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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

No aspirin mortality benefit in diabetic ACS?

Diabetes Care has published the results of a retrospective analysis of a study examining the treatment of acute coronary syndromes (ACS). This analysis aimed to compare mortality reductions in patients with and without diabetes.

The original study was an observational study involving 2,499 patients admitted to hospital with ACS. 17% (n=425) were diabetic with the majority of parameters being similar between the two groups with the exceptions that patients with diabetes were more likely to be treated with an angiotensin converting enzyme inhibitor (ACEIs) and less likely to be treated with a beta-blocker.

The analysis found that benefits of treatment with ACEIs beta-blockers and statins were comparable but that aspirin was associated with a non-significant mortality reduction in patients with diabetes and clopidogrel was associated with a non-significant mortality reduction in both groups.

The number of patients taking clopidogrel is likely to have been low and therefore the results are not discussed further but more weight is given to the difference seen in the aspirin data by the authors. However, this is a secondary analysis of an observational study involving a small number of patients and as such the findings should be viewed with caution and used to generate further clinical trials.

It remains unclear if low-dose aspirin is of any benefit to a diabetic patient with ACS, whether higher doses could confer greater benefits or whether alternative agents or combinations should replace aspirin.

Action: Clinicians should continue with current practice following episodes of ACS until further work confirms the best course of action for diabetic patients with ACS.

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Thiazides first for hypertension?

The Archives of Internal Medicines has published a subgroup analysis of the ALLHAT study examining the rate of cardiovascular outcomes in patients with metabolic syndrome.

The analysis was performed on patients with metabolic syndrome, defined as hypertension and at least two of the following:

  • Body Mass Index greater than 30kg/M2
  • Fasting glucose greater than 5.6mmol/L
  • Triglycerides greater than 1.7mmol/L
  • HDL less than 1.0mmol/L for a man and 1.3mmol/L for a woman

The analysis compared all four study drugs (chlorthalidone, amlodipine, lisinopril and doxazosin) and also studied black and non-black patients in separate groups.

The analysis found significantly higher rates of heart failure for all drugs and irrespective of ethnicity when compared to the chlorthalidone. There was also an increased risk of combined cardiovascular disease for the lisinopril and doxazosin groups irrespective of ethnicity. Finally, there was a higher stroke rate in black patients in the lisinopril and doxazosin groups and end-stage renal disease in black patients in the lisinopril group.

The authors conclude that, "the ALLHAT findings fail to support the preference for calcium channel blockers, alpha-blockers, or angiotensin-converting enzyme inhibitors compared with thiazide-type diuretics".

Action: This analysis adds weight to the positioning of thiazides as first line antihypertensives in the vast majority of patients with hypertension. Clinicians should consider their current practice in comparison to the recommendations made by the National Institute of Health and Clinical Excellence.

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MeReC Extra 31

The National Prescribing Centre (NPC) has published MeReC Extra 31 (PDF). It covers the use of antibiotics to prevent serious complications in URTI, the results of a recent study about adoption of guidelines and a discussion of the lack of evidence supporting modern dressings.

The section discussing the use of antibiotics to prevent serious complications in cases of upper respiratory tract infection (URTI) highlights the Clinical Knowledge Summary recommendations that advise against routine use. A recent study is also identified that calculated a number needed to treat of over 4,000 to prevent on serious complication. Clinicians are advised that the decision to prescribe should not be based on a fear of serious complications.

The study about the adoption of guidelines serves as a useful reminder to producers of guidelines to involve stakeholders in the production process and to provide tools to aid implementation. If uptake remains low then an analysis of barriers to implementation and clinician concerns may help identify reasons.

Finally, the discussion of the lack of evidence supporting the use of modern dressings highlights two recent systematic reviews that reveal inadequate research. Many studies are conducted in small numbers of patients and are not properly randomised or blinded. Both reviews failed to find any benefit for more modern dressings over established dressing. Clinicians are encouraged to consider efficacy, safety, cost and patient choice when prescribing dressings.

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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Rosiglitazone prescribing information updated

The European Medicines Agency (EMEA) has recommended (PDF) new warnings and contraindications for rosiglitazone after it adopted the October 2007 findings of the Committee for Medicinal Products for Human Use (CHMP).

The CHMP recommended that rosiglitazone:

  • Must not be used in patients with an acute coronary syndrome, such as angina or some types of myocardial infarction
  • Should be avoided in patients with ischaemic heart disease and/or peripheral arterial disease

These new warnings are more restrictive than previous advice that recommended careful evaluation of the patient's individual risk.

Action: Clinicians should be aware of these new recommendations and ensure that patients who remain on treatment with rosiglitazone are not contraindicated following this update.

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January CKS Update

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

The update also provides pointers to the "Test of the Week" which focuses on the use of laboratory tests that are frequently ordered by primary healthcare professionals and the Drug Safety Update for January from the MHRA.

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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