Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

COPD, pneumonia and inhaled corticosteroids

The American Journal of Respiratory and Critical Care Medicine has published the results of a study that examined the risk of pneumonia in elderly patients using inhaled corticosteroids (ICS) for chronic obstructive pulmonary disease (COPD).

This study was a retrospective cohort study with case control analysis conducted using health databases in Quebec, Canada. It was prompted by the recent finding in the TORCH Study, a randomised controlled study that identified a possible link between ICS and pneumonia.

This analysis found that use of ICS:

  • Increased the risk of pneumonia, RR 1.70 [95% CI 1.63-1.77]
  • Increased the risk of death within 30 days following pneumonia related admission, RR 1.53 [95% CI 1.30-1.80]
  • At higher doses (equivalent to 1,000micrograms fluticasone) was associated with a higher risk of pneumonia 2.25 [95% CI 2.07-2.44]

The authors conclude that there is an increased risk of hospital admission for pneumonia, and of death following this, for patients with COPD using inhaled corticosteroids. They advise that this risk needs to be considered when prescribing.

Meanwhile, an accompanying editorial points out that COPD is associated with an increased risk of pneumonia and also identifies several flaws in this new analysis including the criteria used for diagnosis of pneumonia, COPD and categorisation of severity of COPD.

The author of the editorial concludes that, "these observations cannot simply be dismissed" however he also calls for further large studies to be conducted which make use of objective pneumonia definitions.

Action: Using ICS in COPD (in combination with long acting bronchodilators) appears to reduce exacerbations. Additional work is required to allow a fuller understanding of the risks and benefits of ICS use in COPD. In the meantime clinicians should continue to implement the NICE Guideline on COPD.

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Which aspirin dose?

The Journal of the American Medical Association published the results of systematic review earlier this year that aimed to clarify the most appropriate daily aspirin dose for the prevention of cardiovascular disease. This study has also been the topic of an InfoPOEM and has been covered in a podcast!

In America the most commonly used doses are 81mg per day and 325mg per day. In Britain doses of 75mg per day, 150mg per day and 300mg per day are used.

This review used MEDLINE and EMBASE to identify English-language research published before February 2007 that contained either aspirin or acetylsalicylic acid and dose in the paper. The bulk of the evidence identified consisted of observational studies of secondary prevention.

Daily doses of aspirin greater than 75 to 81 mg/d were not found to enhance efficacy, but larger dosages were associated with an increased risk of bleeding events, mainly gastrointestinal in nature.

The authors conclude that, "clinical data do not support the routine, long-term use of aspirin dosages greater than 75 to 81 mg/d in the setting of cardiovascular disease prevention".

Action: Clinicians should ensure that aspirin usage for the prevention of cardiovascular disease does not routinely exceed a daily dose of 75mg.

Thanks to Andrew White, Bolton PCT for spotting this study.

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MeReC Bulletin - Newer Insulins

The National Prescribing Centre has published a MeReC Bulletin that provides an update on the role of newer insulins.

This bulletin discusses the evidence and place in therapy for rapid-acting and long acting insulin analogues in both type one and type two diabetes. Inhaled insulin is also covered briefly.

In addition to the Bulletin a range of educational support materials are also available including a quiz, case study and presentation slides. These materials deal with type one diabetes and type two diabetes as separate topic areas.

Action: Clinicians who initiate or manage insulin therapy for patients with diabetes will find the Bulletin is a useful summary of the current evidence. The educational materials will be useful to anyone wishing to test their own understanding or to cascade this information on to other clinicians.

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ABPI threatens generic switch court action

According to PharmaTimes, the Association of the British Pharmaceutical Industry (ABPI) are preparing a legal challenge against the Department of Health for encouraging the wider use of cost-effective medicines.

The ABPI are concerned that local level initiatives that provide incentives to change medications in large numbers of patients may contravene European Law. They are also concerned that much of the switching is being done without due consideration for patient welfare and solely reduce costs. Finally, the ABPI argue that explicit consent should be obtained before changes are made to medication.

The Department of Health responded by pointing out that generic medicines are safe, of high quality and are equally as effective as branded alternatives. It was also noted that the recommended switches are "about achieving best value for money for the taxpayer and are backed by authoritative guidance".

Action: Before implementing changes to therapy clinicians should be assured that the switches provides one the following outcomes:

  • An identical or improved level of clinical control for lower acquisition costs
  • An improved level of clinical control for an acceptably higher acquisition costs

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Which? survey on drug promotion

Which? has published the results of a survey of 200 GPs that collected data on the frequency of promotional contacts and mailings. The BBC and PharmaTimes have both carried this story.

The survey found that, on average, the sample group could expect 4 representative visits per month and five mailings per week. One respondent revealed that, in one month, they received nine visits, 34 mailings and were also invited to attend several conferences or meals.

It was also apparent that the respondents did not trust the information they received with only 7% reporting that they trust the information as much as they trust independent sources. Additionally, almost half (48%) of respondents agreed that more trusted independent sources are needed.

Which? are also critical of the lack of transparency in some drug companies and patient groups about the extent of funding and the projects that these donations are used to support.

Action: Clinicians should ensure that they are using information sources that can be trusted. Robust polices for meeting with drug company representatives and mail screening will minimise the disruption to daily work caused by excessive contacts.

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