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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

PSA screening concerns

Routine screening for prostate specific antigen (PSA) in men is not currently recommended in the UK and it would seem that this position may be justified given some recent results from the European Randomised Study of Screening for Prostate Cancer (ERSPC). These results have been reported in the general media (BBC).

ESRPC is a study that is aiming to assess the risks and benefits of prostate cancer screening with data from 8 European countries. This latest data come from the Finnish arm of the study shows that for every 8 men screened in a four year period, one would get a false positive result that would require further investigations that were likely to be unnecessary. Additionally, these individuals were twice as likely to disengage from future screening.

The BBC article quotes the study lead, Dr Tuomas Kilpelainen: "I don't think routine screening should be advised until more is known on the adverse effects and costs of screening". Men with urinary tract symptoms who are worried about prostate cancer are still encouraged to seek medical help.

Action: Clinicians should be aware of these results. Selective screening of PSA in men with urinary tract symptoms may be appropriate after discussion of the pros and cons.

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Low-cost statins and QOF

The British Journal of General Practice has published the results of a study that aimed to identify any correlation between proportional use of low-cost stains and achievement in the cholesterol indicators of the Quality and Outcome Framework (QOF).

Data were analysed from the 2006-07 financial year comparing proportional use of low-cost statins with QOF achievement in the coronary heart disease (CHD8) and stroke (STROKE8) indicators for cholesterol (less than 5mmol/L).

The National electronic Library for Medicines reports indicates that statin use ranged from 33.6% to 93.6% (median 72.0%) and QOF achievement ranged from 36.4% to 98.1% (median 82.7%) and 46.7% to 97.2% (median 75.7%) for CHD and stroke respectively.

The author concludes that increasing use of lower-cost statins was associated with poorer outcomes on the QOF measures used however there are some limitations in this study.

The cholesterol indicator in the diabetes domain (DM17) was not analysed in this study. It is also unclear if exception reporting was accounted for in this analysis. Additionally, this study does not review clinical outcomes and extrapolating this data to that end is inappropriate.

Action: The results of this study do not change current prescribing practice of using simvastatin 40mg first line where clinically appropriate. Clinicians may need to be aware of this study in order to reassure patients who raise concerns.

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Gingko ineffective for preventing cognitive decline

The Journal of the American Medical Association has published the results of a study that aimed to assess the efficacy of gingko biloba on long-term cognitive functioning in older adults.

The study recruited 3,069 participants aged between 72 and 96 years who were randomly assigned to treatment with gingko biloba 120mg twice daily or a matching placebo and were followed up for a median of 6.1 years.

Participants were reviewed annually and were assessed using modified-mini mental state examination (3MSE), cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-Cog) and in neuropsychological domains of memory, attention, visual-spatial construction, language and executive functions.

Annual rates of decline over the first four years in the neuropsychological domains were not different between the two groups. 3MSE and ADAS-Cog were assessed annually for the entire study and did not differ between the two treatment groups. It was noted that those patients with mild cognitive impairment diagnosed at baseline experiences a more rapid decline. After correcting for age, gender, ethnicity and education (measured by years in education) there were still no differences between the two treatment groups.

The authors conclude that gingko biloba "did not result in less cognitive decline in older adults with normal cognition or with mild cognitive impairment". They also note that there are limitations in the study including baseline differences in the two groups favouring the placebo group but they point out that these were not clinically significant and were corrected in the analysis. Additionally, the neuropsychological assessment schedule was not ideally suited to this study but secondary analysis of 3MSE and ADAS-Cog were consistent with the primary analysis.

Action: Clinicians should be aware of this study. Gingko biloba should not be recommended for preventing cognitive decline in older patients.

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