Prodigy has been updated in April 2012 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.
The Department of Health has announced earlier this year that prescription charges for England will rise by 25 pence to £7.65 with effect from 1st April 2012. Charges have already been abolished in Wales and Northern Ireland and Scotland planning.
The price for both the three and twelve month pre-payment certificates remain unchanged at £29.10 and £104.00 respectively. These represent good value for money for people who would be required to pay an NHS prescription charge and who expect to need 4 or more prescriptions in a 3 month period or 14 or more prescriptions in a year.
Action: Clinicians should be aware of the current prescription charge and also the value for money represented by pre-payment certificates.
The National Prescribing Centre has published a MeReC Bulletin (PDF), the third in a series of three, that focuses on the therapeutic areas of the QIPP agenda.
This bulletin focusses on type 2 diabetes and covers the following topics:
For each of these therapeutic topic areas within type 2 diabetes the evidence base is summarised and current prescribing data are reviewed.
Action: Clinicians who prescribe for patients with type 2 diabetes and who are striving to deliver value for money while maintaining or improving the quality of care will find this information is useful and informative.
The European Medicines Agency (EMA) has completed a review of strontium ranelate (Protelos®). A positive benefit-risk balance has been confirmed but new contraindications and revised warnings have been recommended.
The review was initiated by a French study that identified almost 200 adverse drug reports. Approximately half of these were reports of venous thromboembolism (VTE) and about a quarter were skin reactions. These are both known reactions; VTE was identified during clinical trials and skin reactions, including drug rash with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) identified during post-marketing surveillance.
The review identified that VTE risk is highest in individuals with a personal history of VTE or who are temporarily or permanently immobilised. Skin reactions are best managed by early diagnosis and immediate discontinuation of any suspect drug.
The EMA has made the following recommendations:
Action: Clinicians should be aware of this review and implement any changes to practice made necessary by these new recommendations.
The Lancet has published the results of a meta-analysis that aimed to assess the effects of daily aspirin on cancer incidence, mortality, and non-vascular death. The results of this study have been widely reported in the media (BBC).
This analysis included data from 51 studies involving 77,549 patients. 40,269 were assigned to treatment with aspirin and 37,280 to a control. Trials were included if treatment allocation was random and included an intervention of daily aspirin with a follow up of at least 90 days. The trials were designed to assess cardiovascular outcomes included both primary and secondary prevention of events. The dose of aspirin use varied.
The data were analysed for vascular and non-vascular deaths and cancer death data was accessed at individual patient level where this was possible, otherwise it was extracted from the original trial report or subsequent publications.
Aspirin was reported to reduced cancer deaths (OR 0·85, 95% CI 0·76–0·96, p=0·008) in a dataset involving 34 trials. This became more apparent after 5 years of follow up and onwards (OR 0·63, 95% CI 0·49–0·82, p=0·0005).
In an analysis of primary prevention trials using low dose aspirin cancer risk was reduced from 3 years onwards (OR 0·76, 95% CI 0·66–0·88, p=0·0003) and this effect was present in men and women. It was noted that benefits in reduction of cardiovascular events were offset by an increased risk of major bleeds initially but that over time both of these effects diminished while the cancer benefit appeared to remain.
An analysis to examine consistency across gender, age and smoking status found that the absolute risk reduction is approximately 3 cases per 1000 patient-years across all groups but only after a minimum of three years of treatment.
This analysis does have some limitations. The Women's Health Study was excluded from the analysis as the aspirin was dosed on alternate days; it has not shown a reduction in cancer incidence. The trials were not designed to examine cancer outcomes and in some cases the data for non-fatal cancers was patient reported although this was usually supported by a review of medical records.
The authors conclude that, "prevention of cancer could become the main justification for aspirin" but also note that "more research is required to identify which individuals are likely to benefit most".
An accompanying editorial notes that data are awaited for additional trials. Longer term follow up from the Women's Health Study and Physicians’ Health Study is also awaited, especially as these two studies have not shown a cancer benefit after 10 to 12 years of alternate day dosing of aspirin.
Action: Clinicians should be aware of this recent study and its broad media coverage. The absolute benefit is small; it may be wise to await national guidance before recommending aspirin for use in this way.
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