Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

November CKS Update

Clinical Knowledge Summaries (CKS) has been updated in November 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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Eslicarbazepine launched

A new antiepileptic medication has been launched in the UK as adjunctive therapy for the treatment of partial-onset seizures, with or without secondary generalisation, in adults.

Eslicarbazepine acetate (Zebinix®) is available as 800mg tablets in packs of 30 at a cost of £154.20. The drug is an active metabolite of oxcarbazepine and has the same mechanism of action as carbamazepine.

Concomitant use with oxcarbazepine is not recommended due to the theoretical risk of overexposure to the active metabolites of these drugs. The only apparent advantage of this drug over oxcarbazepine is the once daily administration however this comes at a significant cost.

Action: Clinicians should be aware of this new drug. This new drug may be useful where compliance with twice daily oxcarbazepine is incomplete but changes to therapy should ideally be secondary care led.

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Swine 'flu vaccine ADR data

The Medicines and Healthcare products Regulatory Agency (MHRA) have started publishing weekly summaries of suspected adverse drug reactions (ADRs) associated with the swine 'flu vaccinations.

This area of the MHRA website provides access to the Summary of Product Characteristics and Patient Information Leaflets for Celvapan® and Pandemrix® as well as information about how to report suspected ADRs.

The most recent report includes all suspected ADRs reported up to Thursday 5th November. The report states that, "the most frequently reported suspected adverse reactions are non-serious injection site reactions (e.g. pain, swelling, redness), or are well established minor adverse effects of many vaccines, including the swine flu vaccines (e.g. nausea, vomiting, dizziness muscle pain, fever, fatigue, headache, swollen glands)". They conclude that the balance of benefits and risks of vaccination remain positive.

Action: Clinicians will find this frequently updated report useful when advising patients of the risks and benefits of vaccination.

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SMC November Update

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

Agomelatine (Valdoxan®) has been rejected for the treatment of major depressive episodes. The economic analysis was insufficiently robust to gain approval.

Fentanyl nasal spray (Instanyl®) has been restricted to use in patients who are unsuitable for other short-acting oral opioids (e.g. oral morphine) for the management of breakthrough pain in adults already receiving maintenance opioid therapy for chronic cancer pain.

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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Non-fasting cholesterol tests?

The Journal of the American Medical Association has published the results of study that aimed to assess the association between levels of the major blood lipids and apolipoproteins with the risk of vascular disease. The results of the study have been reported in the wider media (BBC).

Data for 302,430 individuals from 68 studies with 2.79 million person-years of follow up were analysed. During the studies the following outcomes occurred: 8857 nonfatal myocardial infarctions, 3928 coronary heart disease (CHD) deaths, 2534 ischaemic strokes, 513 haemorrhagic strokes, and 2536 unclassified strokes.

This analysis found strong correlations between cardiovascular risk and levels of high-density lipoprotein cholesterol (HDL-C), non-high-density lipoprotein cholesterol and triglycerides after correcting for other non-lipid risk factors. After additional correction for the other lipid variables the association with triglycerides was no longer statistically significant. The association remained significant after this same correction for HDL-C and non-HDL-C. Levels of apolipoproteins were not associated more strongly than HDL-C or non-HDL-C.

The authors conclude that, "lipid assessment in vascular disease can be simplified by measurement of either total and HDL cholesterol levels or apolipoproteins without the need to fast and without regard to triglyceride".

There are several potential merits to these conclusions. The possibility of simplifying cholesterol testing so that fasting is not required is likely to be highly acceptable to patients. It would also seem that apolipoprotein levels provide no additional clinical insight to guide treatment choices. However, clinicians may need to bear in mind than many laboratories calculate LDL-C using the Friedewald equation rather than directly assessing the level of LDL-C. The accuracy of this equation declines at elevated triglyceride levels and fasting samples will still be required for accurate reporting of LDL-C.

Action: Any changes to blood test requesting need careful planning. Total cholesterol and HDL-C can be assessed from a non-fasting blood sample for the purposes of cardiovascular risk prediction however fasting samples will still be necessary in many cases.

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