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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

NICE Guideline on heavy menstrual bleeding

The National Institute of Health and Clinical Excellence (NICE) has published a clinical guideline on heavy menstrual bleeding.

The Quick Reference Guide provides a clinical definition of heavy menstrual bleeding as covered by the guideline and a care pathway for individuals presenting with heavy menstrual bleeding.

The guideline also details the place in therapy for several pharmacological interventions including:

  • Levonorgestrel-releasing intrauterine system (First Line)
  • Tranexamic acid (Second Line)
  • Non-steroidal anti-inflammatory drugs (Second Line)
  • Combined oral contraceptives (Second Line)
  • Oral and Injected progestogen only contraceptives (Third Line)

Additionally, the guideline provides referral criteria for procedures such as endometrial ablation and hysterectomy.

Action: All clinicians and healthcare professionals who provide care to women presenting with heavy menstrual bleeding will find this guideline a useful reference and evidence summary.

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Depression in Children and Adolescents

Panorama, an investigative television show from the BBC aired a programme this week claiming that a leading drug company distorted the results of clinical studies and covered up links between its antidepressant drug paroxetine and suicides in teenagers.

This programme was a follow up of a similar shows aired in October 2002 and May 2003.

In June 2003, the Medicines and Healthcare products Regulatory Agency (MHRA) issued a warning advising that paroxetine "should not be used in children and adolescents under the age of 18 years to treat depressive illness.".

More recently, the National Institute of Health and Clinical Excellence(NICE) has issued a clinical guideline for Depression in Children and Young People that states paroxetine and venlafaxine should not be used in children.

Action: Media coverage may raise concerns among patients and parents about the use of paroxetine (and venlafaxine) in children. Clinicians should ensure that they are prescribing within the recommendations provided by the MHRA and NICE.

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Cochrane Library reviews beta-blockers

The Cochrane Library has published a review of beta-blockers for hypertension.

Two recent systematic reviews that found beta-blockers to be less effective than other antihypertensive in reducing strokes, myocardial infarctions and deaths. This review aimed to "quantify the effectiveness and safety of beta-blockers on morbidity and mortality endpoints in adults with hypertension".

Data from thirteen randomised controlled trials including data for over 91,500 patients was analysed. The trials included comparisons of beta-blockers with placebo or active treatments (diuretics, calcium-channel blockers, renin-angiotensin system inhibitors). The review found that beta-blockers tend towards worse outcomes in comparison to other antihypertensives and are only marginally better than placebo or no treatment.

The authors conclude that, "the available evidence does not support the use of beta-blockers as first-line drugs in the treatment of hypertension". This conclusion supports the current National Institute for health and Clinical Excellence Guideline for Hypertension and the position for beta-blockers in the treatment algorithm.

Action: Clinicians should continue to follow the NICE Guideline for Hypertension and reserve beta-blockers for use as a fourth line treatment in resistant cases.

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Diet and exercise prevents diabetes

Lifestyle interventions, including diet and exercise, can prevent the development of diabetes according to a follow-up of the Finnish Diabetes Prevention Study. This paper was published in the Lancet and has also be the subject of a recent InfoPOEM.

The study followed a group of 522 patients (2 women: 1 man) who were overweight (BMI > 25kg/M2) and who had impaired glucose tolerance. They were randomly assigned to intensive lifestyle interventions or usual care. Over the original four years of the study 11% of the intervention arm developed diabetes compared to 23% of the usual care arm. Respectively, in the two groups the incidence of diabetes was 4·3 and 7·4 per 100 person-years; a relative risk reduction of 43%.

This difference continued for a further 3 years of follow up with corresponding incidence rates of 4·6 and 7·2 per 100 person-years; a relative risk reduction of 36%.

The authors conclude that lifestyle interventions reduce the incidence of diabetes and that this effect remains even after individual lifestyle counselling is stopped.

Action: Clinicians should recommend a healthy, balanced diet and increased physical activity to all patients at risk of developing diabetes and regularly reiterate this advice.

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Varenicline reviewed by Cochrane Library

The Cochrane Library has published a review of the evidence supporting nicotine receptor partial agonists including varenicline.

The authors conclude that varenicline is three times more effective than placebo in achieving successful long-term smoking cessation and is more effective than bupropion based on the currently published trial data. They also highlight the need for comparative studies with nicotine replacement therapy and independent trials of varenicline versus placebo to confirm the findings of industry trial.

Finally, the authors state that the efficacy of varenicline as an aid to relapse prevention has not been clearly established.

Action: Nicotine replacement therapy remains the first line choice. Varenicline (and bupropion) are suitable alternatives where NRT treatment fails. Extended varenicline treatment to prevent relapse cannot be recommended until efficacy has been more clearly established.

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