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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Top Tips for Safer Prescribing

The National Prescribing Centre (NPC) has published Top Tips for GPs - Strategies for safer prescribing (PDF).

Written for the NPC by Professor Tony Avery from the University of Nottingham Medical School it discusses medication errors and patient harm in primary care, including:

  • Which patients are most at risk from medication errors
  • The drugs most commonly associated with preventable adverse events
  • The underlying causes of medication errors and how can these be prevented
  • Practice points – 10 tips for safe prescribing

The main underlying reasons for prescribing errors are also reviewed including human errors, insufficient knowledge about the patient or medication, slips and lapses, communication problems and failure to adequately monitor and review.

Many of the recommendations in this review appear simple and straightforward but the author notes that, "we need to ask why patients continue to be exposed to unnecessary risk from medicines in our practices" before dismissing this advice.

Action: Clinicians will find this article a useful review of strategies that could improve prescribing safety. It may provide a useful resource when training, reviewing existing prescribing systems or reviewing practice after significant events.

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Mortality risk with Tiotropium mist inhaler

The British Medical Journal has published the results of a meta-analysis that aimed to review the risk of mortality associated with use of tiotropium mist inhalers (Spiriva Respimat®).

A recent safety review indicated a non-significant increase in all-cause mortality when treatment was compared with placebo.

This review included data from five randomised controlled trials involving 6,522 participants. The studies were of at least 30 days duration and all compared active treatment with placebo. The studies also examined two different doses of tiotropium, 5micrograms daily and 10micrograms daily. 5micrograms daily is the current recommended dose.

The tiotropium mist inhaler was associated with a significantly increased risk of death (Relative risk 1.52, 95% CI 1.06-2.16, p=0.02). The increase in risk was observed with both study doses and remained present when the three year-long studies were analysed separately. It is estimated that for every 124 patients treated for a year with the inhaler instead of placebo it would be expected to observe one additional death (NNT 124, 95% CI 52 - 5682).

The authors conclude that "clinicians should inform patients about the possibility of this increased risk and exercise caution when prescribing tiotropium mist inhaler".

This analysis does have limitations mainly arising from the study data quality. This analysis did not have access to individual patient data to allow a cause specific mortality analysis or a time to event analysis. Additionally, the included studies varied in duration, drug dose used and the population studied.

Action: Clinicians should be aware of this study. It may be prudent to reserve use of the mist inhaler to patients who cannot tolerate the dry powder device. Patients who are prescribed the mist inhaler should also be advised of the possibility of an increased risk of death.

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SMC Update - June 2011

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

Ferric carboxymaltose (Ferinject®) has been accepted for restricted use for the treatment of iron deficiency when oral iron preparations are ineffective or cannot be used. Use is restricted to administration by intravenous infusion in patients not receiving haemodialysis.

Omalizumab (Xolair®) has been accepted for restricted use in adults, adolescents (12 years of age and older) and children (6 to <12 years of age) with convincing IgE (immunoglobulin E) mediated asthma. Use is restricted to patients who are prescribed chronic systemic steroids and in whom all other treatments have failed. Treatment should be reassessed at 16 weeks and discontinued if there is not a marked improvement in overall asthma control.

Tapentadol prolonged-release (Palexia SR®) has been accepted for restricted use in the management of severe chronic pain in adults. Use is restricted to patients in whom morphine sulphate modified release has failed to provide adequate pain control or is not tolerated.

Triptorelin pamoate (Decapeptyl SR®) is accepted for patients with locally advanced, non-metastatic prostate cancer, as an alternative to surgical castration or treatment of metastatic prostate cancer. This new product allows for 6-monthly administration.

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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Influenza immunisation programme 2011/12

The Chief Medical Officer at the Department of Health has written (PDF) to colleagues within the NHS to provide details of the recommended influenza immunisation programme for 2011/12. The influenza chapter of the Green Book has also been updated.

The letter contains information on the following:

  • Groups eligible for the seasonal flu vaccination for 2011/12
  • Dosage, consent and patient leaflet
  • Further advice on immunising pregnant women
  • Frontline health and social care workers
  • Improving uptake and data collections
  • Vaccine virus strains and available vaccines
  • Vaccine supply
  • Contractual arrangements, service reviews and funding

The letter recommends a vaccination uptake target of 75% for both the over 65 age group and the under 65 with a clinical risk group. For this campaign it is also noted that poultry workers are no longer considered a risk group for seasonal flu and are not recommended for vaccination.

Action: Clinicians should be aware of the target groups for the seasonal influenza immunisation programme this year and the recommendation to reach 75% uptake.

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Drug Safety Update - June 2011

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for June 2011 (PDF).

This issue contains drug safety information advising clinicians how to manage bisphosphonate therapy in light of rare atypical femoral fractures. It is suggested that in the event of an atypical femoral fracture the benefits and risks of treatment are reassessed and that treatment can be discontinued while the patient is evaluated.

Clinicians are also advised that the optimum treatment duration for osteoporosis has not been evaluated and therefore continued treatment should be re-evaluated periodically but particularly after 5 or more years of use.

The drug safety section also informs clinicians about recent epidemiological studies that have shown that the risk of venous thromboembolism (VTE) for drospirenone containing combined oral contraceptives (COCs), including Yasmin, is higher than for levonorgestrel-containing COCs. It is also noted that the risk may be similar to COCs that contain desogestrel or gestodene (so-called ‘third generation’ pills).

The risk of VTE is still small, and less than the risk associated with pregnancy however clinicians should be aware of this information when discussing the most suitable type of contraceptive.

Action: Clinicians will find this publication to be a useful review of current issues in drug safety.

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