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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

More ulcers with increased coxib use

The Canadian Medical [Association] Journal (CMAJ) has recently published a paper reviewing changes in the rates of upper gastrointestinal haemorrhage following the introduction of COX-2 selective non-steroidal anti-inflammatories (NSAIDs).

The paper compares changes in rates of GI bleeds in British Columbia and Ontario in comparison to changes in the use of NSAIDs following the introduction of COX-2 in patients aged 66 and over. In British Columbia, NSAID use rose by 2.2% (25% in relative terms) following the launch of COX-2 NSAIDs. This increase made no statistical difference to the rate of GI bleeds seen.

In Ontario, NSAID use rose by 5.6% (51% in relative terms), this increase may have contributed to the increased rate of GI bleeds observed. The observed number of GI bleeds was 26% greater than expected which is approximately 2 admissions be 10,000 patients.

In interpreting this paper the authors states that although COX-2 NSAIDs are associated with a lower risk of upper GI bleeding than traditional NSAIDs they still increase the risk compared to no treatment. It is therefore possible that a more cautious use of all NSAIDs may have avoided the increased number of GI bleeds seen in Ontario.

This study has some limitations it was observational, however there is a close temporal association seen between the introduction of COX-2 NSAIDs and the increased rate of upper GI bleeds. Additionally, the appropriateness of the treatment for individual patients and any benefits gained are unknown. Despite this it does appear that a more cautious use of new drugs may have may protect against adverse drug effects.

Action: Clinicians should consider the risks and benefits of possible treatments before recommending a particular therapy. This process should account for potentially unknown risks when drugs are new to the market.

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Blood glucose meter safety warning

The Medicines and Healthcare product Regulatory Agency (MHRA) has issued an updated safety warning and press release regarding several blood glucose meters. The MHRA has continued to receive reports of the affected meters (listed below) displaying blood glucose results in mg/dL (milligrams per decilitre) rather than mmol/L (millimoles per litre). This change in units means the numerical readings will be 18 times higher than usual.

This is the latest warning to be issued. The manufacturers of the meters will replace affected units free of charge and will be contacting users early in 2007.

The affected meters are as follows:

  • LifeScan OneTouch
  • LifeScan InDuo
  • LifeScan PocketScan

Action: All clinicians and healthcare staff should be aware of this safety warning and be able to advise patients about the difference in the numerical reading and how to obtain a replacement meter.

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NPC National Campaigns

The National Prescribing Centre has launched a new "National Campaigns" section online. The purpose of this new area is to focus on significant areas of prescribing and medicines management in relation to cost-effectiveness and safety. Each campaign topic will:

  • cover policy and guidance
  • interpret the evidence base
  • provide implementation materials
  • provide monitoring tools for use at a local level

The first of these campaigns is Statins. This campaign contains summaries of key national policy documents. Presentations, commentaries, case studies and quizzes cover the evidence base for statins in ways to suit many different learning styles. Implementation tools include guides, templates and example letters. The monitoring tools include a switch tracker and impact assessment tool.

Action: This first National Campaign focussed on statins will be useful to all clinicians involved in the prevention and treatment of cardiovascular disease.

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NICE Guideline on Obesity

The National Institute for Health and Clinical Excellence (NICE) has published a clinical guideline on the prevention, identification, assessment and management of obesity in adults and children.

The guideline also provides two quick reference guides, one for local authorities, schools and early years providers, workplaces and the public and one for the National Health Service.

These documents contain advice on the key elements of a healthy balanced diet and suggestions on how to remain physically active. They also contain consideration of the place in overall therapy of drug treatments and surgical interventions.

Action: All clinicians who provide lifestyle and dietary advice will find this guideline a useful reminder and reference.

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BJGP survey GP attitudes to hypnotics

The British Journal of General Practice has published the results of a survey into GPs' attitudes to hypnotics including benzodiazepines and Z-drugs (zopiclone, zolpidem and zaleplon).

A questionnaire was sent to all GPs (n=107) in West Lincolnshire PCT to investigate the perceived advantages and disadvantages of benzodiazepines and Z-drugs. The response rate was high at 78.5%, statistical analysis of the responses to individual questions revealed the following:

Responders perceived that Z-drugs were more effective than benzodiazepines in terms of:

  • patients feeling rested on waking (p < 0.001)
  • daytime functioning (p < 0.001)
  • total sleep time (p = 0.03)

Responders also perceived that Z-drugs were safer in terms of:

  • tolerance (p < 0.001)
  • addiction (p < 0.001)
  • dependence (p < 0.001)
  • daytime sleepiness (p < 0.001)
  • road traffic accidents (p = 0.018)
  • use in older people (p < 0.001)

The article concludes that, "GPs' beliefs about effectiveness and safety are not determined by current evidence or national (NICE) guidance" and suggests that this may be a reason for the increase in prescribing of Z-drugs in comparison to benzodiazepines.

The NICE guidance for Z-drugs recommends that non-medicine treatments are first-line. Short courses of hypnotics can be prescribed to treat severe insomnia that is interfering with normal daily life. It is also noted that there is no firm evidence of differences between short acting benzodiazepines and Z-drugs and as such the cheapest drug, taking into account the dose and cost per dose, should be prescribed. Finally, the NICE guidance recommends that there is no reason to change agent based upon lack of efficacy.

Action: Prescribing of all hypnotic drugs should be restricted to short term treatment in severe cases of insomnia. Z-drugs should not be used in preference to short acting benzodiazepines.

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