Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

HPA give flood health advice

The Health Protection Agency has issued several documents containing information following the recent floods that have affected large areas of Britain.

The documents cover:

Action: Clinicians in areas affected by flooding should be aware of these documents and make them available to anyone living or working in a flooded area.

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MTRAC reviews diabetes drugs

The Midlands Therapeutics Review and Advisory Committee has published reviews of pioglitazone, rosiglitazone and exenatide.

The review of pioglitazone suggests that this drug is suitable for prescribing in primary care but only after metformin and sulphonylureas.

The review of rosiglitazone suggests that this drug should not be initiated in primary care. It is also recommended that patients who are well controlled and stable on treatment can be continued until further data become available to aid decision making.

The review of exenatide suggests that this drug is suitable for initiation in secondary care and once the patient is stabilised it can be continued in primary care.

Action: Clinicians who treat diabetes in primary or secondary care will find these product reviews to be a useful summary of the currently available evidence.

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MHRA advice on rimonabant

The Medicines and Healthcare products Regulatory Agency has issued advice regarding the use of rimonabant (Acomplia®) in patients taking antidepressants or those with major depression. This announcement follows the EMEA review of the safety of this drug.

The risk of psychiatric side effects with rimonabant has caused the MHRA to advise that it should not be prescribed to patients with major depression or those being treated with antidepressants. Evidence suggests that 1 in 10 patients who take rimonabant may develop these psychiatric side effects.

Action: Previous advice placed rimonabant as a last line treatment option. This new advice will further restrict prescribing of this drug to patients who are not taking antidepressants and who have no personal history of depression.

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Cochrane Library reviews clopidogrel plus aspirin

The Cochrane Library has published a review of the combination of clopidogrel and aspirin versus aspirin alone for the prevention of cardiovascular disease.

The analysis reviewed randomised studies of more than 30 days duration comparing the combination of clopidogrel and aspirin with aspirin alone or aspirin and placebo.

The literature search identified 2 studies, CURE and CHARISMA. In CURE it was found that, for every 1,000 patients with acute non-ST segment coronary syndromes treated for 9 months, combination treatment would avoid 23 cardiovascular events at the expense of 10 major bleeds. In CHARISMA is was found that, for every 1,000 patients with a high cardiovascular risk (defined as existing CVD or risk factors for CVD) treated for 28 months, combination treatment would avoid 5 events at the expense of 3 major bleeds.

The authors conclude that the combination should not be used in place of long-term aspirin therapy in patients with established cardiovascular disease or those at high risk for the prevention of cardiovascular disease. They also conclude that in patients with acute non-ST segment coronary syndromes the benefits outweigh the harms and "treatment should be considered".

Action: The addition of clopidogrel to aspirin therapy is not necessary for the majority of patients. The exception is in acute coronary syndromes where the National Institute for Health and Clinical Excellence recommends the combination for a period of 12 months, after which treatment is continued with low-dose aspirin alone.

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Cochrane Library reviews rosiglitazone

The Cochrane Library has published a review of rosiglitazone for type 2 diabetes. PharmaTimes has reported on the publication and on the defence offered by the manufacturers.

The Cochrane analysis reviewed randomised studies of rosiglitazone of at least 24 weeks duration with placebo or active comparators. The RECORD study was not included in this review as the trial is ongoing. The aim of the review was to assess the effects of rosiglitazone in the treatment of type 2 diabetes.

The authors of this review found that rosiglitazone did not demonstrate clinically significant differences in glycaemic controlled, measured by HbA1c, when compared to other oral hypoglycaemics. Additionally, there were no data in any of the studies for outcomes of mortality or diabetic complications and the adverse event of oedema occurred approximately twice as often in patients taking rosiglitazone.

In light of the recent safety concerns relating to the risk of fracture and myocardial infarction the authors therefore conclude that clinicians should adopt a cautious approach to rosiglitazone and "other antidiabetic medications should be employed".

Action: It would seem prudent to suspend initiation of rosiglitazone in new patients and to review the risks and benefits of continued treatment in patients on existing therapy. As previously discussed, metformin is the first line hypoglycaemic with a sulphonylurea or pioglitazone suitable second line choices.

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