Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

ABPI code of Practice 2011

As previously discussed, the Association of the British Pharmaceutical Industry (ABPI) recently ratified some changes to the industry Code of Practice with the aim of increasing "transparency and trust".

The Code of Practice 2011 is now available to download (PDF) from the Prescription Medicine Code of Practice Authority. Printed copies will be available before the end of the year.

Action: Clinicians may wish to access the new Code of Practice in order to familiarise themselves with the changes.

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Surgery for hypertension?

The Lancet has published the results of a study that aimed to assess the efficacy and safety of catheter-based renal denervation for reduction of blood pressure in patients with treatment-resistant hypertension. This study has been reported in the general media (BBC).

The study recruited 106 patients with a systolic blood pressure of 160mmHg or more despite taking three or more antihypertensive drugs. Participants were randomly selected for an intervention of renal denervation by catheter-based short burst radio waves or continued on previous treatments. The primary endpoint was systolic blood pressure measured at six months.

52 patients underwent the procedure compared to 54 controls. There was a statistically significant difference in blood pressures between the two groups at six months of 33/11mmHg (p<0·0001). Blood pressure was reduced in the intervention group by an average of 32/12mmHg compared to an increase of 1/0mmHg in the control group.

The authors conclude that, "catheter-based renal denervation can safely be used to substantially reduce blood pressure in treatment-resistant hypertensive patients".

It should be noted that this new technique is still experimental and is an invasive procedure compared to the current method of treating raised blood pressure with lifestyle measures and medication. Further research is needed to assess the long term cardiovascular benefits and effects of this procedure. Patient acceptability of this invasive procedure compared to drug therapy will also need consideration.

Action: Clinicians should be aware of this research. Media coverage of this innovative procedure may generate patient queries.

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MeReC Extra 47

The National Prescribing Centre has published MeReC Extra 47 (PDF) which discusses the latest information regarding ezetimibe (Ezetrol®), antipsychotic drugs and the management of infections in primary care.

The section covering ezetimibe reviews a recent editorial in the Drugs and Therapeutics Bulletin that questioned whether this drug provides good value for money. This discussion reviews the recommendations from NICE and notes that the "acquisition cost considerably over simvastatin 40mg". It is also noted that the current evidence base for ezetimibe has not shown improvements in patient orientated outcomes.

The section covering antipsychotic drugs discusses the results of a meta-analysis that compared first and second generation antipsychotic drugs (also termed typical or conventional and atypical respectively) in early psychosis. This analysis found no significant differences in efficacy or rates of discontinuation between the two classes. There was more weight gain with the second generation drugs and more extrapyramidal symptoms with the first generation drugs. The current NICE guidance does not favour a particular class of antipsychotic so drug selection should be tailored to the individual patient after consideration of the side effect profile and acquisition cost.

This issue also directs readers to updated advice from the Health Protection Agency in the management of common infections in primary care. This update takes into account the advice of other organisations, such as NICE, SIGN and CKS.

Action: Clinicians who prescribe lipid modifying drugs, antipsychotic drugs or who treat infections in primary care will find this information useful and informative.

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SMC Update - November 2010

The Scottish Medicines Consortium (SMC) has issued its monthly advice on new medicines.

Eslicarbazepine (Zebinix®) has been accepted for restricted use after a resubmission for patients with highly refractory epilepsy who remain uncontrolled with existing anti-epileptic drugs as adjunctive therapy in adults with partial-onset seizures with or without secondary generalisation.

Oxycodone hydrochloride injection (OxyNorm®) has been accepted for restricted use for the treatment of moderate to severe pain in patients with cancer who have difficulty in tolerating parenteral morphine or diamorphine therapy.

Glucosamine sulphate (Glusartel®) has been rejected for use in patients for the relief of symptoms in mild to moderate osteoarthritis (OA) of the knee. The economic analysis was not sufficiently robust to gain acceptance.

Action: Clinicians should be aware of the recommendations of the SMC. Routine use of rejected and restricted medicines should be avoided.

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Epanutin supply problems

The manufacturer of Epanutin®, a brand of phenytoin, has written to healthcare professionals advising of a short term supply problem. Phenytoin is used in the treatment of epilepsy. A copy of the letter (PDF) has been made available by the Pharmaceutical Services Negotiating Committee.

The supply problem is affecting the 25mg, 50mg and 100mg strengths. The 25mg and 50mg strengths are expected to be back in stock by week ending 19th November 2010 with the 100mg strength expected week ending 26th November 2010 although stock imported from Greece is expected at the same time as the lower strengths.

It should be noted that phenytoin is also available in a 100mg tablet but a permanent change to this product would be expensive. The Drug Tariff currently lists 28 tablets at £30.00 compared to £2.83 for 84 capsules.

Action: Clinicians should be aware of this supply shortage. Interim prescriptions for alternative strengths or formulations may be necessary while the supply chain is restocked.

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