Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

MeReC Extra 26

The National Prescribing Centre (NPC) has published MeReC Extra 26 that provides an analysis of the available evidence for rimonobant, a reminder about the national statin policy and pointers to recent MeReC Bulletins.

Individual sections are available as follows:

Action: Clinicians involved in the treatment of obesity or in the prevention and treatment of cardiovascular disease will find this MeReC useful. This publication also provides a pointer to other NPC resources covering contraception, common infection and new drugs.

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SSRIs and fracture risk

A recent article discussed the link found between proton pump inhibitors and increased hip fracture risk, now a paper in the Archives of Internal Medicine has identified an association between clinical fragility fracture and daily selective serotonin reuptake inhibitor (SSRI) use.

The study collected data for 5,008 patients aged 50 years and older over a 5-year period. Clinical fragility fractures were identified if radiographically confirmed. Daily SSRI use was report in 137 patients and after adjusting for several covariates the hazard rate was calculated to be 2.1 [95% CI 1.3-3.4]. There were also associations with falls and lower bone mineral density at the hip.

There are potential confounders in the study. Patients with depression may be less likely to eat a well balanced diet. These patients may also have depression as the consequence of chronic co-morbidity.

Action: Clinicians should be aware of the possible increased fracture risk with SSRIs. Depression should still be appropriately treated and fragility fracture risk managed with dietary advice and treatment where appropriate.

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UK PubMed Central launched

UK PubMed Central, a United Kingdom version of PubMed Central has been launched. It is a free digital archive of biomedical and life sciences journal literature.

It provides access to many journal articles, including some published in the British Medical Journal (BMJ), the British Journal of General Practice (BJGP) and the Journal of the Canadian Medical Association (CMAJ), that are currently held in databases hosted at the US National Institutes of Health (NIH). In time it is planned to provide links to articles hosted in the UK and Europe.

Action: This resource may prove useful in sourcing original research articles to aid continuing professional development and lifelong learning.

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Antihypertensive drugs ranked for diabetes risk

The Lancet has published a paper that set out to rank the different classes of antihypertensives in terms of diabetes risk.

The analysis included 22 studies including 48 treatment arms and comprising 143,153 patients. New onset diabetes risk was ranked for each initial drug class. Diuretics were used as the comparator (risk of 1.0); the other antihypertensive drug classes were calculated as having the following odds ratios:

  • Angiotensin receptor blockers - 0.57 [95% CI 0.46-0.72]
  • Angiotensin converting enzyme inhibitors - 0.67 [95% CI 0.56-0.80]
  • Calcium channel blockers - 0.75 [95% CI 0.62-0.90]
  • Placebo - 0.77 [95% CI 0.63-0.94]
  • Beta-blocker - 0.90 [95% CI 0.75-1.09]

This type of analysis, a network meta-analysis, is a novel technique and the results should be viewed with some caution. Additionally, the analysis has accounted only for initial drug therapy but in many drug trials there are steps where additional antihypertensive drug classes are added into existing treatment until a target blood pressure is reached. The impact of polypharmacy has not been assessed in this analysis.

The article concludes that the risk of new-onset diabetes is lowest with angiotensin receptor blockers and angiotensin converting enzyme inhibitors but does not suggest how the results of this analysis should integrate into current care.

Action: Clinicians should continue to follow the Hypertension Clinical Guideline produced by the National Institute of Health and Clinical Excellence.

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Osteonecrosis of the jaw with bisphosphonates

A recent editorial in the British Medical Journal detailed the current understanding of the link between bisphosphonates and osteonecrosis of the jaw.

Some of the Rapid Responses have been critical of the article stating that it has added to the confusion surrounding this complication. Osteonecrosis of the jaw was also covered in Current Problems in Pharmcovigilance issued by the Medicines and Healthcare products Regulatory Agency (MHRA) in May 2006.

The majority of reported cases have been in patients treated with high dose intravenous bisphosphonates however there have been some cases reported in association with oral agents too. The risks of this complication appear to be lower with the oral products available for the treatment of osteoporosis.

Additionally, some contributory risk factors have been identified including a diagnosis of cancer, chemotherapy, treatment with steroids, poor oral hygiene, tooth extractions and oral surgery.

The MHRA recommended that:

  • before treatment is started in patients with risk factors a dental examination is performed with appropriate preventative treatment
  • dental procedures are avoided while patients with risk factors are on treatment

Action: Clinicians should be aware of this complication and the current recommendations to minimise the risk. Lower dose oral therapy appears to carry a lower risk which patients may find reassuring.

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