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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

October CKS Update

Clinical Knowledge Summaries (CKS) has been updated in October 2009 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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Prediabetes vision

Diabetes UK, the UK charity for people with diabetes, has published a position statement the reveals several care recommendations for prediabetes.

The statement acknowledges the current method of diagnosis of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). A new term, impaired glucose regulation (IGR) or non-diabetic hyperglycaemia (NDH) is recommended to describe presence of these conditions (exclusively or jointly) by healthcare professionals. It is recognised that the term prediabetes may be more appropriate when communicating with the public.

The statement supports current Government plans (England only) to screen more widely for IGR and recommends appropriate lifestyle interventions to prevent or delay progression to diabetes. Weight reduction, changes in dietary habits and increased physical activity are recommended intervention strategies.

Pharmacological interventions are not recommended to slow progression to diabetes as there are no therapies currently approved or licensed for this use in the UK. It is noted that weight loss medications and bariatric surgery may play a role in the management of obese patients with IGR.

Action: Clinicians should be aware of this statement. Lifestyle interventions and patient education are the mainstay of any treatments aimed at halting progression to diabetes.

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Paracetamol may lower antibody response

The Lancet has published the results of a study indicating that antibody response to vaccination may be reduced by the concurrent administration of paracetamol. These results have been reported in the wider media (BBC).

The study was conducted in the Czech Republic and recruited 459 healthy infants. The study was open-label with participants being assigned to taken 3 doses of paracetamol at 6-8 hourly intervals after immunisation (n=226) or to give no prophylactic paracetamol (n=233). Participants were administered with a primary vaccination course at 3, 4 and 5 months of age and then a booster dose between 12 and 15 months of age. The vaccinations used differ from those recommended in the UK and included pneumococcal non-typeable Haemophilus influenzae protein D-conjugate vaccine (PHiD-CV), hexavalent diphtheria, tetanus, 3-component acellular pertussis, hepatitis B, inactivated poliovirus types 1 and 2, and 3-H influenzae type b vaccine (DTPa-HBV-IPV/Hib) and oral human rotavirus vaccine (HRV).

The primary objective of the study was to assess fever response in the total cohort with a secondary objective to assess immunogenicity of the vaccines. Incidence of fever (temperature of 38C or greater) was significantly lower in participants who received paracetamol in the primary (42% versus 66%) and booster studies (58% versus 36%). Fever greater than 39.5C was uncommon and occurred in 9 participants of the entire study. However, it was also noted that antibody response (measured by geometric mean concentration) was lower in the group who received paracetamol. Rates of seroconversion were still high in both groups, especially after administration of the booster dose.

The authors conclude that, "prophylactic administration of antipyretic drugs at the time of vaccination should nevertheless no longer be routinely recommended without careful weighing of the expected benefits and risks".

Action: Clinicians should be aware of these findings and the wider media coverage. Parents should be advised to avoid administering paracetamol unless deemed clinically necessary and reassured that seroconversion rates were still high after completion of the vaccination schedule.

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Antiviral treatment ineffective for Bell's palsy

The Cochrane Library has published an updated review of the available evidence for the use of antiviral agents in the treatment of Bell's palsy.

This review included data from seven trials involving 1,987 patients. This adds five new studies to the previous review. The analysis found no significant benefit in the rate of incomplete recovery from antiviral treatment compared with placebo. Additionally, antiviral treatment was significantly worse than corticosteroids although there were unexplained differences in the study populations. It was noted that there was no significant difference in rates of adverse events between antiviral treatments and placebo, antiviral treatments and corticosteroids or the antiviral-corticosteroid combination and placebo.

The analysis acknowledges that some studies have suggested that Bell's palsy may be caused by infection with the cold sore (herpes simplex) virus. However, since antiviral drugs appear to be clinically ineffective it is suggested that other causes for Bell's palsy should now be considered. Clinical Knowledge Summaries currently recommends prednisolone monotherapy for the treatment of Bell's palsy in adults presenting with 72 hours of symptom onset. The recommended dose is 25mg twice daily for 10 days.

Action: Clinicians should be aware of this review and avoid prescribing antiviral medication to treat Bell’s palsy.

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SMC October Update

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

Metformin modified release (Glucophage SR®) has been restricted to use in patients who are intolerant of immediate release metformin where prolonged release tablet allows the use of a dose of metformin or in patients for whom a once-daily preparation offers a clinically significant benefit. It is noted that evidence of improved gastrointestinal tolerability is not convincing and that the prolonged-release formulation is more expensive.

Vildagliptin (Glavus®) has been accepted for use in combination with a sulphonylurea for the treatment of type 2 diabetes. This appraisal only reviews combination use with a sulphonylurea; previous advice has been issued for combination use with metformin, combination use with glitazones cannot currently be recommended pending a submission.

Olmesartan/amlodipine (Sevikar®) has been accepted for treatment of essential hypertension in patients whose blood pressure is not adequately controlled on olmesartan or amlodipine monotherapy. The review notes that angiotensin receptor blockers are an alternative to ACE inhibitors where these are not tolerated. It is also noted that this fixed dose combination product offers a cost advantage over the individual drugs at certain doses but that other treatment options may be available which are less expensive.

Estradiol/dienogest (Qlaira®) has been rejected for use as a contraceptive in the absence of a submission from the manufacturer.

Etonogestrel (Nuvaring®) has been accepted for use as a contraceptive. Cost efficacy was demonstrated against women who chose to discontinue oral contraceptives and it is therefore noted that other non-oral contraceptives are available at lower cost.

Quetiapine (Seroquel®) has been rejected for the treatment of major depressive episodes associated with bipolar disorder. Efficacy relative to current practice was not demonstrated.

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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