Prescribing Advice for GPs

Obesity

August 8, 2005 on 10:57 am | In Prescribing Extra - Other |  Print | No Comments

The Royal Pharmaceutical Society released Practice Guidance on Obesity to Pharmacists. This document is clear, detailed and most importantly concise (two sides of A4).

It defines the terms Overweight and Obesity and provides and insight to the extent of the problem in the UK as well as information on the causes, consequences and prevention of obesity.

Perhaps most clearly of all though it details what must be done at individual level to combat obesity with the following wording:

Quote: “Weight loss can be achieved only by reducing energy intake to a lower level than energy expenditure. The healthiest way yo manage this is through a diet relatively low in saturated fat, and increased physical activity. There are no miracle diets.”

Action: Clearly the only way to loose weight is to:

• eat less
• exercise more

This is the message we should be communicating to all patients who are advised to loose weight for health reasons.

2005 Influenza Immunisation Programme

August 7, 2005 on 9:41 am | In Prescribing Extra - Other |  Print | No Comments

The Department of Health has released details of the 2005 Influenza Vaccination Programme. This year will see the addition of a further two groups of patients who should be offered the vaccination. These are:

• People with chronic liver disease
• People who are the main carer for an elderly or disabled person whose welfare would be put at risk if the carer falls ill

The release of this information has prompted several requests for the update Patient Group Direction (PGD) for Influenza Vaccinations. The PGD will be made available as soon as we are able to obtain the required information from the manufacturers of the vaccinations, this is likely to be September.

Action: The PGD will be disseminated as soon as it is complete following the release of information about this years influenza vaccination products. Until the PGD is released any influenza vaccinations must be administered with a Patient Specific Direction (or Prescription). As the vaccinations are as yet unavailable, this situation will cause not problems.

National Antiplatelet Guidance Published

August 6, 2005 on 8:31 pm | In Prescribing Extra - Other |  Print | No Comments

Clopidogrel (Plavix) is being used much more as time passes as an alternative when patients cannot tolerate Aspirin as an antiplatelet follwing a cardiovascular event, such as a heart attack or stroke.

NICE recently published a Technology Appraisal in respect of Clopidogrel and Dypridamole (Persantin) in occlusive vascular events. It has also been summarised by the NPC in a recent MeReC Bulletin.

In summary:

For Secondary Prevention

• Low dose Aspirin (75mg daily) is first line and should be prescribed indefinitely
• Dypridamole (prescribed as Asasantin) is of additional benefit for the first two years after a stroke
• Clopidogrel is a suitable alternative to aspirin where aspirin is contraindicated or not tolerated

For Primary Prevention

• Low dose Aspirin (75mg daily) is first line and should be considered for all patients over the age of 50 at higfh risk of CVD, provided hypertension is controlled
• Clopidogrel and Dypridamole are neither indicated nor licensed for Primary Prevention

Action: Ensure you are using antiplatelets appropriately to ensure greatest benefit to the patient in terms of effect and safety.

NSAID Cardiovascular Safety Review

August 6, 2005 on 10:28 am | In Prescribing Extra - Other |  Print | No Comments

The MHRA have conducted a full review of the cardiovascular safety of NSAIDs and concluded that the availbale data does not support a change to current practice.

The current advice can be found in the full review. In summary:

• Use Paracetamol based analgesia as first line where ever possible
• prescribing of NSAIDs should be based on overall safety profiles (including cardiovascular and gastrointestinal safety) as set out in product information, and risk factors for individual patients
• all patients should take lowest effective dose of NSAIDs or COX-2 inhibitors for the shortest time necessary to control symptoms

Particular to COX-2 Inhibitors:

• patients with established ischaemic heart disease (IHD), cerebrovascular disease should not take coxibs: celecoxib (Celebrex), etoricoxib (Arcoxia), and parecoxib (Dynastat)
• for patients with risk factors for cardiovascular events, individual risk assessment is appropriate before a selective COX-2 inhibitor is prescribed

Action: Ensure that you are using Paracetamol based analgesia as first line and that appropriate risk assessments are carried out on patients prescribed NSAIDs.

Vesicare - STAR Study doesn’t shine

August 5, 2005 on 4:38 pm | In Prescribing Extra - Drugs |  Print | No Comments

Solifenacin (Vesicare^®)is a new generation antimuscarinic, recently licensed for the treatment of overactive bladder. The product license was granted based upon the S.T.A.R Study - but do the results shine?

Well, yes and no is the honest answer. Vesicare was statistically better in terms of urgency episodes and incontinence episodes over 24 hours compared to Tolterodine XL. How this translates in clinical practice is difficult to see when give a 6.01% reduction in urgency episodes compared to a 5.84% reduction with Tolterodine XL.

But this is not the whole story, the promotional material makes no reference to side effects of the new drug, this is unusual as the number of patients who have tried the drug will be quite small and therefore the drug should have few reported side effects. When referring to the trial paper there may be a reason why. Patients treated with Vesicare were more likely to get dry mouth and constipation when compared to Tolterodine XL. Statistical analysis was not carried out on these data so significance is unknown, but the relative risk of side effects is 16.6% higher with Vesicare.

Action: Given the marginal clinical benefit of Vesicare balanced with the greater likelihood of side effects this drug is not appropriate for first line use in patients with overactive bladder. It may be of use in those patients who feel their symptoms are still problematic following treatment with Tolterodine XL.