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.