1/ Benzodiazepines in Older People
A paper recently published in the BMJ reviewed 24 trials of sedatives in older people with insomnia. This study calculated an NNT of 13 for improved sleep quality against an NNH of 6 for any adverse event. This indicates that an adverse event is twice as likely as improved sleep. There are limitations in this study as there were no corrections for dose, half life or potency of the sedative, however it does make clear that the benefits of sedatives in older people are marginal and are outweighed by the risks.
Action: Review sedative prescribing for insomnia in older people and encourage patients to consider stopping treatment whenever possible.
The blood pressure lowering arm of the ASCOT study was recently published and reported in the general media. The trial did not reach statistical significance for the primary outcome and there were blood pressure differences between the two arms that could account for all of the differences noted in the secondary and post-hoc tertiary end points. Despite this the study is being heralded as a landmark trial.
It certainly aids our understanding of hypertension management and rightly, NICE and BHS have agreed to work together to clarify the position of all antihypertensive agents to aid clinicians. In the meantime this study should not negate 40 years of experience in hypertension. Clinicians should continue to follow current guidelines, preferably the NICE Guideline of Hypertension Management, until the new Guidance becomes available.
Action: Continue to follow Hypertension Guidelines to aid prescribing in Hypertension. The NICE Guideline for Hypertension is recommended.
3/ NICE Primary Prevention with Statins
NICE have published the Final Appraisal Determination for Statins in Prevention of Cardiovascular Events. This document gives the clearest indication yet of the direction of the final appraisal. There is no mention of cholesterol targets in the document but it seems likely that the Primary Prevention risk threshold for treatment will be rolled back to 15% CHD risk (or 20% CVD) as originally detailed in the National Service Framework for CHD. The cost models produced by NICE are based upon using Simvastatin 20mg and 40mg. Simvastatin is currently the most evidence-based and cost-effective statin.
Action: Clinicians should be aware of the imminent NICE Guidance. Simvastatin should be used as the statin of choice wherever possible.
You may recall that in June the use of Algicon or Peptac was recommended in place of Gaviscon following the decision to remove Gaviscon from Prescription.
It is therefore unfortunate that manufacturers of Algicon are having stock problems and are currently unable to supply Algicon. As yet, they have not made a decision to discontinue this product although this outcome seems increasingly likely.
Apologies to those of you who have already implemented the recommendation, obviously Algicon would not have been a recommended option if it had been known there would be future problems.
The manufacturers of Peptac have confirmed that are there are no current stock problems or any plans to discontinue the product. The recommendation that was originally made still applies with some minor revision.
Action: Any patient on an Alginate and concurrent GI medication for acid (PPI or H2RA) should have the Alginate (Gaviscon or Algicon) stopped and have their symptoms re-assessed. Patients on Gaviscon or Algicon only should be changed to Peptac.
A letter and information pack was sent to GPs about recently announcing that Gavsicon was being discontinued in NHS pack sizes. For several reasons including assessment of sodium content and the fact that patients on Gaviscon don't use spoons to measure doses we recommended that you did not change prescriptions to Gaviscon Advance.
Action: Any patient on a concurrent GI medication for acid (PPI or H2RA) should have the Gaviscon stopped and be re-assessed. Patients on Gaviscon only should be changed to Algicon (or Peptac if for pregnancy).
2/ Aspirin and PPI safer than Clopidogrel
A POEM published in the BMJ in May 2005 presented the results of a study comparing Aspirin and PPI with Clopidogrel. The study showed that while there were bleeding complications in the clopidogrel group there were none in the Aspirin and PPI group.
Action: In patients with significant GI history who need an antiplatelet for secondary prevention, consider using aspirin and omeprazole in combination instead of clopidogrel.
3/ Glyceryl Trinitrate for Anal Fissures
It has recently come to my attention that prescriptions for GTN for anal fissures are often generated incorrectly. The product strength as recommended in the BNF should be 0.2% to 0.3% however this product is not available on the market and must be made specially. This is further confused by the fact that there is a product available in 2% (licensed for Angina). Prescriptions generated for the latter item will cause headaches and dizziness without any beneficial effect if applied to fissures. There is a new product available in 0.4% strength called Rectogesic that may be more appropriate now.
Action: Take care when generating prescriptions for GTN for the treatment on Anal Fissures, ensure you choose the correct strength or amend the prescription by hand.
1/ Generic Lamotrigine
You may be aware that the patent on Lamictal, an anti-epilepsy drug from GSK, is due to expire soon. The DH have taken the unusual step of re-assuring prescribers that the generic will be a safe and effective alternative to the brand. This view is also supported by the Medical Director at the National Society for Epilepsy.
Action: Continue to prescribe Lamotrigine as generic, change prescriptions to brand only where you clinically feel this action is appropriate.
2/ Esomeprazole on Hospital Discharges
You may be getting some discharge notes from the hospital trust, usually written by SHOs asking for patients to be prescribed Esomeprazole (Nexium). This drug is not on the hospital formulary and is initiated by the hospital. The evidence available on the efficacy between PPIs shows that like for like there is nothing to choose between them.
Action: Continue to prescribe Omeprazole capsules at a suitable dose for patients where a PPI is indicated.
3/ Glucophage SR
A sustained release version of metformin has been released by Merck. They are claiming that the product is better tolerated than 'instant release' (IR) metformin. This assertion is backed by an observational study but a randomised controlled trial (RCT) did not support this finding. The RCT showed that the SR version was no better tolerated then the IR version. There is also a greater limitation on the dosing scope (2000mg maximum compared to 3000mg with IR metformin) and the substantially increased cost there can be no good reason to use Glucophage SR.
Action: Continue to prescribe the IR version of Metformin to those diabetic patients where metformin is indicated.