Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Drug Update on blood glucose monitoring

The Regional Drug & Therapeutics Centre has published a drug update investigating the self-monitoring of blood glucose.

The update summarises the current guidelines from the National Institute for Health and Clinical Excellence (NICE) for type 1 and type 2 diabetes with respect to self-monitoring of blood glucose (SMBG). NICE recommend that, in patients with type 1 diabetes, SMBG should be offered as part of an integrated care package. In patients with type 2 diabetes NICE recommend SMBG should be taught if the need and/or purpose are clear and agreed with the patient.

The update recommends that in patients with type 1 diabetes or insulin-treated type 2 diabetes that SMBG is an integrated part of self-care and that testing frequency will be reliant upon the patient and their insulin regimen.

It is also recommended that in patients with non-insulin treated type 2 diabetes routine monitoring is not required and that six monthly HbA1c should be used to monitor glucose control. This recommendation is based upon the inconclusive findings of two meta-analyses and a systematic review comparing SMBG with other strategies in reducing HbA1c.

The update therefore suggests that during a medication reviews the following questions should be considered:

  • What action is prompted by the results of self-monitoring of blood glucose?
  • If no action can be taken, what value does self-monitoring add to the patient's care?

Finally, the update reveals that approximately 25% of NHS spending on diabetes is funding self-monitoring test strips. A reduction in inappropriate prescribing of these strips will release funds to reinvest in other areas of care.

Action: All clinicians involved in the care of patients with diabetes should be aware of the cost of self-monitoring test strips. Reducing inappropriate use of these strips will release funds and allow the NHS to invest in other areas of care.

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Antibiotics cause resistance

The Lancet has published a paper that aimed to demonstrate a causal link between antibiotic resistance and antibiotic use.

Previous studies have shown an association between increased antibiotic use and increased resistance. This study recruited healthy individuals aged 18 or older who had not had any antibiotics in the preceding three months (n=224). Entrants were randomised to treatment with azithromycin, clarithromycin or placebo. Throat swabs were taken before the treatment (day 0) and at regular intervals after administration of the trial medication (8, 14, 28, 42 and 180 days).

The proportion of streptococci that were resistant to macrolide antibiotics was assessed from each swab. Bacterial resistance was higher in both antibiotic arms of the study when compared to placebo:

  • Azithromycin group - mean increase 53.4% [95% CI 43.4-63.5; p<0.0001]
  • Clarithromycin group - mean increase 50.0% [95% CI 41.7-58.2; p<0.0001]

Peaks in resistance occurred at day 4 for azithromycin and day 8 for clarithromycin although resistance was statistically increased at all points of the study. The authors conclude that, "physicians prescribing antibiotics should take into account the striking ecological side-effects of such antibiotics".

Action: All clinicians should already be aware of the long-term risks posed by antibiotic resistance and adopt strategies to minimise unnecessary use of antibiotics.

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GOLD and GINA updates

The National Guideline Clearinghouse has published updates to the Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.

GINA contains information about the diagnosis, evaluation, management and treatment of asthma. This guideline is often used as the standard in drug trials for asthma medication.

GOLD contains information about the diagnosis, classification, management and treatment of chronic obstructive pulmonary disease (COPD). This guideline is also often used as the standard in drug trials for COPD medication.

In the UK equivalent guidelines are produced for Asthma and COPD. The Asthma Guideline is produced by the British Thoracic Society and Scottish Intercollegiate Guidelines Network and the COPD Guideline by the National Institute for Health and Clinical Excellence.

Action: Clinicians should continue to implement the BTS/SIGN Asthma and NICE COPD guidelines. GINA and GOLD may provide additional information to those with a particular interest in asthma or COPD.

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SMC reject rimonobant

The Scottish Medicines Consortium (SMC) has rejected rimonobant (Acomplia®) for use on the NHS in Scotland.

The recommendation states that the economic case has not been demonstrated although it also indicates that a resubmission is likely.

Rimonobant has already been identified as having a lower place in therapy by the Midlands Therapeutic Review and Advisory Committee and it was previously recommended as a fourth line option when it was launched.

Action: Until an economic case is demonstrated it would be sensible to restrict prescribing of rimonobant to patients who have already started treatment and are achieving weight loss.

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Insulin Discontinuation brought forward

In August 2006, the manufacturer of Mixtard® and Velosulin® announced that several products in the range were to be discontinued with effect from 31st December 2007.

The manufacturer has now warned that, due to slower than expected transfer of patients from Velosulin® to alternative treatments it is expected that this product will no longer be available from June 2007.

Action: Patients who are currently using Velosulin® should be identified as soon as possible and transferred to an alternative insulin therapy.

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