Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Lancet calls for NICE support

The Lancet has called for the government to "show vocal support for NICE" (National Institute of health and Clinical Excellence) in a recent editorial [Free registration required]. The BBC has also reported the editorial.

NICE has been criticised recently, in particular by the Alzheimer's Society in relation to the review of the existing guidance for donepezil, rivastigmine, galantamine and memantine in Alzheimer's disease.

Neil Hunt, chief executive of the Alzheimer's Society, accused NICE of "blatant cost cutting" by selling the health of hundreds of thousands of patients for £2.50 per day. Putting this figure into a fuller context, treating 100,000 patients for 365 days at £2.50 per day would cost £91 million each year! It may come as no surprise then that in the Alzheimer's Society Annual Review a thank you is extended to Eisai, Lundbeck, Novartis, Pfizer and Shire - the same five companies involved in the production and marketing of the four available drugs for Alzheimer's Disease.

Action: The Lancet editorial highlights a key tension in the NHS, how to provide a universal health system, free at the point of delivery, within the restraints of a limited amount of funding.

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MeReC Bulletin - Hypertension

The National Prescribing Centre has published a MeReC Bulletin that provides an update on the management of hypertension in primary care following the publication of the updated NICE clinical guideline in June.

The bulletin is available as a complete document or in the following sections:

Action: Clinicians involved in the diagnosis and treatment of hypertension will find this bulletin of interest.

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Lack of evidence for lipid targets

The Annals of Internal Medicine has published a paper reviewing the available evidence to support the currently proposed treatment goals for lipid levels.

Treatment goals for total cholesterol and low-density lipoprotein have been lowered in recent years in America and the United Kingdom. Despite these reductions in the targets the authors of this review found no high-quality evidence to support the targets. They also conclude that there is no reason that evidence could not be produced very quickly from a cohort analysis of large clinical trials such as the Heart Protection Study (HPS).

Aggressively pursuing lower lipid targets is not supported by high quality evidence at this time. In the first instance clinicians should ensure that patients are prescribed a cost-effective statin as per previous recommendations. The targets specified in the GP contract will remain important because they are income related but caution should be exercised when considering reducing lipid levels further.

Action: Clinicians should carefully consider the risks and benefits of treating patients to lower lipid targets when there is no high quality evidence to support these targets.

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Cervical cancer vaccine

A letter to healthcare professionals has announced the launch of Human Papillomavirus Vaccine (Gardasil®).

The vaccine is licensed for use in the prevention of high-grade cervical dysplasia (CIN 2/3), cervical carcinoma, high-grade vulvar dysplastic lesions (VIN 2/3) and external genital warts causally related to human papillomavirus types 6, 11, 16 and 18.

Based upon data from efficacy trials use is recommended only in adult females aged 16 to 26 years. Additionally, immunogenicity trials have been conducted successfully in 9 to 15 year old females.

Additionally, the product license states that the vaccine should only be used in accordance with official recommendations. According to the BBC, the Department of Health has requested expert advice from the Joint Committee on Vaccination and Immunisation (JCVI) on the "on the efficacy, safety and benefits that these new vaccines may offer".

Action: Clinicians should be aware of this new vaccine as patients may request more information. The product should not be prescribed on the NHS until the JCVI provide official recommendations regarding appropriate use.

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Becotide Discontinuation

The manufacturer of Becodtide® and Becloforte® pressurised Metered Dose Inhalers (pMDI) has written to healthcare professionals to announce the discontinuation of these inhalers from the third quarter in 2007.

The discontinuation will affect the following products:

  • Becotide 50microgram pMDI
  • Becotide 100microgram pMDI
  • Becotide 200microgram pMDI
  • Becoloforte 250microgram pMDI

Since the majority of beclometasone inhalers are prescribed generically this announcement is likely to affect small numbers of patients. The inhalers listed above will still be available over the next 12 months so changes in therapy can be made during routine reviews.

Action: Consideration should be given to opportunistically changing therapy to the CFC-Free alternatives because the CFC containing products will all eventually be discontinued. The MHRA advice should be followed if CFC-Free inhalers are prescribed.

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