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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Blood glucose monitoring is not beneficial

Self-Monitoring of Blood Glucose (SMBG) does not offer any glycaemic benefit according to a paper published in Diabetes Care.

This study was an observational study of 1,286 patients with Type II diabetes in Freemantle, Western Australia. It included a five-year follow up of 531 of these patients who attended 6 consecutive annual reviews. Comparisons were made between patients who reported performing SMBG and those who did not in an overall cohort and also broken down into three treatment types, namely diet controlled, taking oral hypoglycaemic agents or using insulin.

Over the period studied, HbA1c and fasting plasma glucose did not differ between those who use SMBG and those who do not in all of the groups studied. Additionally, the frequency of monitoring was also examined and again made no difference to glycaemic control.

The paper suggests that SMBG still has a place in prevention and early detection of hypoglycaemia and to aid dose adjustments in patients using insulin. The role of SMBG for improving glycaemic control in patients with Type II diabetes who are controlled by diet or oral hypoglycaemic agents is not supported. The paper goes as far to suggest that, "money and time currently spent on SMBG in non-insulin-treated patients might be better utilized on alternative, proven interventions to improve glycaemic control".

Action: Routine use SMBG should not be recommended to every patient with diabetes. Use should be restricted to where it is likely to be clinically beneficial. This would include Type I diabetes, Type II diabetes treated with regular insulin injections, for early recognition of hypoglycaemia and as an aid to dietary education.

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Do ARBs increase MI risk?

In 2004, an editorial in the British Medical Journal raised a concern that Angiotensin II Receptor Blockers (ARBs) may increase the risk of myocardial infarction.

Since this article several reviews have been published that have dismissed the link however two new articles [subscription required] published in Circulation may revive the debate.

In both articles the authors have conducted reviews of available evidence using different inclusion criteria. One article concludes that MI event risk is increased in ARB users, the other finds no difference between ARB users and control subjects.

The common ground shared by the two papers is that Angiotensin Converting Enzyme Inhibitors (ACEIs) are superior to ARBs. Furthermore, neither paper demonstrated that ARBs actually reduce MI risk; ARBs may not be "ACEIs without a cough".

Action: ACEIs remain the first line drug choice in this class of medicines. ARBs should only be used when ACEIs are not tolerated and in these cases patients should be informed of the differences in MI risk.

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Lansoprazole Orodispersible price drop

The manufacturer of Lansoprazole Orodispersible Tablets (Zoton FasTabs®) has written to healthcare professionals informing them of a price reduction on this product effective from 1st September 2006.

28 x 15mg tablets have seen the price drop from £10.86 to £5.97; this is £1.80 per month more than lansoprazole 15mg capsules (£4.17 in August 2006 Drug Tariff).

28 x 30mg tablets have seen the price drop from £19.88 to £11.00; this is £4.73 per month more than lansoprazole 30mg capsules (£6.27 in August 2006 Drug Tariff).

Action: Despite this welcome cost reduction lansoprazole capsules are still the first choice PPI.

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Pimecrolimus Safety Letter

The manufacturer of Pimecrolimus (Elidel®) has written to healthcare professionals regarding rare reports of cancers in patients using pimecrolimus. Based on current data, the letter states, "a causal link can neither be confirmed nor refuted."

The letter reiterates the EMEA recommendations made earlier this year, reported here. It recommends that:

  • It should only be prescribed for short term and intermittent long term therapy of mild to moderate atopic dermatitis where use of topical steroids is inadvisable or not possible.
  • It is not recommended for use in those aged under 2 years.
  • Treatment should only be initiated by clinicians with experience in diagnosis and treatment of atopic dermatitis.
  • It should not be used in immunocompromised patients.
  • It should be applied sparingly twice a day to affected areas only.
  • Once the affected area has cleared, treatment should be discontinued.
  • If no improvement after 6 weeks or in case of disease exacerbation, diagnosis should be re-evaluated and other treatments considered.
  • Avoid use on potentially malignant or pre-malignant skin conditions.

Action: Clinicians should be aware of these recommendations and ensure they are being followed.

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NICE accept Herceptin

The National Institute of Health and Clinical Excellence (NICE) has published a technology appraisal on the use of trastuzumab in early breast cancer.

NICE recommend that trastuzumab (Herceptin®) is given to women with early stage HER2-positive breast cancer after they have had surgery and chemotherapy (and radiotherapy if appropriate). It should be given every three weeks for a period of twelve months or until the breast cancer returns, which ever is sooner, provided that the patient has good cardiac function.

Before treatment is started cardiac function should be assessed. Treatment should not be offered if the patient has:

  • a left ventricular ejection fraction (LVEF) of 55% or less
  • a history of documented congestive heart failure
  • high-risk uncontrolled arrhythmias
  • angina pectoris requiring medication
  • clinically significant valvular disease
  • evidence of transmural infarction on electrocardiograph (ECG)
  • poorly controlled hypertension

NICE also recommend that cardiac assessments are carried out every 3 months and treatment suspended if LVEF drops below 50% or by 10% from the baseline.

Action: The use of trastuzumab in early-stage breast cancer has been the subject of huge media interest. Clinicians may wish to be aware of the latest developments.

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