Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Medicines non-adherence costs millions

According to a costing report published by the National Institute for Health and Clinical Evidence (NICE) the cost to the NHS of non-adherence to medicines could be as high as £196 million.

In 2006–07, the cost of hospital admissions (excluding critical care costs) was approximately £16.4 billion. 3-4% of these admissions are as a consequence of avoidable medicine-related illness with 11-30% of this subgroup arising from patients not taking medicines as recommended by the prescriber. This would place a cost estimate of between £36 million and £196 million in terms of the cost of the hospital admission alone.

NICE note that the potential for savings in terms of reducing hospital admissions and improved adherence are large but impossible to quantify. This may be especially true if more patients choose not to take medicines since this may result in an increase number of admissions for disease related complications.

Action: Clinicians should still aim involve patients in making decisions about prescribed medicines. This strategy may reduce medication related harms and generate savings.

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January NICE Guidance

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

There are two guidelines that may impact on primary care, a public health intervention looking at promoting physical activity for children and young people (QRG) and a clinical guideline covering medicines adherence (QRG).

NICE recommends that clinicians promote physical activity based on a minimum of 60 minutes moderate to vigorous physical activity a day. This can include opting for a physically active mode of travel for some journeys each day, for example travel too and from places of education. Clinicians should also be aware of locally arranged activity opportunities for sign posting.

The guidance on medicines adherence discusses both intentional and non-intentional non-adherence. It is noted that a patient has the right to decide not to take a medicine and that non-adherence is common.

NICE encourage clinicians to involve patients in decision making about their medication while understanding the patient's perspective. Adherence can be supported by exploring levels of adherence and addressing beliefs, concerns and practical problems. The importance of regular review of long term medication and good communication between healthcare professionals is also highlighted.

Action: Primary care clinicians should be aware of these new guidelines. Clinicians who prescribe or review medication and who consult children and young people will find this information useful.

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Smoking cessation and weight gain

The Cochrane Library has published a review of interventions that aim to prevent weight gain following smoking cessation.

According to the review, most people who stop smoking gain weight, on average about 7kg in the long term. The review examined data for pharmacological and behavioural interventions.

Pharmacological interventions including treatment with fluoxetine produced significant weight loss at the end of treatment but these effects were not found to persist at 6 or 12 months.

Of the behavioural interventions assessed only very low calorie diets and cognitive behavioural therapy (CBT) were associated with improved abstinence and reduced weight gain at end of treatment and at long-term follow up. Exercise interventions had no effect during treatment but if continued these were found to have an effect at 12 months.

Overall the authors conclude that, "the data are not sufficient to make strong clinical recommendations for effective programmes". The plain language summary indicates that drug therapies are not a long term solution. Behavioural interventions that are individualised are most successful but lack long term evidence.

Action: The risk of weight gain may pose a barrier to smoking cessation and continued abstinence for many people. Clinicians should be aware of these barriers and provide tailored lifestyle advice if this would encourage smoking cessation.

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Safety review on methylphenidate

The European Medicines Agency has completed a safety review and made on several recommendations to ensure safer use of methylphenidate.

According to the press release safety concerns have been raised in recent years in terms of cardiovascular and cerebrovascular risks. A question and answer document provides more details about the review.

The review concludes that the benefits of methylphenidate continue to outweigh the risks but that prescribing information needs to be made more consistent across the European Union. It is also recommended that the product information for all methylphenidate products contain the following:

  • Before treatment, all patients should be screened to see if they have any problems with their blood pressure or heart rate. The family history of cardiovascular problems should also be checked. Any patients with these problems should not be treated without specialist evaluation
  • During treatment, blood pressure and heart rate should be monitored regularly. Any problems that develop should be investigated promptly
  • There is a lack of information on the long-term effects of methylphenidate. For patients who take methylphenidate for more than a year, doctors should interrupt treatment at least once a year to determine whether continued treatment with methylphenidate is necessary
  • The use of methylphenidate could cause or worsen some psychiatric disorders such as depression, suicidal thoughts, hostility, psychosis and mania. All patients should be carefully screened for these disorders before treatment and monitored regularly for psychiatric symptoms during treatment
  • The height and weight of patients treated with methylphenidate should be monitored during treatment

Action: Clinicians should be aware of these recommendations and ensure that screening and monitoring checks are completed as suggested.

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MeReC Extra 37

The National Prescribing Centre (NPC) has published MeReC Extra 37 (PDF).

This MeReC discusses recent concerns regarding the cardiovascular safety of anticholinergics in chronic obstructive pulmonary disease (COPD). These concerns were raised in a recent meta-analysis however the data are not conclusive and more work is required. The article recommends discussing the risks and benefits of treatment with patients and provides numerical data for heart attacks in comparison to reductions in exacerbations and hospital admissions.

This publication also discusses recent research that indicated a lack of benefit for aspirin in primary prevention of cardiovascular events in patients with diabetes. The study in question was too small to definitively rule out a benefit for aspirin however it is still important to manage cardiovascular risk factors in people with diabetes mellitus including smoking cessation, blood pressure management and treatment with a statin.

Action: Clinicians who see patients with COPD or diabetes will find this information useful and informative.

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