According to an article on the BBC website MPs are recommending that more is done to control and contain the annual NHS drugs spend.
According to the article, spend has doubled in a decade to £8.2 billion each year. Recommendations included greater use of generic drugs, putting prices onto packets so patients are aware of the cost of their medicines and restricting the influence of the pharmaceutical industry by forcing GPs to declare significant gifts and hospitality. MPs also cite the variation in the use of cheaper statins; in some trusts use is just 28% while in others it is 86%.
The Pharmaceutical Industry refute many of these recommendations stating that branded drugs are under-used in Britain and that generic prescribing rates are the highest in relation to comparable countries. Despite this the article reports that 20% of GPs admitted to being more influenced by pharmaceutical firms than NHS advisers.
There does not appear to be any mention of the impact of earlier detection, diagnosis and treatment of a wide range of medical conditions and the obvious increase in drugs spend that would be associated with this change.
Action: Clinicians may wish to reflect on their current prescribing habits and make greater use generic medicines where appropriate before changes are enforced. NHS advisers may wish to the results of the reported survey and assess how they can affect greater influence and prescribing change.
The Archives of Internal Medicine has published the results of a prospective observational study that aimed to assess the impact of discontinuing warfarin therapy before an invasive procedure on thromboembolic risk.
The study included 1,204 patients and 1,293 separate interruptions of warfarin therapy. The average age of the patients was 71.9 years and 42.8% were female. The main indications for warfarin therapy were atrial fibrillation (46%), venous thromboembolism (12%) and mechanical heart valves (11%). Patients were followed up for thromboembolism or clinically significant bleeds occurring within 30 days of stopping warfarin therapy.
The results of the study are as follows:
- Perioperative heparin was used in a total of 8.3% of cases
- 7 patients developed thromboembolism within 30 days, none had received perioperative heparin
- 23 patients had clinically significant bleeds, 14 had received perioperative heparin
- More than 80% of patients had therapy withheld for 5 days or less
The authors conclude that, "interruption of warfarin therapy is associated with a low risk of thromboembolism". They also recommend that, "the risk of clinically significant bleeding should be weighed against the thromboembolic risk of an individual patient before the administration of bridging anticoagulant therapy".
Action: This observational data indicates that short-term interruptions to anticoagulant therapy are associated with a low risk of thromboembolism and that bridging therapy increases the risk of significant bleeding events. Clinicians should consider how this information affects the advice they currently give to patients on anticoagulant therapy who are referred for invasive procedures.
The Scottish Medicines Consortium has issued its monthly advice on new medicines.
Allergen extract of phleum pratense (Grazax®) has been rejected following a resubmission. Despite some modest clinical benefit the economic analysis was insufficiently robust to gain acceptance.
Beclometasone / formoterol metered dose inhaler (Fostair®) has been accepted for use in the treatment of asthma where a combination product is appropriate. This would be Step 3 of the British Thoracic Society Asthma Guidelines.
Latanoprost and timolol eye drops (Xalacom®) has been accepted for the treatment of raised intraocular pressure in patients with open angle glaucoma and ocular hypertension who are insufficiently responsive to topical beta-blockers or prostaglandin analogues.
Action: Clinicians should be aware of the recommendations of the SMC. Routine use of rejected medicines should be avoided.
The Lancet has published the results of a prospective meta-analysis of 14 statin trial in patients with diabetes. The BBC has also reported this story.
The analysis included data from 14 trials (inclusion criteria excluded small studies, unpublished studies and those in languages other than English) containing data for 18,686 patients with diabetes. Outcomes were assessed in relation to a reduction in low-density lipoprotein cholesterol (LDL-C) of 1mmol/L. The results are as follows:
- 13% relative risk reduction in vascular mortality [0.87, 95%CI 0.76 - 1.00, p=0.008]
- 21% relative risk reduction in major vascular events [0.79, 95%CI 0.72 - 0.86, p<0.0001]
- 22% relative risk reduction in myocardial infarction or coronary death [0.78, 95%CI 0.69 - 0.87, p<0.0001]
The authors conclude that, "Statin therapy should be considered for all diabetic individuals who are at sufficiently high risk of vascular events". An accompanying editorial notes that the results are reassuring but is critical of some aspects of the paper. The editorial also points out that cardiovascular risk reduction should not neglect the importance of lifestyle changes including smoking cessation, healthy diet and regular exercise.
Action: Clinicians should continue to formally assess cardiovascular risk in patients with diabetes. Statin therapy should be considered a core part of a wider treatment strategy to include a healthy lifestyle, blood pressure control, blood glucose control and lipid management.
The Department of Health has notified health professionals today after rising levels of influenza activated the NICE guidance for the supply of oseltamivir (Tamiflu®). The Health Protection Agency has also issued a press statement.
The notification contains a summary of the NICE guidance for the prevention and treatment of influenza.
Prevention: Oseltamivir can be prescribed for the prevention of flu to people aged 13 years* or older who:
- belong to an 'at-risk' group, and
- have not had a flu jab this season, or who had one but too recently for it to have given good protection, or have had a flu jab but the vaccine does not match the virus circulating in the community, and
- have been in close contact with someone with flu-like symptoms, and
- can start taking oseltamivir within 48 hours of being in contact with the person with flu-like symptoms.
* - Oseltamivir has gained a license for prevention of influenza in children aged 1 year and older since the publication of the NICE Guidance. It would be appropriate to prescribe to this younger age group, at the appropriate dose, using the criteria above.
Treatment: Within licensed indications, influenza treatment can be prescribed as follows, provided that the treatment can start within 48 hours of the onset of symptoms:
- oseltamivir can be prescribed to adults and children over 1 year old
- zanamivir can be prescribed to adults and children aged 5 years and older
Figures published on the Health Protection Agency website indicate that there is a regional variation in the report of influenza like illness, with lower reporting in North and Southern England and higher reporting in Central England. It may be appropriate to seek the advice of local Health Protection Units before prescribing.
Action: Clinicians should be prepared to prescribe for the treatment and prevention of influenza if advised to do so by local health protection units.
