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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Healing rate unchanged by silver dressing

The British Journal of Surgery has published the results of a trial that aimed to assess the cost-effectiveness of silver-donating versus non-silver low-adherence dressings in the treatment of venous leg ulcers.

The study recruited 213 patients who were randomly assigned to treatment with a silver dressing (n=107) or a low-adherence dressing (n=106) beneath graduated compression. The primary outcome of the study was healing rate at 12 weeks with secondary outcomes assessing time to healing, quality of life and cost-effectiveness.

There was no statistical difference in primary outcome of healing rate at 12 weeks between the two dressing (59.6% for the silver dressing and 56.7% for the low-adherence dressing). Additionally, there was no difference in healing rates at 6 or 12 months or in quality of life measures.

The authors note that there were differences in demographic data and healing rates between the two centres that participated in the study. The timing of the study also coincided with a period of restructuring in the provision of community services at the trial locations and this impacted upon recruitment. Finally, the study used a generic measure for quality of life.

The authors note, that despite these limitations, the results are consistent with recent systematic reviews that have failed to find any evidence of benefit with antimicrobial dressings. Higher costs were associated with use of silver dressings by an average of £97.85 per patient. The authors therefore conclude that clinicians should use the "least expensive, inert dressings beneath compression therapy as standard care".

Action: Clinicians should be aware of this study. Routine use of antimicrobial dressings for treatment of venous leg ulcers is not evidence based and should be avoided.

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Medicines discharge could be better

The Care Quality Commission has issued a press release that highlights several flaws in the current systems used to managing patients’ medicines after discharge. This has been reported in the general media (BBC).

A survey of 280 surgeries within 12 primary care trusts (PCTs) was conducted and found that, "there are generally good systems in place to ensure that repeat prescribing is safe, and that people don’t carry on taking a medicine for longer than they should". However the following concerns were raised:

  • GPs and hospitals do not always exchange enough information about medicines, and don’t share it on time
  • In a minority of GP practices (17%), administrative staff rather than clinical staff update records, and they don’t have the clinical skills to check whether medications are right
  • There’s not enough being done to talk to patients themselves about their medications, either when they’re discharged from hospital or in the longer term
  • Monitoring and learning from serious incidents is patchy

Individual study reports are available for the 12 participating PCTs and may provide useful pointers for service improvement.

Action: Clinicians should be aware of this study and consider reviewing local systems to ensure that medicines safety is optimal.

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October NICE Guidance

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

There are two guidance documents that have an impact in primary care. A technology appraisal recommends (QRG) that prasugrel (Efient®) is an option in combination with aspirin for patients who are treated by percutaneous coronary intervention following an acute coronary syndrome. This applies only when they have had a ST-segment-elevation myocardial infarction (STEMI), have had a blocked stent while on treatment with clopidogrel or have diabetes. The Summary of Product Characteristics recommends treatment continues for up to 12 months unless discontinuation is clinically indicated at an earlier time, perhaps due to side effects.

There is also a clinical guideline that covers the treatment and management of depression in adults (QRG). This is an update of an existing guideline and is published along with a summary guideline that contains information relevant to general hospital settings. A stepped approach is recommended with higher intensity therapies recommended for more severe cases.

Action: Clinicians who are involved in the treatment of adults with depression or who provide continuing care for patients after an acute coronary syndrome should consider these guidelines to be required reading.

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Liraglutide for obesity?

The Lancet has published the results of a study that aimed to assess the efficacy and tolerability of liraglutide in the treatment of obesity in individuals without type 2 diabetes. This study has been reported in the general media (BBC).

The study recruited men and women aged 18 to 65 years old with a body mass index (BMI) of 30-40kg/m2. Patients with type1 or type 2 diabetes and those with a fasting glucose of 7mmol/L or above were excluded. Participants were then randomly assigned to a placebo injection, one of four dose regimens of liraglutide (1.2mg, 1.8mg, 2.4mg or 3.0mg daily) or open-label orlistat. Follow up was for 20 weeks in total which included a 4 week titration phase and 16 weeks of stable dosing. All participants were also advised regarding a 500 kcal per day energy-deficient diet and increased their physical activity throughout the trial.

Mean body weight, waist size and blood pressure were reduced in all groups. Liraglutide produced significantly greater reductions in body weight compared to placebo at all doses and at the two higher doses when compared to orlistat. Participants on the higher dose of liraglutide (3.0mg daily) lost an average of 7.2kg over the 20 week study.

Nausea and vomiting occurred much more frequently with liraglutide therapy and these side effects were also dose related. 5.1% of patients on the placebo injection experienced nausea compared to 24.2% to 47.3% of patients on liraglutide.

The authors note that the open label orlistat treatment and the different injection volumes of the daily doses of liraglutide may introduce some bias. They also note that the long-term effects of this treatment on body weight, lipids, cardiovascular risk and mortality need to be assessed in longer studies.

The authors conclude that, "the results of this study indicate the potential benefit of liraglutide" but also suggest that "the long-term risk–benefit profile for liraglutide, as well as its weight maintenance capabilities, remain to be established". In addition, patient acceptability of an injectable therapy to aid weight loss remains unknown.

Action: Clinicians should be aware of the results of this study. Liraglutide is not currently licensed as a weight management product. Use of this drug in patients without diabetes, with the aim of aiding weight loss, should be avoided pending further research and a license for this indication.

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Swine Flu Vaccination Tools

The Department of Health (DH) has written to doctors, nurses and pharmacists working in primary care to provide information about the Swine Flu Vaccination Programme. Information materials are now available on the DH website to support the programme.

The materials comprise information materials, training tools and data issues including:

  • Template GP letters
  • Template consent forms
  • A template patient group direction
  • Slide set for training staff who will conduct vaccinations
  • Recommended Read Codes

In addition, readers are directed to the online Green Book and are reminded of the recommended vaccination schedule for Pandemrix®.

  • Children aged 6 months to 10 years - two half doses (0.25ml) with at least 3 weeks between doses
  • Individuals aged 10 years to 60 years - one dose (0.5ml)
  • Individuals aged over 60 years - one dose (0.5ml) although this may be revised
  • Immunocompromised individuals aged over 10 years - two doses (0.5ml)

Action: Clinicians should be aware of this information portal and utilise these materials if appropriate.

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