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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

CKS Update - December 2010

Clinical Knowledge Summaries (CKS) has been updated in December 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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DTB - December 2010

The Drugs and Therapeutics Bulletin (DTB) for December 2010 has been published. It reviews insulin therapies, topical antibacterials for acne and Targinact®.

The review of insulin therapies compares human insulins with analogue insulins, regimens and devices. Relative costs and national guidelines from NICE and SIGN are also considered. The authors note that there is little cost difference between devices and therefore device choice should be patient-led. However, they also note that "analogue insulins offer no significant clinical advantage and are much more expensive" and it is recommended that it would be appropriate to start most patients on basal isophane insulin treatment with the addition of short-acting human insulin if needed.

The review of topical antibacterial products for acne considers the place in therapy for these products, either alone or in combination with benzoyl peroxide, compared to benzoyl peroxide alone. The review also considers the impact of microbial resistance to the continued use of such products. The authors note that these products are effective but are no more effective than benzoyl peroxide alone. Where antibacterial agents are indicated in acne they recommend use "in combination with a topical agent that has anti-resistance properties" with a short term review.

The review of Targinact® considers whether this product offers any advantages over using strong opioids plus laxatives where required. Targinact contains oxycodone and naloxone. The addition of naloxone is proposed to counteract opioid-induced constipation. This review notes that there little data to demonstrate a reduced need for laxatives and that no comparative studies with usual care (morphine plus laxative) have been performed. The authors conclude that they "can see no reason why Targinact should be prescribed".

Action: Clinicians will find these review articles useful and informative. Current practices may need review based on these recommendations.

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ABPI code of Practice 2011

As previously discussed, the Association of the British Pharmaceutical Industry (ABPI) recently ratified some changes to the industry Code of Practice with the aim of increasing "transparency and trust".

The Code of Practice 2011 is now available to download (PDF) from the Prescription Medicine Code of Practice Authority. Printed copies will be available before the end of the year.

Action: Clinicians may wish to access the new Code of Practice in order to familiarise themselves with the changes.

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Surgery for hypertension?

The Lancet has published the results of a study that aimed to assess the efficacy and safety of catheter-based renal denervation for reduction of blood pressure in patients with treatment-resistant hypertension. This study has been reported in the general media (BBC).

The study recruited 106 patients with a systolic blood pressure of 160mmHg or more despite taking three or more antihypertensive drugs. Participants were randomly selected for an intervention of renal denervation by catheter-based short burst radio waves or continued on previous treatments. The primary endpoint was systolic blood pressure measured at six months.

52 patients underwent the procedure compared to 54 controls. There was a statistically significant difference in blood pressures between the two groups at six months of 33/11mmHg (p<0·0001). Blood pressure was reduced in the intervention group by an average of 32/12mmHg compared to an increase of 1/0mmHg in the control group.

The authors conclude that, "catheter-based renal denervation can safely be used to substantially reduce blood pressure in treatment-resistant hypertensive patients".

It should be noted that this new technique is still experimental and is an invasive procedure compared to the current method of treating raised blood pressure with lifestyle measures and medication. Further research is needed to assess the long term cardiovascular benefits and effects of this procedure. Patient acceptability of this invasive procedure compared to drug therapy will also need consideration.

Action: Clinicians should be aware of this research. Media coverage of this innovative procedure may generate patient queries.

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