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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

MTRAC reviews varenicline

The Midlands Therapeutic Review and Advisory Committee (MTRAC) has published a review of varenicline (Champix®) for smoking cessation.

Varenicline has been assessed as a Q3 drug, having a lower place in therapy and strong evidence. The reason given for the lower placing in therapy is the lack of comparative efficacy data versus nicotine replacement therapy. The overall advice is that varenicline is "suitable for prescribing in primary care for healthy adult smokers with no serious medical conditions (e.g. major depression, cardiovascular disease, uncontrolled hypertension)".

Action: As already discussed, nicotine replacement therapy remains the first line choice. Varenicline (and bupropion) are suitable alternatives where NRT treatment fails.

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SMC reject Grazax and BuTrans

The Scottish Medicines Consortium has released advice covering several new medicines including standardised allergen extract of grass pollen (Grazax®) and buprenorphine transdermal patches (BuTrans®).

Both of these items have been rejected. Grazax® was rejected because the data presented was not "sufficiently robust economic analysis to gain acceptance". BuTrans® was rejected because the "justification of the treatment's health benefits in relation to its cost was not sufficient to gain acceptance".

As previously discussed, it is recommended that initiation and treatment with Grazax is restricted to physicians who are experienced in the treatment of allergic disease. Treatment should be started 16 weeks before the start of the grass pollen season. These recommendations regarding initiation and treatment with Grazax® will severely limit the numbers of patients who will be treated with this product this year.

Action: Clinicians should be aware of this latest advice for Grazax®. Additionally, prescribing of buprenorphine transdermal patches should be restricted to patients already on treatment and who are achieving good pain control.

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BMJ debates patient group sponsorship

The current issue of the British Medical Journal debates the sponsorship of patient groups by drug companies in a "Head to Head".

Alastair Kent argues in favour of accepting money from the drug companies stating that not accepting sponsorship will limit the effectiveness of patient groups.

Barbara Mintzes argues against accepting money from the drug companies stating that, in accepting the money, the independence of the patient group is undermined.

The issue of sponsorship will always be a topic for debate. In the meantime, all patient groups should declare full details of sponsorship and provide easy access to this information. This transparent approach would improve confidence in the independence of the patient group and also allow individuals to assess any potential for bias.

Action: Clinicians should consider the transparency and bias of patient groups before implementing any recommendations made by these groups.

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WHO patient safety solutions

The World Health Organisation has launched nine patient safety solutions aimed at reducing health care-related harm.

The National Patient Safety Agency was involved in the development of these solutions and has already issued guidance covering some topics.

The nine areas identified are:

  • Look-alike, sound-alike medication names
  • Patient identification
  • Communication during patient hand-over
  • Performance of correct procedure at correct body site
  • Control of concentrated electrolyte solutions
  • Assuring medication accuracy at transitions in care
  • Avoiding catheter and tubing misconnections
  • Single use of injection devices
  • Improved hand hygiene to prevent health care-associated infection

Each topic area is discussed in an individual patient safety solution document that provides a summary of the issue and identifies actions to reduce the risk of harm.

Action: Clinicians should consider which of these topic areas are relevant to their working activities and ensure that appropriate measures are being taken to reduce the potential for harm.

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Study confirms glitazone bone problems

The Journal of Clinical Endocrinology and Metabolism has published the results of a fourteen-week study that has confirmed that rosiglitazone does have detrimental effects on bone formation and bone mineral density (BMD).

There have been concerns raised recently regarding fractures in women taking rosiglitazone and pioglitazone.

This study recruited 50 healthy and postmenopausal women. Using double blind trial design the intervention of rosiglitazone (8mg/day) was compared to placebo with random treatment allocation.

The study found statistically significant reductions in two markers of bone formation activity (procollagen type I N-terminal propeptide and osteocalcin) and also in BMD measured at the hip. There was a statistically significant decrease in BMD at the spine compared to baseline data but the difference between the two groups was not significant.

The study concludes that all future long-term trials of the glitazones should include end points assessing skeletal outcomes. This may include assessing rates of fractures as well as markers of bone formation, quality and BMD.

Action: Particularly in female patients, fracture risk and general bone health should be considered before starting treatment with any glitazone and during medication reviews for patients already on treatment. Alternative treatment, for example with a sulphonylurea, may be appropriate where fracture risk is considered to be high.

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