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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

First line antihypertensive review

The Cochrane Library has published a review of the available evidence that aimed to quantify the benefits and harms of the major first line antihypertensive drug classes: thiazide diuretics, beta-blockers, calcium channel blockers (CCB), angiotensin converting enzyme (ACE) inhibitors, alpha-blockers, and angiotensin II receptor blockers (ARB).

The review included data from 24 trials with 58,040 participants that were of at least one year duration and compared one of the study drugs with placebo or no treatment. 70% of participants in each study were required to have a blood pressure above 140/90 mmHg at baseline.

The review found that low-dose thiazide diuretics reduced all morbidity and mortality outcomes. ACE inhibitors and CCBs provided similar benefits but the evidence was less robust. No trials were found for ARBs or alpha-blockers.

Action: Thiazide diuretics are, once again, supported by the evidence for first line use in the treatment of hypertension.

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Second July CKS Update

Clinical Knowledge Summaries (CKS) has been updated for a second time in July 2009. CKS may have change their publishing schedule. Updates are available for the following clinical areas:

Action: Clinicians who see patients with any of these conditions may find the new and updated information useful when reviewing current clinical practice.

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BNF for Children 2009

The British National Formulary for Children 2009 has been updated, published and made available online.

Hard copies can be ordered from the publishers however many NHS staff will already have received a free hard copy through usual channels and can also access the online version at http://www.bnfc.nhs.uk.

Updates in this revision include:

  • Management of acute asthma: A new table summarises the latest information on the management of acute asthma
  • Chapter 14: Immunological products and vaccines: The chapter on immunological products and vaccines has been updated and reformatted for ease of use
  • Influenza: BNFC summarises the latest guidance on the prevention and treatment of influenza, and includes recommendations on the use of osteltamivir in children under 1 year
  • Otitis media and hospital-acquired pneumonia: Guidance on the antibacterial treatment of otitis media and hospital-acquired pneumonia has been updated
  • Nutrition: New tables have been introduced on enteral feeds and nutritional supplements for infants and older children
  • Intravenous infusions for neonatal intensive care: A new appendix on intravenous infusions for neonatal intensive care has been added
  • Caffeine: Safe practice advice has been introduced on the use of caffeine
  • Tacrolimus: Healthcare professionals are alerted to the danger of switching between different preparations of tacrolimus
  • How BNFC is constructed: This new section provides valuable insight into how the national prescribing resource is constructed

Action: BNFC is the primary source of prescribing information when prescribing to all children up to the age of 18 years.

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Doctors sometimes say 'No'

The BBC Health website has published a 'Viewpoint' by Dr James Armstrong of the Medical Defence Union.

The article details the increasing involvement that patients have in treatment decisions and the obligation that doctors have to listen to their patients. However, the article also acknowledges that doctors are under no obligation to provide treatments that are not clinically appropriate.

In such a situation it is recommended that alternative approaches are discussed and that the patient is reminded that they can seek a second opinion.

Action: The contents of this article may be useful in supporting a clinical decision to not provide a treatment and could even be adapted to form a leaflet.

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MeReC Extra 40

The National Prescribing Centre has published MeReC Extra 40 (PDF) which covers the results of recent studies into the benefits of prostate cancer screening, the effect of rosuvastatin on venous thromboembolism (VTE) and the efficacy of clopidogrel in preventing major vascular events in patients with atrial fibrillation.

The first section reviews the results of two studies, one European and one America, that found systematic screening of prostate specific antigen (PSA) with our without a digital rectal examination results in greater detection of prostate cancer. What remains unclear is whether greater detection results in increased survival rates.

A review of results of a recent study of rosuvastatin found a reduced risk of VTE in patients at a low risk of cardiovascular disease when taking rosuvastatin compared to placebo. The interpretation of this study does not support the use of statins for prevention of VTE in the general population.

Lastly, a review of the ACTIVE A study found that the combination of aspirin and clopidogrel reduced major vascular event (stroke, non-central nervous system embolism, myocardial infarction, or death from vascular causes) in patients with atrial fibrillation who were unsuitable for treatment with warfarin. However, this reduction was balanced by an increased risk in major bleeds results in no overall net benefit.

Action: Clinicians who see patients in well man clinics or patients with a history of VTE or atrial fibrillation will find this information useful and informative.

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