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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Cardura XL

Pfizer continue to experience stock problems with Cardura XL. This problem appears to be affecting the 4mg to a greater extent than the 8mg strength.

Before considering switching back to immediate release (IR) doxazosin it may be worth considering if the patient should be on doxazosin anyway. It is a fourth / fifth line drug for hypertension now, especially after its arm in the ALLHAT study was stopped early. This is an ideal opportunity to review patients who are on this drug and optimise therapy to current thinking.

For those patients who are on a cocktail of antihypertensives and need to stay on doxazosin, Pfizer are suggesting using a lower dose to avoid postural hypotension (ie, Cardura 4mg XL to Doxazosin 2mg tablets) and review regularly, increasinging the dose (maximum 16mg od) until BP is at target or the patient can't take any more becuase of side effects.

Another possible approach would be to switch to an equivalent dose (ie, Cardura 4mg XL to Doxazosin 4mg tablets). The patient can be counselled regarding BP related problems, perhaps with a recommendation to half tablets for the first few days

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Inegy is a new product that containes Simvastatin and Ezetimibe and it is licensed for hypercholesterolaemia.

The combination product would mean that a patient already taking the two separate products, or a patient who is not reaching target on a statin alone could be prescribed a single tablet that would have two cholesterol lowering effects.

However, the combination product cost approximately £8 per month more than the separate ingredients. This is equivalent to an additional 2 patients on treatment with the statin alone.

Action: At this time there can be no good reason to use this product over the separate ingredients, except perhaps for those patients with a known and significant compliance problem.

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Prescribing Bulletin 2

1/ Gaviscon

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.

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Prescribing Bulletin 1

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.

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Important Information

Welcome to my blog (or web log).

I work for the NHS (National Health Service) in the North West of England. In my work I advise doctors on medicines, appraising the usefulness of each product against those already available.

This blog aims to publish the prescribing information I produce in my NHS work for ease of access and to enable searching. As such the content will be a brief resume rather than a complete review of all of the evidence.

The content of this site should be read in conjunction with the appropriate Guideline (links will be available in the articles) and it should be noted that this sites interpretation of the evidence will apply to the majority of people for the majority of the time. However, there will always be exceptions where clinical discretion should be used.

The content of this blog will regularly change so please check back or subscribe to our emails or RSS feed.

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