UK General Practice Research Database (uk + general_practice_research_database)

Distribution by Scientific Domains

Selected Abstracts

Unspecified abdominal pain in primary care: the role of gastrointestinal morbidity

M.-A. Wallander
Summary Background:, Many patients with abdominal pain have no obvious cause for their symptoms and receive a diagnosis of unspecified abdominal pain. Aim:, The objective of this study was to ascertain risk factors and consequences of a diagnosis of unspecified abdominal pain in primary care. Methods:, A population-based, case,control study was conducted using the UK General Practice Research Database. We identified 29,299 patients with a new diagnosis of abdominal pain, and 30,000 age- and sex-matched controls. Only diagnostic codes that did not specify the type or location of abdominal pain were included. Results and discussion:, The incidence of newly diagnosed unspecified abdominal pain was 22.3 per 1000 person-years. The incidence was higher in females than in males, and 29% of patients were below 20 years of age. Prior gastrointestinal morbidity was associated with abdominal pain, but high body mass index, smoking and alcohol intake were not. Patients newly diagnosed with abdominal pain were 16 to 27 times more likely than controls to receive a subsequent new diagnosis of gallbladder disease, diverticular disease, pancreatitis or appendicitis in the year after the diagnosis of abdominal pain. The likelihood of receiving other gastrointestinal diagnoses such as peptic ulcer disease, hiatus hernia, gastro-oesophageal reflux disease (GERD), irritable bowel syndrome (IBS) or dyspepsia was increased three- to 14-fold among patients consulting for abdominal pain. Conclusion:, When managing abdominal pain in primary care, morbidities such as GERD and IBS should be considered as diagnoses once potentially life-threatening problems have been excluded. [source]

Systematic review: the epidemiology of gastro-oesophageal reflux disease in primary care, using the UK General Practice Research Database

Summary Background, Gastro-oesophageal reflux disease (GERD) is a common diagnosis in primary care; however, there has been no comprehensive review of the epidemiology of GERD in this setting. Aim, To review systematically articles that used the General Practice Research Database to study the epidemiology of GERD. Methods, Systematic literature searches. Results, Seventeen articles fulfilled the inclusion criteria. The incidence of GERD in primary care was 4.5 new diagnoses per 1000 person-years in 1996 (95% CI: 4.4,4.7). A new diagnosis of GERD was associated with being overweight, obese or an ex-smoker. Prior diagnoses of ischaemic heart disease, peptic ulcer disease, nonspecific chest pain, nonspecific abdominal pain, chronic obstructive pulmonary disease and asthma were associated with a subsequent new GERD diagnosis. A first diagnosis of GERD was associated with an increased risk of a subsequent diagnosis of oesophageal adenocarcinoma, oesophageal stricture, chronic cough, sinusitis, chest pain, angina, gallbladder disease, irritable bowel syndrome or sleep problems. Mortality may be higher in patients with a GERD diagnosis than in those without in the first year after diagnosis, but not long term. Conclusion, The General Practice Research Database is an effective way of studying the epidemiology of GERD in a large population-based primary care setting. [source]

The epidemiology of haemochromatosis: a population-based study

Summary Background, The discovery of the HFE genotype has revolutionized the diagnosis of haemochromatosis, changing the associated mortality and morbidity. Aim, To investigate the clinical significance of a diagnosis of haemochromatosis. Methods, In a cohort study, we identified 501 people with haemochromatosis and 4950 age- and gender-matched controls from the UK General Practice Research Database between 1987 and 2002. Results, The incidence of a diagnosis of haemochromatosis increased approximately 2-fold over the study period and was associated with a 2.2-fold increase in mortality [hazard ratio, 95% confidence interval (95% CI), 1.6,3.0]. There was no increase in extra hepatic malignancy, but an absolute risk excess of liver cancer of 0.89% per year. Diabetes, impotence, osteoarthritis and crystal arthritis were associated with haemochromatosis with odds ratios of 5.4 (95% CI, 4.1,7.0), 2.7(95% CI, 1.8,4.0), 1.9(95% CI, 1.5,2.4) and 2.1(95% CI, 1.4,3.1) respectively. Conclusion, Increasing numbers of people are being diagnosed with haemochromatosis, and the mortality associated with this disease remains high. However, people are living with considerably lower levels of morbidity than previously reported. This encouragingly suggests earlier diagnoses are being made, prior to the development of complications. [source]

Risk of schizophrenia in people with coeliac disease, ulcerative colitis and Crohn's disease: a general population-based study

Summary Background Recently, interest has been revived in whether people with coeliac disease, in contrast to other inflammatory gastrointestinal diseases, have an increased risk of schizophrenia. Aim To compare the risk of schizophrenia in people diagnosed with coeliac disease, ulcerative colitis and Crohn's disease with the general population. Methods We used data from the UK General Practice Research Database. People with coeliac disease, Crohn's disease and ulcerative colitis were matched individually with five age-, sex- and general practice-matched controls. The prevalence of schizophrenia was calculated and compared between disease groups and their respective controls. We calculated odds ratios for schizophrenia using conditional logistic regression adjusting for smoking status. Results In people with coeliac disease, Crohn's disease and ulcerative colitis the prevalence of schizophrenia was 0.25%, 0.27% and 0.24%, respectively, compared with a general population prevalence of 0.37%. The adjusted odds ratios showed no association between schizophrenia and gastrointestinal disease (coeliac disease vs. controls 0.76, 95% CI: 0.41,1.4; Crohn's disease vs. controls 0.74, 95% CI: 0.44,1.3; ulcerative colitis 0.71, 95% CI: 0.44,1.1). Conclusions Contrary to recent findings we found no evidence of an increased risk of schizophrenia in people with coeliac disease compared with the general population. [source]

Combination therapy with sulfonylureas and metformin and the prevention of death in type 2 diabetes: a nested case-control study,

Laurent Azoulay PhD
Abstract Purpose To determine whether combination of sulfonylureas and metformin increases the risk of death from any cause in patients with type 2 diabetes. Methods A nested case-control study was conducted within a population-based cohort from the UK General Practice Research Database (GPRD). The cohort included patients over the age of 40 who were prescribed a first oral hypoglycaemic agent between 1 January 1988 and 30 June 2008. Cases included all patients who deceased during follow-up. Up to 10 controls were matched to each case on year of birth, date of cohort entry (±1 year) and duration of follow-up. Conditional logistic regression was used to estimate rate ratios (RRs) of death from any cause associated with the use of combination of sulfonylureas and metformin, relative to sulfonylurea monotherapy. Results The cohort comprised 84,231 users of oral hypoglycaemic agents, of whom 14,996 died from any cause during a mean of 4.3 years of follow-up (mortality rate 4.1 per 100 per year). Patients currently exposed to a combination of sulfonylureas and metformin were at a decreased risk of death from any cause compared to patients exposed to sulfonylurea monotherapy (adjusted RR: 0.77, 95%CI: 0.70, 0.85). Similar results were obtained for patients currently exposed to metformin monotherapy (adjusted RR: 0.70, 95%CI: 0.64, 0.75) when compared to sulfonylurea monotherapy. Patients had to be exposed to the combination therapy for at least 4 months prior to index date to experience a lower risk of mortality compared to sulfonylurea monotherapy. Conclusions The combination of sulfonylureas and metformin does not increase the risk of death. In contrast, it may moderately reduce this risk compared to sulfonylurea monotherapy. Copyright © 2010 John Wiley & Sons, Ltd. [source]

Thiazolidinediones and the risk of incident strokes in patients with type 2 diabetes: a nested case-control study,

Laurent Azoulay PhD
Abstract Purpose To determine whether the use of thiazolidinediones (TZDs) decreases the risk of incident strokes in patients with type 2 diabetes. Methods We conducted a nested case-control study within a population-based cohort from the UK General Practice Research Database (GPRD). The cohort comprised patients over the age of 40 who were prescribed a first oral hypoglycemic agent between 1 January 1988 and 30 June 2008. Cases included all subjects who experienced a first stroke during follow-up. Up to 10 controls were matched to each case on age (±2 years), sex, date of cohort entry (±1 year), and duration of follow-up. Rate ratios (RRs) of stroke associated with TZD use, including rosiglitazone and pioglitazone, relative to combinations of other oral hypoglycemic agents, were estimated using conditional logistic regression. Results The cohort comprised 75,717 users of oral hypoglycemic agents, of whom 2417 had a stroke during follow-up. The rate of stroke in users of TZDs given as monotherapy (RR: 1.20, 95%CI: 0.77, 1.86) or in combination with other oral hypoglycemic agents (RR: 0.78, 95%CI: 0.58, 1.04) was not lower than combinations of other oral hypoglycemic agents. The RRs were similar for rosiglitazone and pioglitazone. Conclusions The results of this study indicate that TZDs do not appear to decrease the incidence of first strokes. Copyright © 2009 John Wiley & Sons, Ltd. [source]

The safety of rosuvastatin in comparison with other statins in over 100,000 statin users in UK primary care,,

Luis Alberto García-Rodríguez MD
Abstract Purpose To compare mortality and the incidence of hospitalization for myopathy, rhabdomyolysis, acute renal failure and acute liver injury in patients receiving rosuvastatin and those taking other statins. Methods Patients prescribed a statin that they had not used before were selected from the UK General Practice Research Database (GPRD) and followed up from 1 April 2003 to 31 December 2005. Results We studied 10,289 patients on rosuvastatin and 117,102 taking other statins. No cases of myopathy, rhabdomyolysis or acute liver injury occurred among rosuvastatin users. In those taking statins other than rosuvastatin, the incidence of myopathy was 0.4 (95% confidence interval (CI): 0.1,0.9), of rhabdomyolysis was 0.4 (95%CI: 0.1,0.9) and of acute liver injury was 0.4 (95%CI: 0.2,1.0), per 10,000 person-years. Fourteen cases of acute renal failure were identified (two among rosuvastatin users and 12 among other statin users). Among current users, the relative risk (RR) of acute renal failure in rosuvastatin users compared with other statin users was 1.16 (95%CI: 0.15,9.03). We identified 3232 deaths during the study period (173 in the rosuvastatin-treated group and 3059 in the other statin group). The RR of death associated with current use of rosuvastatin compared with other statins was 0.55 (95%CI: 0.44,0.68). Conclusions We found no evidence that patients prescribed rosuvastatin were at greater risk of these outcomes than patients prescribed other statins. There was no evidence of increased mortality among patients taking rosuvastatin, even after allowing for age, sex and prior statin use. Copyright © 2008 John Wiley & Sons, Ltd. [source]

Safety of medications prescribed before and during early pregnancy in a cohort of 81,975 mothers from the UK General Practice Research Database,

Janet R. Hardy PhD
Abstract Purpose To demonstrate a linkage methodology for mother and baby automated medical records, and describe frequency, type, and pregnancy risk level of medications prescribed during pregnancy in a GPRD cohort, 1991,1999. Methods We linked records using a two-stage algorithm and selected pairs with ,7 months prenatal records and ,2 records in baby's first year of life. Periods of interest were: 90 days prior to a woman's earliest identified pregnancy record (Period I), and this record plus 70 days (Period II, approximate early pregnancy). Medications were classified using the British National Formulary and US Food and Drug Administration Pregnancy Risk Categories. Results We achieved over 80% record linkage and defined a cohort of 81,975. Sixty-five per,cent of mothers had ,1 prescription during both periods combined. Most frequent medications in Period I were anti-bacterial, contraceptive, topical steroid, and bronchodilator. In Period II, they were folic acid, anti-bacterial, antacid, and gynecological anti-infective. In Period I, 4% were FDA category A (considered safest), 34% B, and 49% C and D combined. By Period II, prescription of category A medications increased (folic acid, iron) while other categories declined. Category X medications, with potential teratogenic risk that outweighs maternal benefit, were prescribed to 5714 (7%) women in Period I, and 501 (0.6%) women in Period II (46% progesterone). Conclusions One in every 164 women received a category X prescription in early pregnancy. The visit when pregnancy is first medically recognized represents an opportunity to review prescribed medications in light of contraindication and/or fetal risk. Copyright © 2006 John Wiley & Sons, Ltd. [source]

Prevalence of risk factors for suicide in patients prescribed venlafaxine, fluoxetine, and citalopram,

Daniel Mines MD
Abstract Purpose Three recent observational studies reported that the risk of fatal overdose is greater with venlafaxine than SSRI use. It is not clear whether patient factors could account for this finding. We evaluated whether risk factors for suicide are more prevalent among patients prescribed venlafaxine than patients prescribed fluoxetine or citalopram. Methods Using data from the UK General Practice Research Database (GPRD), we identified patients who were first prescribed any of the three drugs between January 1995 and April 2002. We ascertained risk factors for suicide documented in the 1 year before that first prescription. Separate analyses compared venlafaxine (N,=,27,096) and fluoxetine (N,=,134,996) cohorts, and venlafaxine and citalopram (N,=,52,035) cohorts. Results Previous suicidal behaviors were documented for 1.0% of the venlafaxine cohort compared to 0.4% of the fluoxetine cohort (OR 2.8, 95%CI: 2.4, 3.2) and 0.4% citalopram cohorts (OR 2.4, 95%CI: 2.0, 2.9). 72.5% of venlafaxine patients had been prescribed at least one other antidepressant compared to 27.6% of fluoxetine (OR 6.9, 95%CI: 6.7, 7.1) and 39.5% of citalopram (OR 4.0, 95%CI: 3.9, 4.2) patients. Venlafaxine patients were also four to six times as likely to have been previously hospitalized for depression. Conclusion In the UK, venlafaxine has been selectively prescribed to a patient population with a higher burden of suicide risk factors than patients prescribed fluoxetine and citalopram. Unless baseline population differences are accounted for, observational studies that compare the risk of suicide in patients receiving these agents may produce biased results. Copyright © 2005 John Wiley & Sons, Ltd. [source]

Venous thromboembolism associated with cyproterone acetate in combination with ethinyloestradiol (Dianette®): observational studies using the UK General Practice Research Database,

H. E. Seaman
Abstract Purpose To derive risk estimates for venous thromboembolism (VTE) in women prescribed cyproterone acetate combined with ethinyloestradiol (CPA/EE), a drug licensed in the UK for the treatment of women with acne or hirsutism. CPA/EE provides a treatment option for women with polycystic ovary syndrome (PCOS). CPA/EE has been associated with an increased risk of VTE. Methods Using the General Practice Research Database, we conducted cohort and case-control analyses in all women aged 15,39 and then nested in a population of women of the same age with acne, hirsutism or PCOS. Results The incidence rate ratio (IRR) for VTE in women exposed to CPA/EE versus conventional combined oral contraceptives (COCs) was significantly raised (all women: 1.92; 95%,CI: 1.22,2.88; nested: 2.51; 95%,CI: 1.07,5.75). Using exposure to conventional COCs as the reference, the adjusted odds ratio (ORadj) for VTE associated with CPA/EE was 1.45 (95%,CI: 0.80,2.64) in all women and 1.71 (95%,CI: 0.31,9.49) in women with acne, hirsutism or PCOS. Conclusions The risk of VTE associated with CPA/EE use does not differ significantly from that associated with the use of conventional COCs. These data are reassuring and together with knowledge of the risks associated with other treatments for acne, in particular, should influence prescribing practice. Copyright © 2003 John Wiley & Sons, Ltd. [source]

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PRESCRIBER, Issue 10 2008
Article first published online: 3 JUN 200
Glitazones more than double fracture risk An analysis of the UK General Practice Research Database has found that both glitazones increase the risk of fracture more than two-fold (Arch Intern Med 2008;168:820-5). Compared with nonusers, the odds ratio for fracture (mostly hip and wrist) was 2.59 for pioglitazone and 2.38 for rosiglitazone. The risk increased with dose but was unrelated to age and sex. Reduce antipsychotics in dementia patients Antipsychotics should be prescribed for patients with dementia only as a last resort at times of severe distress or critical need, the All-Party Parliamentary Group on Dementia has concluded. Its inquiry (available at found that antipsychotics are being prescribed for patients with mild behavioural symptoms and for prolonged periods despite the limited benefits they offer and the risk of serious adverse effects such as stroke. Contributory factors include lack of training for staff, inadequate leadership and exclusion of family and friends from decisions about treatment. High-dose atorvastatin in chronic kidney disease High-dose atorvastatin (Lipitor) reduces cardiovascular events in patients with chronic kidney disease (CKD) more than a low dose , despite similar reductions in LDL-C (J Am Coll Cardiol 2008;51:1448-54). A post hoc subgroup analysis of the Treating-to-New-Targets study involving 10 001 patients with CHD, with or without CKD, found that atorvastatin 10 and 80mg per day reduced LDLC and triglycerides to similar levels; there was no change in HDL-C. After a median follow-up of five years, the incidence of cardiovascular events in patients with CKD was 9.3 per cent at 80mg per day and 13.4 per cent at 10mg per day (number needed to treat to prevent one event, NNT, 24). In patients with no CKD, the corresponding figures were 7.9 vs 9.2 per cent (NNT 74). There was no difference in all-cause mortality; adverse events were more frequent at the higher dose. COX-2 NSAIDs not more cost-effective An economic analysis of COX-2 selective NSAIDs has concluded that they are not more cost effective than older agents plus a proton pump inhibitor (PPI) in the treatment of osteoarthritis and rheumatoid arthritis (Health Technology Assessment 2008;12:No. 11). The analysis concluded that selective and nonselective NSAIDs were similarly effective but selective agents were associated with a lower risk of upper GI events and a higher risk of cardiovascular events. However, the available evidence includes only low numbers of events and further studies are needed. Compared with ibuprofen or diclofenac plus a PPI, the COX-2 selective NSAIDs look ,generally unattractive from a cost effectiveness point of view', even in high-risk patients with a history of peptic ulcer. There were insufficient data to allow a reliable comparison within the COX-2s. Naftidrofuryl helps intermittent claudication Naftidrofuryl increases pain-free walking distance (PFWD) in patients with intermittent claudication, a new Cochrane review has shown (Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD001368. DOI: 10.1002/ 14651858.CD001368.pub3; also see page 49 in this issue). The meta-analysis of six trials involving a total of 1083 patients found that, compared with placebo, naftidrofuryl increased PFWD by over a third with a proportion successfully treated of 20 per cent (NNT 4.5). Coversyl Arginine To clarify any confusion following our recent news item (Perindopril brand switch, 19 April issue, page 12), Servier has asked us to reiterate that the new formulations Coversyl Arginine 2.5, 5 and 10mg are equivalent to 2, 4 and 8mg of the discontinued Coversyl formulation. Coversyl Arginine contains perindopril arginine, a salt that offers greater stability and a longer shelf-life. Prescriptions for the Coversyl brand of perindopril must in future be written as Coversyl Arginine in its revised strengths. Coversyl Plus has also been replaced by Coversyl Arginine Plus and the same revised dosages apply. Generic formulations of perindopril remain unaffected. Copyright © 2008 Wiley Interface Ltd [source]

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PRESCRIBER, Issue 3 2007
Article first published online: 14 MAR 200
PPIs and hip fracture Treatment with a PPI may increase the risk of hip fracture, with longer use associated with higher risk according to a study in UK patients (J Am Med Assoc 2006;297:2947-53). The case control study compared use of PPIs by 13 556 patients with hip fracture and 135 386 controls in the UK General Practice Research Database. Use of a PPI for more than one year was associated with an increase of 44 per cent in the odds of hip fracture. The risk was higher for longer- term use (59 per cent after four years) and at higher doses (more than doubled with long-term high doses). The mechanism for this possible effect may be impaired calcium absorption associated with hypochlorhydria and reduced bone resorption. CHD NSF Statin prescribing has increased by 30 per cent every year since the publication of the Coronary Heart Disease NSF, the Department of Health says. The estimated number of lives saved attributable to statins had risen to 9700 in 2005. The proportion of patients with acute MI who were given thrombolysis within 30 minutes of admission has increased to 83 per cent. Flu jabs cut pneumonia deaths A US study suggests that flu vaccine protects against death during the flu season in patients admitted with community-acquired pneumonia (Arch Intern Med 2007;167:53-9). Nineteen per cent of patients admitted with pneumonia during the winters of 1999-2003 were known to have been vaccinated against flu. Their risk of death during their hospital stay was 70 per cent lower than that of nonvaccinated individuals. After adjustment for antipneumococcal vaccination and comorbidity, the odds of death were still 39 per cent lower. Model to predict admissions The King's Fund, together with New York University and Health Dialog, has published a model that predicts the risk of emergency hospital admission (see The model is intended for use by PCTs and draws on data from secondary and primary care to define clinical profiles, allowing patients whose condition is deteriorating to be identified before they need admission. Problem drinking The National Treatment Agency for Substance Misuse (NTA), a special authority within the NHS, has published a critical appraisal of the evidence for various treatments for alcohol problems ( The 212-page document estimates that over seven million hazardous or harmful drinkers may benefit from brief interventions by any health workers, and over one million dependent drinkers may benefit from specialist intervention. It concludes that cognitive behavioural approaches to specialist treatment are most effective and that treatment probably accounts for about one-third of improvements made in problem drinking. of patients remained on the same treatment after one year, falling to half at two years and about 40 per cent at three years. Treatment was more frequently stopped for lack of efficacy than for adverse effects. Stopping anti-TNFs Discontinuation of treatment with anti-TNF agents is more common in clinical practice than in clinical trial populations, a French study has found (J Rheumatol 2006;33:2372-5). The retrospective analysis of a single centre's experience of treating 770 patients with etanercept (Enbrel), infliximab (Remicade) or adalimumab (Humira) found that fewer than two-thirds of patients remained on the same treatment after one year, falling to half at two years and about 40 per cent at three years. Treatment was more frequently stopped for lack of efficacy than for adverse effects. There were no statistically significant differences between the three agents but there was a trend for infliximab to be least well tolerated. Generic statin savings The Department of Health has estimated that prescribing simvastatin and pravastatin generically would save £85 million per year. Its analysis of the ,Better care, better value' indicators (see shows that statin prescribing has increased by 150 per cent in the past five years, with costs totalling £600 million in 2005. The Department says that if every PCT prescribed pravastatin and simvastatin by generic name in only 69 per cent of cases ,the level achieved by the top quarter of trusts ,the savings would be over £85 million a year. Herceptin reporting Press reports of a two-year trial of trastuzumab (Herceptin) were generally accurate in reporting its effectiveness but few reported an increased risk of adverse effects, according to the NHS National Library for Health ( The Herceptin Adjuvant (HERA) trial (Lancet 2007;369:29-36) found that, after an average follow-up of two years, 3 per cent of women treated with trastuzumab died compared with 5 per cent of controls; estimated three-year survival rates were 92.4 and 89.7 per cent respectively. All four press articles reported these findings accurately, but only two mentioned the increased risk of adverse effects. Updated guidance on CDs The Department of Health has published updated guidance on the strengthened governance requirements for managing controlled drugs, taking into account new regulations that came into force on 1 January ( Root/04/14/16/67/04141667.pdf). Statin adherence lowers MI mortality Patients with acute myocar- dial infarction (MI) who take their statins as prescribed are significantly more likely to survive for two to three years than those with low adherence (J Am Med Assoc 2007;297: 177-86). The four-year observational study of 31 455 patients with acute MI found that, compared with those who had taken at least 80 per cent of prescribed daily doses, the risk of death in those with less than 40 per cent adherence was 25 per cent greater over 2.4 years. For individuals with intermediate adherence (40-79 per cent), the risk was 12 per cent greater. Both differences were statistically significant after adjustment for potential confounding factors. The authors believe their finding is explained by differences in adherence rather than healthier behaviour because the excess risk of low adherence was less marked with beta-blockers and not significant for calcium-channel blockers. Improving community medicines management Mental health trusts need to improve medicines management by their community teams and improve information sharing with GPs, the Healthcare Commission has found ( Its national report revealed limited evidence of pharmacist involvement in community mental health teams, even though 90 per cent of patients were cared for in the community. Only 11 per cent of assertive outreach patients had the tests necessary to ensure safe use of their medicines. Medication reviews found that 46 per cent of patients in mental health trusts and 12 per cent of those in acute trusts were not taking their medication appropriately. The Commission also reported that acute trusts received a complete drug history from GPs for fewer than half of audited patients when they were admitted to hospital, and only 30 per cent of PCTs reported that GPs received adequate information on patients' medicines on discharge. Copyright © 2007 Wiley Interface Ltd [source]

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PRESCRIBER, Issue 2 2007
Article first published online: 1 MAR 200
Venlafaxine: same suicide risk Venlafaxine (Efexor) is probably not associated with a higher risk of suicide than citalopram, fluoxetine or dosulepin, even when prescribed for patients at higher risk, according to an analysis of the UK General Practice Research Database (BMJ, doi:10.1136/bmj.39041.445104.BE. Published 12 December 2006). The retrospective cohort study found that venlafaxine was associated with a significantly higher risk of completed and attempted suicide in adults than the other antidepressants but, after adjusting for risk factors, the authors concluded that much, if not all, of the difference could be explained by confounding. Raised glucose with thiazides not clinically significant? A new analysis of the ALLHAT trial suggests that the small increase in blood glucose levels associated with long-term thiazide therapy is not associated with an increased risk of cardiovascular events (Arch Intern Med 2006;166:2191-201). The ALLHAT trial compared cardiovascular outcomes in over 18 000 patients with hypertension who were treated with chlortali- done (Hygroton), amlodipine and lisinopril. After two years, fasting blood glucose had increased in all groups (by 0.47, 0.31 and 0.19mmol per litre respectively); compared with chlortalidone, the odds of developing diabetes were 45 per cent lower with lisinopril and 27 per cent lower with amlodipine. However, there was no significant link between fasting blood glucose levels and cardiovascular events, end-stage renal disease or death; developing diabetes was associated with an increased risk of CHD overall but this was not statistically significant for chlortalidone in particular. Withdrawing alendronate after five years' treatment Discontinuing treatment of osteoporosis with alendronate after five years does not significantly increase fracture risk for many women, a US study has shown (J Am Med Assoc 2006;296:2927-38). In this five-year extension to the Fracture Intervention Trial, 1099 women who had taken alendronate for five years were randomised to continue treatment or switch to placebo for a further five years. In those taking placebo, bone mineral density decreased by 2.4 per cent at the hip and 3.7 per cent in the spine but remained above pre- treatment levels. Continuing with alendronate was associated with a lower risk of clinical vertebral fractures (2.4 vs 5.3 per cent) but no significant reduction in morphometric vertebral fractures (9.8 vs 11.3 per cent respectively). The cumulative risk of nonvertebral fractures was 19 per cent in each group. The authors conclude that women at very high risk of clinical vertebral fractures may benefit from continuing alendronate, but for many discontinuation does not appear to increase fracture risk. Instructions on labels Patients with low levels of literacy are at high risk of not understanding medicines labelling (Ann Intern Med 2006;145:887-94). In 395 English-speaking adults, 71 per cent correctly repeated simple label instructions, but only 35 per cent could demonstrate the correct number of tablets involved. Low literacy levels were associated with a twofold increased risk of misunderstanding labelling. Statins campaign The National Prescribing Centre (NPC) has launched a campaign to increase prescribing of low-cost statins. Resources available from its website at are divided into four categories: policy and guidance, therapeutics, implementation resources and monitoring tools. Formats include documents and case studies, Powerpoint presentations and E-learning workshops. patients feeling rested on waking and daytime functioning. The Z-drugs were also believed to cause fewer adverse effects. GPs believe in ,Z' drugs A survey of GPs in Lincolnshire has revealed that their beliefs about nonbenzodiazepine hypnotics are inconsistent with NICE guidance and published evidence (Br J Gen Pract 2006; 56:964-7). Responders believed that zaleplon (Sonata), zopiclone and zolpidem were superior to benzodiazepines in increasing sleep time, patients feeling rested on waking and daytime functioning. The Z-drugs were also believed to cause fewer adverse effects. The authors note that, while benzodiazepine prescribing is declining, that of the Z-drugs is increasing, and they suggest this may be explained by misplaced beliefs about their relative effectiveness and safety. Pharmacy EHC guidance Pharmacists can supply emergency hormonal contraception (EHC) in advance but should consider when it is clinically appropriate to do so, according to revised guidance from the Royal Pharmaceutical Society. The move follows support for advance supply from the British Pregnancy Advisory Service and Marie Stopes International. Pharmacists are advised to decline repeated requests and recommend contraception instead, and to counsel users on using EHC safely and appropriately. More support from NICE NICE has developed two databases to support implementation of its recommendations. The shared learning database ( sharedlearning) includes experiences of implementing NICE guidance. The second, known as ERNIE (Evaluation and Review of NICE Implementation Evidence), includes data provided by NICE on uptake of its advice and external information ( Mental health briefings The DoH ( has published several briefing documents to explain the main changes to mental health legislation, covering professional roles, criteria for detention and supervised community treatment (SCT). SCT applies to patients with a stable chronic mental disorder who have been discharged from hospital and who, but for their treatment, may pose a risk to themselves or others. Patients remain the responsibility of the mental health team. Copyright © 2007 Wiley Interface Ltd [source]