Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

July NICE Guidance

The National Institute of Health and Clinical Excellence has published new guidance for the month of July.

There are two new Clinical Guidelines that impact on primary care. Respiratory tract infections – antibiotic prescribing (PDF) covers treatment of upper respiratory tract infections including otitis media, pharyngitis, tonsillitis, common cold, sinusitis and cough. The guideline discusses three treatment strategies for no, delayed or immediate prescription of antibiotics.

The second guideline (PDF) covers diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). It recommends using the Face Arm Speech Test (FAST) to screen patients with sudden onset of neurological symptoms for stroke and TIA to allow appropriate onward referral to emergency care.

  • Facial weakness – can the person smile? Has their mouth or eye drooped?
  • Arm weakness – can the person raise both arms?
  • Speech problems – can the person speak clearly and understand what you say?
  • Test all three symptoms

Action: Primary care clinicians should be aware of these new guidelines. The respiratory tract infection contains some useful information that will help reduce antibiotic prescribing and the stroke guideline recommends a useful tool for screening patients who experience a sudden onset of neurological symptoms.

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Melatonin for Primary Insomnia

Melatonin prolonged release (Circadin®) has been launched for the treatment of primary insomnia.

It is currently only recommended for patients aged 55 years or older and for a period of three weeks. The Regional Drugs and Therapeutics Centre has published a review that highlights the lack of comparative trials, small effect size and cost difference.

Similarly, the National Prescribing Centre has written a Rapid Review that draws attention to the need for clinicians to accurately diagnose primary insomnia and provide patient education to improve sleep hygiene. The lack of comparative data means it is difficult to place this therapy in relation to existing treatments, including hypnotics.

Action: The benefits of the drug are modest. Usage is currently limited to patients aged 55 years and over who already practice behaviours in keeping with good sleep hygiene.

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Combination asthma treatments are equivalent

The Cochrane Library has published a review comparing combination fluticasone and salmeterol (Seretide®) versus combination budesonide and formoterol (Symbicort®) for chronic asthma.

The review aimed to assess the efficacy of each treatment in terms of asthma control, safety and lung function. Any randomised controlled trial comparing the two treatments was included provided the study ran for a minimum of 12 weeks and was not a crossover study. Five studies were included in the analysis with data from 5,537 participants.

Primary outcome measures were exacerbation requiring oral steroids, exacerbation requiring hospital admission and serious adverse reactions. There was no difference in any of these outcomes. The authors note the wide confidence interval and state that the findings "do not exclude clinically important differences between treatments". They conclude that additional trials are justified to better determine any differences.

Action: It would seem that these two combination therapies are equivalent in terms of efficacy and safety. Until differences are demonstrated the choice of appropriate treatment should be based on patient factors and acquisition cost.

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HPV debate continues

The British Medical Journal (BMJ) has published an economic evaluation that aimed to assess the cost effectiveness of routine vaccination of 12 year old schoolgirls against human papillomavirus (HPV) infection.

The Department of Health recently announced that the national programme contract had been awarded to Cervarix® with details of the price remaining confidential. This evaluation estimates that Cervarix® should be costing between £13 and £21 per dose less that the quadrivalent alternative Gardasil®.

There is continued debate over the choice of vaccine (Times and Guardian) accusing the government of selecting an inferior vaccine in order to save money. This article in the BMJ is likely to further inflame the debate and may generate patient questions in primary care.

Action: Clinicians should be aware of the current situation and ongoing debate regarding HPV vaccination.

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Roche suspended from ABPI

Roche has been suspended from the Association of the British Pharmaceutical Industry (ABPI) after serious breaches of the code of practice were ruled.

A former employee of the company alleged the sales of orlistat (Xenical®) to a private diet clinic were excessive and that agreement had been reached to financially support acquisition of a new clinic. It further transpired that the medication has been sold to the owner of the clinic and that this individual held no medical qualifications and was therefore essentially a member of the public.

The ruling noted that Roche were made aware of irregular activities at this clinic in a representative report in May 2003. Despite this knowledge they continued to sell product for almost 2 years! In light of this the panel noted the apparent "disregard for patient care" and recommend suspension from the ABPI for undermining confidence in and bringing discredit upon the industry.

Action: Clinicians should be aware of this ruling and suspension.

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