Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

NICE likely to reject rimonabant

The National Institute for Health and Clinical Excellence (NICE) are in the process of reviewing Rimonabant for the treatment of overweight and obese adults.

The Appraisal Committee are due to meet again early next year to produce a Final Appraisal Determination but the preliminary recommendations indicate that NICE is unlikely to recommend rimonabant. They have requested additional information from the manufacturer to include evidence from the clinical trials on health outcomes (including cardiovascular risk factors) and evidence on the cost effectiveness of rimonabant compared with diet and exercise alone, as well as the cost effectiveness of rimonabant compared with orlistat and sibutramine.

Action: Clinicians should avoid starting new patients on rimonabant until full guidance is published. Patients who are currently on treatment can continue treatment, within licensed indications, while it continues to be effective.

Thanks to NPCi for the original article

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December CKS Update

Clinical Knowledge Summaries (CKS) has been updated in December for the following clinical areas:

The update also provides pointers to the Mental Health Specialist Library for Bipolar Disorder National Knowledge Week and an extensive evidence update in the Diabetes Specialist Library. Details are also given of three new Specialist Libraries covering Neurological Conditions, Public Health and Stroke.

Action: Clinicians who see patients with any of these conditions may find the updated information useful when reviewing current clinical practice.

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Treatment of Acute Sinusitis

The Journal of the America Medical Association has published the results of a randomised controlled trial that aimed to assess the effectiveness of amoxicillin and topical budesonide in acute maxillary sinusitis.

240 adults with two or more diagnostic criteria (purulent rhinorrhea with unilateral predominance, local pain with unilateral predominance, purulent rhinorrhea bilateral, presence of pus in the nasal cavity) were recruited from primary care setting over a 4 year period. Patients were randomised to one of the following treatment groups:

  • Amoxicillin 500mg three times a day for 7 days and budesonide nasal spray 200micrograms in each nostril once per day for 10 days
  • Amoxicillin 500mg three times a day for 7 days and a placebo nasal spray
  • Placebo antibiotic and budesonide nasal spray 200micrograms in each nostril once per day for 10 days
  • Double placebos

Patients were assessed for clinical cure at day 10 using patient symptom diaries and the duration and severity of symptoms. All three of the active treatments failed to produce a statistically significant increase in the number of patients cured at day 10.

Action: Antibiotics and nasal steroids appear to be ineffective first line treatments for acute sinusitis. Clinicians should ensure they adopt the Clinical Knowledge Summary recommendations to use analgesia and short term intranasal decongestants.

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Orange Book updated

The Department of Health has started distributing revised copies of the Orange Book, otherwise known as Drug Misuse and Dependence - Guidelines on Clinical Management to GP practices and drug services. It is also available online via the National Treatment Agency for Substance Misuse.

The revised version aims to provide an evidence-based framework for the clinical treatment of drug misuse and places greater emphasis on the importance of planning care and the importance of keyworking. Detailed guidance on opioid drug treatment is provided with clearer distinctions made between detoxification treatment regimens and opioid maintenance regimens.

Action: Clinicians who treat drug misuse will find this updated guidance useful in ensuring that services are provided safely and effectively for the benefit of patients and their families.

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MeReC Extra 30

The National Prescribing Centre (NPC) has published MeReC Extra 30 (PDF). It covers the cardiovascular and gastrointestinal safety of NSAIDs, an update on the cardiovascular (CV) risk of glitazones and the results of the ADVANCE study.

The section discussing the safety of NSAIDs examines the safety of NSAID therapy with due consideration of cardiovascular, cardiorenal and gastrointestinal risks. Current prescribing figures for England are presented with this information and are used to estimate the level of harm being caused by this level of prescribing.

The update on the CV risk of glitazones provides additional information that has become available since the publication of MeReC Extra 29.

Finally, the results of the ADVANCE study are discussed in the context of the current evidence. The NPC conclude that tight blood pressure control reduces cardiovascular complications and deaths in patients with diabetes and that "based on their safety, efficacy, tolerability and cost, thiazide diuretics are a good first choice agent for most people".

Action: Clinicians will find this MeReC Extra to be useful and informative. It is of the usual high standard expected from the NPC.

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