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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Doxepin discontinued

Doxepin (Sinequan)® capsules are being discontinued in all strengths according to the National Electronic Library for Medicines.

Doxepin is a tricyclic antidepressant with sedative properties. It is expected that supplies will be exhausted by October 2006 although some strengths may disappear sooner.

Doxepin is not widely used but is not available generically and therefore alternative products will need to be used if treatment needs to continue. Amitryptiline, Dosulepin or Clomipramine may be suitable choices.

Action: Clinicians should be aware of this products discontinuation and may wish to identify individuals currently taking this drug. Alternative treatments will need to be investigated if treatment will continue beyond October 2006.

Update: In early 2022 several generic manufacturers are continuing to supply doxepin in the UK. It appears to be readily available in 25mg and 50mg strengths.

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Seasonal Allergic Rhinitis

Seasonal Allergic Rhinitis or Hayfever is a common condition that may affect up to 10% of the population between May and August. Treatment is based upon use of oral antihistamines and nasal corticosteroids.

Prodigy categorises symptoms as follows:

  • Mild intermittent
  • Mild persistent or moderate-severe intermittent
  • Moderate-severe persistent

Treatment selection can be based upon the severity of symptoms and patient preference for oral or topical treatment. Prodigy and the MeReC Bulletin titled Common questions about hay fever (2004) recommend that:

  • Mild intermittent symptoms are treated with oral antihistamines
  • Mild persistent or moderate-severe intermittent are treated with oral antihistamines or intranasal corticosteroids
  • Moderate-severe persistent are treated with intranasal corticosteroids

A previous MeReC Bulletin titled Treatment of seasonal allergic rhinitis (hay fever) (1998) stated "There is no difference in efficacy between the individual nasal steroids". Similarly, Clinical Evidence can find no evidence to support preferential use of any individual oral antihistamine.

Based upon the above the main consideration becomes cost-effectiveness of individual treatments. Cetirizine and Loratadine are half the price of other drugs in the class including desloratadine, fexofenadine, levocetirizine and mizolastine.

Intranasal corticosteroids can vary four-fold in cost depending upon the dose used. It would seem sensible to use the lowest effective dose for the shortest duration to minimise adverse effects. Beclometasone and Budesonide 100mcg nasal sprays 25-50% less expensive than alternative product depending upon the dose used.

Action: Depending upon the severity of symptoms, patients with seasonal allergic rhinitis should be offered first line treatment with Cetirizine or Loratadine where an oral antihistamine is indicated and Beclometasone or Budesonide 100mcg where an intranasal corticosteroid is indicated.

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Statins are equal

The American Heart Journal has published a meta analysis of statin trials involving Simvastatin, Pravastatin and Atorvastatin.

The review includes 8 trials involving over 63,000 patients. All trials had a similar lipid reducing effect and statistical analysis showed minimal heterogeneity between the effect sizes.

Overall, there was no difference between the three statins in reduction of fatal coronary heart disease and nonfatal myocardial infarctions. Similarly, there were no detectable differences in fatal and nonfatal strokes, all cardiovascular deaths, and all-cause mortality.

Action: Clinicians can be confident that using Simvastatin 40mg first line, as recommended here, will reduce the risk of cardiovascular events to a similar extent compared to other statin therapies.

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DTB review Strontium

The Drugs and Therapeutics Bulletin has published a review of Strontium Ranelate (Protelos)® for osteoporosis.

NHS staff can access the iDTB via the National Electronic Library for Health.

The article discusses the trial data, which shows a statistically significant reduction in vertebral factures. A post-hoc analysis was also conducted that found a significant reduction in hip fracture. However, post-hoc analyses should be viewed with caution.

Adverse effects are also discussed, nausea and diarrhoea are common and although transient these effects account for most of the discontinuations of the treatment. Of greater concern is the statistically significant increase (42%) in venous thromboembolism. There have also been reports of disturbances of consciousness, memory loss and seizures.

The article concludes that Bisphosphonates (e.g. Alendronate) remain first line treatment for secondary prevention of fractures in osteoporosis. Strontium should be reserved for patients who cannot tolerate any bisphosphonate and all side effects should be reported via Yellow Cards.

Action: Clinicians should continue to use bisphosphonates as first line treatment, with calcium and vitamin D supplements, for prevention of fractures in patients with osteoporosis.

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Public Health Guidance from NICE

The National Institute of Health and Clinical Excellence (NICE) has published guidance on Smoking Cessation and Physical Activity.

This guidance is the first to be issued by NICE in a new category called Public Health Intervention Guidance. A quick reference guide for healthcare professionals is available for both topics.

The Smoking Cessation guidance recommends:

  • using simple opportunistic advice to all smokers
  • assessing a patients commitment to stopping smoking
  • offering pharmacological and/or behavioural support
  • provision of self help materials and referral to specialist services

The Physical Activity guidance recommends:

  • encouraging physical activity for 30 minutes at least 5 times a week where appropriate
  • taking into account an individuals needs, preferences and circumstances
  • endorsing exercise referral schemes that are part of properly conducted studies designed to assess efficacy
  • encouraging participation in properly run walking and cycling schemes
  • endorsing use of pedometers in properly conducted studies designed to assess efficacy

Action: All healthcare professionals should be encouraging patients to undertake more physical activity and to stop smoking. This guidance makes clear recommendations about how this can be accomplished.

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