Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Duloxetine for Depression

Duloxetine (Cymbalta) is licensed for depression as well as Stress Urinary Incontinence

This new antidepressant has not been allowed onto the formulary of Lancashire Care Trust. Also, there are concerns from some of the trial data and more recently from clinical use of a relationship between this drugs use and impulsive suicide attempts

Finally, once again this antidepressant has been shown to be effective in moderate to severe depression, not mild depression. Mild depression is the most commonly seen presentation of depression in Primary Care.

Action: There is no evidence to support the use of any antidepressant as first line in Mild Depression. The additional fact the Cymbalta is not on the local Care Trust formulary and the possible link with suicides means that this drug does not currently have a place in the treatment of depression in Primary Care.

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Impact of MMR Shortage

Due to the recent outbreaks of mumps and the ensuing "catch up" campaign in 16-24 year olds, there is a national shortage of the UK licensed MMR Vaccine (both MMR-II and Priorix).

The Department of Health has endeavoured to provide an interim solution to this shortage by procuring extra vaccine supplies from Germany and the USA. Your surgery may already have received a delivery of these imported vaccines.

Several issues have been raised in relation to this situation that can broadly be split into licence issues and administration issues.

  • Product Licence
    The imported vaccines were not intended for UK use and are therefore not licensed in the UK. They are however identical to the UK product and consideration of this fact should be taken into account before deciding to use the product or not.
  • Administration
    The majority of vaccines are administered under Patient Group Directions (PGD). The existing PGD does not name the German or American vaccine and therefore these vaccines cannot be used when operating under the PGD. If you only have the imported products available, you will have to obtain a Patient Specific Direction - this can be a Prescription, a clinic list print out with a written annotation for vaccination by a GP or and entry made in the electronic computer record by a GP.

Action: Practices should be confident in using the imported vaccines as they are identical to the UK version of the MMR vaccine. When using the vaccine ensure you have appropriate authorisation to administer it before use, in the form of a Patient Specific Direction.

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Cipralex

Escitalopram(Cipralex) is one of the isomeric forms of the drug citalopram. The manufacturers found that citalopram actually consisted of two versions of the same molecule, with one apparently more active than the other. They refined this 'more active' version into a new drug.

The promotional material supporting escitalopram includes a trial1 that put it head-to-head with citalopram in patients with major depression (i.e. not routine primary care patients). The trial looked at reduction in MADRAS Depression score (a validated scale).

At the end of the trial period of 8 weeks escitalopram was statistically better than citalopram. However, on closer examination of the paper the statistical difference may not equate to a clinical difference. The difference in MADRAS scores between the two drugs was 2 points with confidence intervals on each estimate of approximately 12.

Clinically a difference of 2 points measured on a scale of 60 is not going to be noticeable. Furthermore, although the paper demonstrates statistical difference the confidence intervals on the point estimates overlap massively and therefore the findings are not conclusive.

Action: There are three things to consider here:

  1. Escitalopram has not been shown to be clinically better than citalopram. Citalopram or Fluoxetine remain first line antidepressants, based upon predominant symptoms and where an antidepressant is clinically appropriate. See NICE Guideline
  2. This trial was in Major Depression and therefore does not extrapolate to primary care patients with Minor Depression. Antidepressant medication is not a suitable first line treatment for minor depression, unless it is recurrent.
  3. This drug has not been placed on the Lancashire Care Trust Formulary so patients who are treated and then referred may be changed anyway.

References

  1. Prospective, multicentre, randomized, double-blind study of the efficacy of escitalopram versus citalopram in outpatient treatment of major depressive disorder. International Clinical Psychopharmacology. 20(3):131-137, May 2005. Moore, N; Verdoux, H; Fantino, B

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