Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Levonelle-2 (POM) to be replaced

The Emergency Hormonal Contraceptive tablet, Levonelle-2 will be replaced from November 2005 with Levonelle-1500.

The new product contains a dose of 1500 micrograms of levonorgestrel in a single tablet that is taken as a single dose. This replaces the current method of taking two tablets (of 750 micrograms) 12 hours apart. The summary of product characteristics will be made available online at launch. [Update: SPC now available]

The new product is the same price and should offer greater convenience to patients.

Action: All clinicians (Doctors, Nurses and Pharmacists) who are involved in the provision of Emergency Hormonal Contraception should be aware of the change in product name and method of administration.

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Systematic Review of Beta-blocker Benefit

The Lancet has published a systematic review of Beta Blockers in Hypertension. The title of the review is "Should β blockers remain first choice in the treatment of primary hypertension? A meta-analysis". The review has been picked up already by the Daily Mail and the newspapers article is available online.

The review consisted of two parts. Firstly, a review of 7 placebo controlled trials totalling about 27,500 patients. Secondly, a review of 13 active comparator trials totalling about 160,000 patients. The review looked at strokes, myocardial infarction and all cause mortality as endpoints. It should be noted that all figures quoted below are relative risk reductions (RRRs). Actual risk reductions (ARRs) or calculated numbers needed to treat (NNTs) would be more helpful in clarifying the full impact of the differences.

In comparison to placebo, Beta Blockers reduced the relative risk of stroke by 19%. No benefit was shown overall on myocardial infarctions or all cause mortality.

In comparison to active treatments, it was found that the 'newer' drugs reduced the relative risk of stroke by 16%. There were no differences in relation to myocardial infarctions or all cause mortality.

The Lancet article questions the place of Beta Blockers as a first line treatment for Hypertension. The NICE Guideline for Hypertension places Thiazides as first line anti-hypertensives. These guidelines do not place Beta Blockers as first line. The Daily Mail article puts spin on the numbers by down playing the stroke risk reduction of beta blockers compared to placebo and up playing the benefits of the 'newer' drugs.

Action: Prescribers should continue to follow the NICE Guideline for Hypertension. Patients on mono-therapy with Beta Blockers who have stable and controlled blood pressure should be re-assured about the efficacy of the medication. Patients who are newly diagnosed or who are not at optimal blood pressure should be managed as per the NICE Guideline.

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ASH release new guidance

Action on Smoking and Health (ASH) has released new guidance for Healthcare Professionals on Smoking Cessation.

This document suggests that Nicotine Replacement Therapy (NRT) should be used to help smokers to cut down as well as to stop, although it is clear that stopping completely is still the best option when it comes to health.

ASH Director, Deborah Arnott said:

"Although quitting altogether is obviously best for health, smokers who want to cut down first need help, and NRT can and should be used to support them. We consider this an essential measure of harm reduction for smokers, and part of an overall harm reduction strategy which, once we achieve a law to end workplace smoking, must be the next major step forward in combating the health damage done by cigarettes."

Action: Patients who express a desire to stop smoking or to cut down should be supported with NRT. ASH recommends that regular reviews of progress are undertaken with treatment continued where there is evidence of reduced consumption.

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Bricanyl pMDI being discontinued

Terbutaline (Bricanyl) metered dose aerosol inhalers are being discontinued in December 2005 according to the Pharmaceutical Journal.

The manufacturers have confirmed that the inhalers are being discontinued and that the product is unlikely to be available after December 2005. They do not foresee any problems with supply until December based upon current stock holding.

Consideration needs to be given to the alternatives that are available. The choice will be based upon changing the drug or the device. If an aerosol inhaler (pMDI) is the preferable device then Salbutamol Inhalers are readily available. If maintaining the drug is preferable then the Terbutaline Breath Actuated Dry Powder Device (Turbohaler) is an alternative. NOTE: This device is not being discontinued.

Action: Prescribers will need to identify all patients currently being prescribed Terbutaline Aerosol Inhalers and discuss the alternatives. Patients will be used to using an aerosol type device and therefore a Salbutamol Aerosol Inhaler is likely to be the most satisfactory alternative in many patients.

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ASCOT hype continues

The British Medical Journal this week carries an editorial on the recently published ASCOT Study.

This trial has received a lot of media attention from organisations such as the BBC.

The editorial is factually correct but perhaps it goes a little too far in attempting to second guess the reaction of the National Institute of Clinical Excellence and the British Hypertension Society as they revise their advice.

Continuing the hype around this study the editorial also quotes relative risk reductions that the original paper admit are derived from "fairly small absolute benefits". Adding to the concern is the declaration of competing interests by two of the three authors who appear to work closely with drug companies who are active in the hypertension and diabetes market.

Action: Prescribers should reassure patients about their treatment until the National Guidelines are reviewed and published. Changing practice at this early stage is premature and may mean it needs to be re-changed at a later date.

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