Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Evidence is poor for silver dressings

The Cochrane Library has published a review of the available evidence for topical silver for wounds. The aim of the analysis was to assess the efficacy of silver-containing wound dressings and topical agents in preventing wound infection and aiding healing of wounds.

The review identified 26 trials involving 2,066 participants. The studies were mainly conducted in patients with burns although 6 were conducted in non-burn wounds. The trials also varied in design by comparing silver-containing products to non-silver dressings, silver-containing dressings to silver-containing cream and one trial compared two types of silver dressing.

The review noted that the overall quality of the studies was poor. Half failed to report funding of the study and only three trials reported any details of the blinding process or the randomisation sequence.

The authors of this review conclude that, "there is insufficient evidence to establish whether silver-containing dressings or topical agents promote wound healing or prevent wound infection". They also suggest that there is "not enough evidence to support the use of silver-containing dressings or creams". These conclusions are consistent with trial work published in the British Journal of Surgery.

Action: Clinicians should be aware of this review. Routine use of silver-containing dressings and topical agents should be avoided.

EMA updates clopidogrel - PPI advice

The European Medicines Agency (EMA) has issued an update (PDF) to their advice relating to the interaction between clopidogrel and proton-pump inhibitors (PPI).

Previous advice recommended against using clopidogrel in combination with PPIs due to concerns that the efficacy of clopidogrel may be reduced. This update notes that since this advice was issued several further studies have raised doubts as to whether the interaction is clinically significant.

It is also noted that two studies have confirmed that circulating levels of clopidogrel in the blood are reduced by omeprazole. This supports the hypothesis of an interaction between clopidogrel and omeprazole and esomeprazole. The review suggests that, "there are no solid grounds to extend the warning to other PPIs".

Action: Clinicians should be aware of this interaction. Concomitant use of clopidogrel with omeprazole or esomeprazole should be avoided where possible.

CKS Update - March 2010

Clinical Knowledge Summaries (CKS) has been updated in March 2010 for the following clinical areas:

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

NICE Guidance – March 2010

The National Institute of Health and Clinical Excellence has published new guidance for the month of March 2010.

This month there are three clinical guidelines that have an impact on primary care. Two guidelines cover assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin (QRG) and early management of unstable angina and non-ST-segment-elevation myocardial infarction (QRG). These guidelines will provide useful information for primary care clinicians.

There is also a guideline for the pharmacological management of neuropathic pain in adults in non-specialist settings (QRG). This guideline replaces previous recommendations for the management of painful diabetic neuropathy and also extends the guidance to cover non-diabetic conditions such as post-herpetic neuralgia and trigeminal neuralgia. The guidance details treatment options and referral to specialist services.

Action: Clinicians should be aware of these guidelines. They will be a useful resource for clinicians who see patients following episodes of cardiac chest pain or with neuropathic pain.

MeReC Bulletin - Angiotensin-II receptor antagonists

The National Prescribing Centre (NPC) has published a MeReC Bulletin (PDF) that reviews the evidence for the place in therapy for angiotensin-II receptor antagonists (A2RA).

This bulletin reviews the evidence for angiotensin converting enzyme inhibitors (ACEI), A2RAs and a combination of both agents. The strength of the evidence is then compared for indications including hypertension, heart failure, diabetes and chronic kidney disease.

The frequency of cough is also considered for both drug classes. Data from the ONTARGET study are used to produce a patient decision aid that summarises the small benefit of A2RAs in reduction of cough. The levels of prescribing of both drug classes in primary and secondary care settings and cost savings are projected based on an increased proportional use of ACEIs.

Action: Clinicians who prescribed ACEIs or A2RAs will find this bulletin useful and informative.

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