercollegiate Guidelines Network (2008, updated 2019).

Vernooij, RW, Sanabria AJ, Solà I et al. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implementation Sci. 2014;9(3). https://doi.org/10.1186/1748-5908-9-3.

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