Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

MeReC Bulletin - Opiate Dependence

The National Prescribing Centre (NPC) has published a MeReC Bulletin (PDF) that provides an update on the drug treatment of opiate dependence in primary care.

The bulletin provides a background to scale of opiate dependence detailing the physical and mental health problems as well as the wider social problems associated with illicit drug use. The bulletin also defines the aims and principles of treatment and a discussion of the evidence supporting maintenance and detoxification.

The current guidance from the National Institute for Health and Clinical Excellence is summarised into several key points:

  • Methadone and buprenorphine (oral formulations), using flexible dosing regimens, are recommended as options for maintenance therapy in the management of opioid dependence
  • The decision about which drug to use should be made on a case-by-case basis
  • If both drugs are equally suitable, methadone should be prescribed as the first choice
  • Methadone and buprenorphine should be administered daily, under supervision, for at least the first 3 months. Supervision should be relaxed only when the patient's compliance is assured
  • Both drugs should be given as part of a programme of supportive care

Finally, the bulletin identifies sources of evidence that support 'real life' benefits of treatment programmes and details the potential risks of drug treatment.

Action: Clinicians involved in the treatment of patients with opiate dependence will find this bulletin useful and informative.

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Glucosamine ineffective for hip OA

The Annals of Internal Medicine has published the results of a randomised trial into the efficacy of glucosamine sulphate in reducing symptoms and structural damage in osteoarthritis (OA) of the hip.

The study recruited 222 patients who were randomised to blinded treatment with 1,500mg of glucosamine sulphate daily or matching placebo. Data were collected for a period of 2 years for primary outcome measures including pain and function assessments (using Western Ontario and McMaster Universities scales) and joint space narrowing.

The study failed to detect any statistical or clinically meaningful differences between the two study groups for any outcomes. Pain and function assessments were not statistically different and use of analgesics was not lower in the glucosamine group.

The study was limited by a significant number of hip replacements being undertaken in study participants during the course of the study. An analysis of the impact of this limitation has identified that a statistical difference may have been hidden however this difference would have been clinically unimportant.

Action: Clinicians should avoid prescribing glucosamine sulphate for OA of the hip.

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MTRAC reviews dementia drugs

The Midlands Therapeutics Review and Advisory Committee (MTRAC) has published reviews of the four drugs available for Alzheimer's disease.

The reviews of donepezil, galantamine, memantine and rivastigmine place all of the drugs as having a lower place in therapy with relatively weak evidence supporting use. Donepezil, galantamine and rivastigmine are suitable for prescribing in primary care provided that there is continued monitoring in secondary care or through shared care arrangements and treatment is stopped when appropriate as specified in the existing NICE Guidance. Memantine is classified as unsuitable for use in primary care.

Action: Clinicians will find these reviews contain a useful summary of the trial data for each drug. Throughout the trial data the reviews reveal small overall benefits, inconsistent results and use of subjective measures.

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ADR reporting campaign launched

The Medicines and Healthcare products Regulatory Agency (MHRA) has launched a six week campaign to encourage members of the general public to report suspected adverse drug reactions (ADRs). The BBC has reported this campaign.

The scheme will see the distribution of materials to pharmacies including updated Yellow Card reporting forms, information leaflets and a poster for display in the pharmacy. It is hoped that this scheme will promote greater use of the new, easier to use forms. Reporting of any suspected reaction is encouraged, including reactions already listed in information leaflets or mentioned by healthcare professionals.

Patients may approach healthcare professionals asking for more information about how they can submit a report and seeking reassurance that the report should be submitted at all.

Action: Clinicians should be aware of this campaign and support reporting of any suspected ADR.

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Nursing integrity reduced by industry promotion

PLoS Medicine has published a paper discussing the influence that the pharmaceutical industry has on nurses and in particular nurses with prescribing qualifications. The British Medical Journal has also reported on the article.

The authors searched the MEDLINE and CINAHL databases for articles that made reference to the relationship between nursing and drug companies. 32 articles were included, only two of these declared any competing interests and neither of these were from nursing literature.

The authors also highlight apparent confidence expressed in nursing literature that, "nurses will not be caught by marketing practices" despite the lack of formal training in critical appraisal skills and the general acceptance that the promotional activity of the pharmaceutical companies provides educational benefits.

The study concludes that the pharmaceutical industry has recognised and invested heavily in promotional activity aimed at nurses at the "expense of the health budget, evidence-based care, and nursing integrity".

Action: Clinicians should consider carefully what benefits they gain from their interactions with the pharmaceutical industry in terms of clinical knowledge and skills. It would be prudent to ensure that any meetings with representatives from the pharmaceutical industry are multidisciplinary and that information presented is discussed among the multidisciplinary team before implementing any changes to practice.

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