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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

BNF 60

The 60th Edition of the British National Formulary was published in September and is currently being distributed within the NHS.

New or revised content in this version includes updated advice regarding:

  • Use of beta-blockers in patients with asthma or chronic obstructive pulmonary disease
  • Prophylaxis of venous thromboembolism
  • Antiplatelet drugs in patients with a coronary stent
  • Chronic obstructive pulmonary disease
  • Neuropathic pain
  • Influenza vaccination
  • Meningococcal A, C, W135, and Y conjugate vaccine

The web version has already been updated and printed version is available for purchase.

Action: All clinicians should start using BNF 60 as soon as the print version arrives. The web version can be used to access the latest information if necessary.

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NICE Guidance - October 2010

The National Institute of Health and Clinical Excellence has published new guidance for the month of October 2010. This month there is one clinical guideline and one technology appraisal that impact upon primary care.

The nocturnal enuresis clinical guideline (QRG) provides evidence-based advice on the assessment, care and treatment of children and young people up to the age of 19 with bedwetting.

The technology appraisal (QRG) reviews the place for liraglutide (Victoza®) in the treatment of type 2 diabetes mellitus. It is recommended as an alternative to exenatide (Byetta®) in the following circumstances:

  • At a maximum dose of 1.2mg daily (1.8mg daily is not recommended)
  • In triple therapy combination with metformin and a sulphonylurea or a glitazone
  • In dual therapy combination with metformin or a sulphonylurea when other oral treatments (including metformin, sulphonylureas, glitazones and gliptins) are not tolerated or contraindicated
  • Control of blood glucose remains or becomes inadequate (HbA1c above 7.5% or other higher level agreed with the individual)
  • BMI > 35kg/m2 and associated weight based medical problems or BMI < 35kg/m2 where weight loss would benefit co-morbidities, or insulin therapy would have significant occupational implications
  • Treatment should only be continued if successful in reducing HbA1c by 1% at 6 months and body weight by 3% in the same time period when use in triple therapy

Action: Clinicians should be aware of these recommendations and implement any necessary changes to practice.

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Bisphosphonates and fracture risk

The Food and Drugs Administration (FDA) has issued a warning about a possible risk of a rare type of thigh bone (femoral) fracture in people who take bisphosphonates to treat osteoporosis. This has been reported in the general media (BBC).

The FDA has recommended a labelling change for oral and injectable bisphosphonate medications although they note it remains unclear whether the medication is the cause of the fractures (subtrochanteric and diaphyseal femur fractures). The Medicines and Healthcare products Regulatory Agency reviewed the risk of atypical stress fractures with alendronate in the March 2009 issue of Drug Safety Update.

At that time it was noted that other bisphosphonates may also increase the risk of these fractures. It was also noted that these kinds of fracture occurred after minimal trauma, were sometimes associated with thigh pain and tended to be bilateral and that examination of the contralateral femur in patients who experience such a fracture while on bisphosphonate treatment would be wise. It was also suggested that patients discontinue treatment with bisphosphonates unless the benefits of continued treatment are thought to clearly outweigh the risks to the individual.

Action: Clinicians should be aware of the possibility that bisphosphonates may increase the risk of these rare fractures. Media coverage may generate patient queries.

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SMC Update - October 2010

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

Roflumilast (Daxas®) has been rejected as an add on to bronchodilator treatment in severe chronic obstructive pulmonary disease (COPD) (forced expiratory volume in 1 second post-bronchodilator <50% predicted) associated with chronic bronchitis in adult patients with a history of frequent exacerbations. The manufacturer did not present a sufficiently robust economic analysis.

Four combined oral contraceptive pills (Rigevidon®, Gedarel®, Millinette® and TriRegol®) were all accepted for use in patients where these products would provide an appropriate form of contraception. They provide an alternative to the existing preparations at a lower cost.

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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CKS Update - October 2010

Clinical Knowledge Summaries (CKS) has been updated in October 2010 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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