Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

NPSA anticoagulant alert

The National Patient Safety Agency (NPSA) has issued a patient safety alert detailing steps that can make anticoagulant therapy safer.

The alert recommends that prescribers and pharmacists:

  • Ensure that blood clotting (International Normalised Ration - INR) is being monitored regularly before issuing or dispensing repeat prescriptions for oral anticoagulants
  • Consider the impact of clinically significant interactions when co-prescribing or dispensing medication with oral anticoagulants ensuring that safety precautions have been made including additional monitoring

Action: Healthcare professionals who prescribe or dispense oral anticoagulants need to be aware of this Patient Safety Alert and should ensure they act upon these recommendations.

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NICE Guidance to reduce substance misuse

The National Institute of Health and Clinical Excellence (NICE) has published a public health intervention guidance aimed at reducing substance misuse among vulnerable young people.

The document recommends a range of interventions for NHS and non-NHS practitioners including those working in local authorities and the education, voluntary, community, social care, youth and criminal justice sectors.

For NHS primary care practitioners the recommendations mainly focus upon identification of individuals who are at risk of misusing substances and onward referral to appropriate services including education welfare services, children's trusts, child and adolescent mental health services and school drug advisers.

Action: Clinicians should ensure they are aware of their locally available services and referral criteria to access these services. Individuals who are identified as being at high risk of substance misuse should be referred into an appropriate service.

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A spotlight on the ILLUSTRATE Trial

The New England Journal of Medicine has published the results of the ILLUSTRATE Trial1. The full article is currently available through early release.

This trial aimed to assess the impact of torceptrapib, a drug that increases level of high-density lipoprotein cholesterol (HDL-C), on progression of atherosclerosis. All development work on torceptrapib was stopped late last year after an increased number of deaths were recorded in patients taking this drug, possibly as a consequence of increases in blood pressure.

The study recruited 1,188 patients and treated low-density lipoprotein cholesterol (LDL-C) to below 2.59mmol/L using atorvastatin. Patients were then randomised to torceptrapib or placebo.

Despite the torceptrapib arm significantly increasing the level of HDL-C (by 61% relatively speaking) there was no difference in progression of atherosclerosis with a 0.12% increase in the active arm and a 0.19% increase in the placebo arm. This study also noted increases in blood pressure with a mean difference in systolic blood pressure of 4.5mmHg. There were also more cardiovascular events noted in the active arm of the study although these were not statistically significant and the study was not powered to detect these differences.

According to PharmaTimes, the manufacturer of atorvastatin is "putting a positive spin" on these results by highlighting that atorvastatin treatment alone (in the placebo arm) halted progression of atherosclerosis. This assertion would of course require further investigation since the original study was not designed to assess this outcome. Additionally, it remains unclear if halting or reversing atherosclerosis directly delivers reductions in fatal and non-fatal cardiovascular events.

Action: Simvastatin 40mg remains the statin of choice for lipid lowering therapy as required in the prevention of cardiovascular events.

  1. ILLUSTRATE is the Investigation of Lipid Level Management Using Coronary Ultrasound to Assess Reduction of Atherosclerosis by CETP Inhibition and HDL Elevation

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BNF 53

The 53rd Edition of the British National Formulary is currently being printed and distributed.

Priority is given to the print version before the web version is updated.

The print version is distributed by the Department of Health to Dentists, Doctors, Nurses and Pharmacists providing NHS services.

Action: All clinicians should start using BNF 53 as soon as the print version arrives.

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NICE to face judicial review

The two manufacturers of donepezil are taking the National Institute for Health and Clinical Excellence (NICE) to court after the recently published and controversial guidance on Alzheimer's drugs according to the BBC.

This particular guidance is a Technology Appraisal, NICE detail on their website that the process involves consideration of two factors:

  1. Clinical evidence - measuring how well the medicine or treatment works
  2. Economic evidence - measuring how well the medicine or treatment works in relation to how much it costs the NHS - does it represent value for money?

This judicial review may reveal more details of the calculations used by NICE to derive an indication of efficacy and value for money however the full guidance reveals the full detail the process with examination and interpretation of the evidence covering some 40 pages!

This action has the unfortunate consequence of diverting resources including staff time and money away from generating guidance for the benefit of the NHS. A speedy resolution would be of greatest benefit to the NHS.

Action: Clinicians who prescribe treatments for Alzheimer's disease should continue to implement the current guidance until the outcome of this review is completed.

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