Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Encouraging NSAID trends

The National Prescribing Centre (NPC) has published a blog article that reveals encouraging improvements in the prescribing of non-steroidal anti-inflammatory drugs (NSAIDs).

Prescribing data demonstrate a 5.6% reduction in NSAID prescribing between December 2005 and November 2008. In addition, prescribing of diclofenac has declined by approximately 5% since November 2007 while naproxen usage increased by approximately 4%.

Recent analyses have revealed differences in the cardiovascular (CV) and gastrointestinal (GI) risk profiles for different NSAIDs. Advice from the NPC and the Medicines and Healthcare products Regulatory Agency recommends cautious use of NSAIDs after consideration of the individual patient's risk factors.

Action: Clinicians should continue to review CV and GI risk when considering prescribing NSAIDs and use the agent of lowest overall risk.

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Research data fabricated

The British Medical Journal has published a news item after a prominent researcher admitted fabricating data. Much of this research focussed on cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (Cox-II NSAIDs).

Data were fabricated in 21 of his 72 articles indexed by PubMed by Scott S Reuben. An evaluation of the remaining 51 articles was inconclusive in identifying potential fraud.

A full list of the 21 studies has been issued to announce retraction and ensure these studies are not referenced in future articles. A quote in the article also calls for a further retraction of the remaining 51 articles.

Action: Clinicians should be aware of this fraud. The results of any these articles should not be used to guide clinical decision.

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Newer insulins no better

The Journal of the Canadian Medical Association has published the results of a meta-analysis that aimed to assess the efficacy and safety of insulin analogues for the management of diabetes mellitus.

This analysis updated two previous analyses. This review identified 5 new studies of rapid-acting insulin analogues and 22 new studies of long-acting insulin analogues.

The review compared HbA1c results for newer insulins compared to conventional insulins in both type 1 and type 2 diabetes. The differences were minimal and inconsistent.

Type 1 diabetes:

  • Lispro -0.09%, 95% confidence interval [CI] –0.16% to –0.02%
  • Aspart -0.19%, 95% CI –0.20% to –0.07%
  • Glargine -0.11%, 95% CI –0.21% to –0.02%
  • Detemir -0.06% (not significant)

Type 2 diabetes:

  • Lispro -0.03% (not significant)
  • Aspart -0.09% (not significant)
  • Glargine -0.05% (not significant)
  • Detemir +0.13%, 95% CI +0.03% to +0.22%

The analysis could not draw any conclusions with respect to reductions in long-term diabetes-related complications or death due to insufficient data. Reductions in hypoglycaemia are also inconsistent.

The authors conclude that, "insulin analogues offer little benefit relative to conventional insulins in terms of glycaemic control or reduced hypoglycaemia". They also recommend long-term high quality studies to determine efficacy in diabetes-related complications.

Action: When treatment with insulin therapy is necessary consideration should be given to the available alternatives. Insulin analogues may be useful in selected patients, for example those who experience nocturnal hypoglycaemia.

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BNF 57

The 57th Edition of the British National Formulary is currently being printed and distributed.

New or revised content in this version includes a revised layout for chapter 14 - Immunological products and vaccines and:

Updated Prescribing information for:

  • Treatment of irritable bowel syndrome
  • Emergency use of oxygen
  • HIV infection
  • Oral antidiabetic drugs in pregnancy and breast-feeding
  • Prevention of osteoporotic fractures in postmenopausal women

New safety information for:

  • Fibrotic reactions and ergot-derived dopamine receptor agonists
  • Tendon damage with quinolones

The web version has already been updated and printed version is available for purchase.

The print version is distributed by the Department of Health to Dentists, Doctors, Nurses and Pharmacists providing NHS services.

Action: All clinicians should start using BNF 57 as soon as the print version arrives. The web version can be used to access the latest information if necessary.

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Lifestyle advice overlooked in diabetes?

Diabetes UK has published the results of a study that indicates that approximately one third of patients diagnosed with type 2 diabetes are initiated on medication within a month of diagnosis. They suggest that this is being done "without giving healthy lifestyle changes a chance". This study was been reported in the general media (BBC).

The study of 652 patients diagnosed with type 2 diabetes within the last month found that 36% were prescribed medication. It was also noted that 13% were prescribed two drugs.

Current guidelines recommend a trial of lifestyle measures before drug treatments are initiated. Diabetes UK reinforces this view stating, "a healthy, balanced diet and doing physical activity should always be the foundation of good diabetes management".

This study may be limited by not correcting for initial assessment of individual patients ability or motivation to make lifestyle changes. It is also worth noting that, in England, patients who control their diabetes with lifestyle measures are not exempt from prescription charges while those who are prescribed medication get all prescriptions free of charge.

Action: Clinicians should continue to ensure that diabetes management regularly reinforces the importance of lifestyle measures including a healthy diet and exercise.

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