Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Education may help diabetic patients

The British Medical Journal has published the results of a study that aimed to assess the efficacy of a structured group education programme in improving disease control in patients with diabetes.

The study recruited 824 participants from 207 general practices in the UK and followed them up for a year. Patients were randomised to usual care or given six hours of education were delivered and regular assessments were taken including HbA1c, blood pressure, cholesterol profile, weight and quality of life.

Overall the study found that there was greater weight loss and a higher rate of smoking cessation in the intervention group. Patients also had a better understanding of their illness and were more optimistic about the future. There were no differences in HbA1c, blood pressure or lipid profiles.

The authors conclude that, "a structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness". Delivering structured education in the primary care setting appears to be worthwhile.

Action: Clinicians should ensure that patients who are newly diagnosed with diabetes are offered educational support about their illness. Delivery of this education in a structured group format may make better use of resources.

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February NICE Guidance

The National Institute of Health and Clinical Excellence has published new guidance for the month of February.

The published guidance includes Clinical Guidelines that cover Irritable bowel syndrome (IBS), osteoarthritis (OA) and prostate cancer.

The IBS guideline details the support, treatment and advice people should be offered by their GP and the circumstances that would require a referral to a specialist.

The osteoarthritis guideline details the diagnosis of OA, patient education, the place of exercise and physiotherapy, drug and non-drug treatments and indications for surgery.

The prostate cancer guideline details the tests, treatment, care and support that should be offered to men who have suspected or diagnosed prostate cancer.

Action: Clinicians who diagnose and treat patients with any of the above conditions will find these guidelines are a useful aid to management of these conditions.

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Digoxin may increase mortality in AF

Heart has published the results of an analysis into the survival of patients taking digoxin compared to those not taking digoxin in the SPORTIF III and V studies.

The Stroke Prevention using an ORal Thrombin Inhibitor in atrial Fibrillation (SPORTIF) studies involved 7,329 patients with atrial fibrillation (AF) at moderate to high risk of stroke. They were randomly assigned to warfarin or the oral direct thrombin inhibitor ximelagatran. This analysis was planned before the studies closed but the study was not blinded or randomised for digoxin.

Mortality was higher in digoxin users (255/3911 - 6.5%) compared to non-users (141/3418 - 4.1%). The hazard ratio was 1.58 [p<0.001, 95% CI 1.29 to 1.94]. After correcting for several baseline variables including study drug, age, race, gender, BMI, smoking status, BP and co-morbidities the risk remained; hazard ratio 1.53 [p<0.001 95% CI 1.22 to 1.92].

The authors conclude that, "digitalis, like other inotropic drugs, may increase mortality" but they also stress that the results must be viewed with caution because "patients were not randomised with respect to digitalis use".

The results of this analysis support the positioning of digoxin in the current NICE Guidance for AF. Beta-blockers or rate-limiting calcium antagonists are preferred initial monotherapy. Digoxin should only be used as monotherapy in predominantly sedentary patients.

Action: Clinicians should continue to follow the existing NICE Guidance using digoxin in combination with rate limiting drugs or as monotherapy in sedentary patients.

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Are antidepressants just placebos?

A meta-analysis of trials of antidepressants has been published in PLoS Medicine. The study concluded that differences between these drugs and the placebo effect are small. This study has been reported in the general media.

The study included data requested under the Freedom of Information Act from the Food and Drugs Administration for six antidepressant medications. Forty seven trial papers were examined including some studies that remain unpublished, of these 35 were included in the full analysis.

The analysis found that there was no clinically significant difference between the antidepressants and placebo except for the most severely depressed patients (those with a baseline Hamilton Scale of greater than 28). A recent NPCi blog has also reported on the apparent publication bias in studies of antidepressants.

Action: Media reporting of this study is likely to generate queries from patients and may affect confidence in treatment. Clinicians should continue to follow existing NICE guidelines including making use of non-drug interventions and watchful waiting in milder cases with drug treatment reserved for more severe cases.

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February CKS Update

Clinical Knowledge Summaries (CKS) has been updated in February for the following clinical areas:

Action: Clinicians who see patients with any of these conditions may find the updated information useful when reviewing current clinical practice.

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