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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

'Dealing with the downturn'

The NHS Confederation has published an article in the future of leadership series reviewing the challenges facing the NHS in the coming years as a consequence of financial predictions indications a real term reduction in funding.

This article is aimed at NHS Managers but may be of interest to clinicians because of the recommendations that are made. This article suggests that we learn from history and avoid growing waiting lists, diluted quality and structural change.

Instead, the article proposes strong leadership and radical quality and efficiency improvement. More specific proposals include non-treatment of certain illnesses where there is little proven benefit and restricted funding towards interventions that target lifestyle or cosmetic problems.

Action: Clinicians should be aware of this document and the recommendations it makes. The NHS seems to be in a permanent financial crisis but planning ahead will allow best use of a limited resource.

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Tomato-pill for heart disease

A launch of a natural supplement that reduces oxidation levels of low density lipoprotein has been reported in the general media, as detailed on NHS Choices.

Ateronon® contains a form of lycopene, an antioxidant founds in tomatoes. It is claimed that the product can help to reduce "cholesterol oxidation – a leading cause of atherosclerosis, heart attacks and strokes".

It is worth remembering that large randomised controlled studies of antioxidants conducted in parallel with the statin studies have failed to find a benefit for antioxidant therapy. Scientific evidence supporting this product that is available via the product website is limited to two small, open label studies in which 22 patients took the study medication. The research has involved analysis of surrogate markers only and there is no evidence in terms of reductions in heart attacks or strokes.

The manufacturers advise that patients on prescription medication talk to their doctor before starting this supplement. It should also be noted that this product is classed as a food supplement and therefore it has no product licence. Responsibility for any prescription would rest entirely with the prescribing clinician.

Action: Clinicians should be aware of this product and the media interest. There are no data to support long term health benefits and as such this product cannot be considered as a replacement for proven therapies, for example statins. This is also the recommendation made by the British Heart Foundation.

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SMC June Update

The Scottish Medicines Consortium (SMC) has issued its monthly advice on new medicines.

Aripiprazole (Abilify®) has been rejected for the treatment of moderate to severe manic episodes in bipolar I disorder and for the prevention of a new manic episode in patients who experienced predominantly manic episodes and whose manic episodes responded to aripiprazole treatment. The review notes that efficacy data are comparisons with placebo rather than active treatments and that the economic case was not sufficiently robust.

Tadafil (Cialis®) 2.5mg and 5mg tablets have been accepted for regular once-daily administration in patients with erectile dysfunction responding to an on-demand regimen of tadalafil who anticipate frequent use (at least twice weekly).

Action: Clinicians should be aware of the recommendations of the SMC. Routine use of rejected and restricted medicines should be avoided.

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New antidepressant class

Agomelatine (Valdoxan®) has been launched in the UK for the treatment of major depressive episodes in adults.

This new drug is a melatonin receptor agonist and serotonin-2c antagonist. The initial dose is 25mg daily taken at night and this dose may be doubled after two weeks if there is no symptom improvement.

The drug is not recommended in people under 18 years of age and those with active liver disease. Caution is required in people aged over 65 years and those who consume large quantities of alcohol. Liver function should be monitored at 12 and 24 weeks and treatment stopped if serum transaminases exceed three times the upper limit of normal.

Common side effects include gastrointestinal disturbances (nausea, diarrhoea, constipation and abdominal pain), headache, dizziness, insomnia, somnolence and liver function changes.

Agomelatine is available in 25mg tablets in packs of 28 at a cost to the NHS of £38.53. A month of treatment will therefore cost £38.53 to £77.06 depending on the daily dose.

Action: Clinicians should be aware of this new drug. It's place in therapy is currently unclear and it may be prudent to limit use to specialists and continue to follow existing guidelines.

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Drug Safety Update - June 2009

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for June 2009 (PDF).

This issue contains stop press information about a potential interaction between clopidogrel and proton pump inhibitors, counterfeit NovoFine® needles and hepatitis risk from incorrect use of lancet devices. Drug safety advice covers the following areas:

  • Antipsychotics: risk of venous thromboembolic events
  • Chloral hydrate and Triclofos: not first-line options for insomnia
  • Oral salicylate gels: not for use in those younger than age 16 years
  • Topical ketoprofen: reminder on risk of photosensitivity reactions

Action: Clinicians will find this publication to be a useful review of current issues in drug safety.

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