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PRESCRIBER, Issue 5 2008
Article first published online: 3 APR 200
Newer antidepressants no better than placebo? A new meta-analysis suggests that newer antidepressants are no superior to placebo in most patients with depression , the exception being those with very severe depression, who can expect a small benefit. Writing in the online-only open access journal PLoS Medicine (5:e45.doi:10.1371/ journal.pmed.0050045), researchers from Hull and the US analysed published and unpublished trials submitted to the Food and Drug Administration in marketing applications for fluoxetine, paroxetine, venlafaxine (Efexor) and nefazodone (no longer available). Using the Hamilton Rating Scale for Depression (HRSD) score as an endpoint, meta-analysis of 35 trials involving 5133 patients and lasting six to eight weeks showed that mean HRSD score improved by 9.6 points with drug treatment and 7.8 with placebo. The authors say the difference of 1.8 was statistically significant but below the criterion for clinical significance (3.0) set by NICE in its clinical guideline on depression. A review of the study by the NHS Knowledge Service (www.nhs.uk) points out that it omits trials published after the drugs were licensed (1999) and those not sponsored by the pharmaceutical industry. It did not include any patients with severe depression and only one trial in patients with moderate depression. An earlier US study of data submitted to the FDA (N Eng J Med 2008;358:25260) showed that published trials of antidepressants were more likely to be positive (37/38) than unpublished ones (3/25). Further, FDA analysts concluded that 51 per cent of trials (published and unpublished) demonstrated positive findings compared with 94 per cent of those that were published. Audit reveals variations in hospital psoriasis care There are unacceptably large variations in the quality of care for patients with psoriasis in UK hospitals, a report by the British Association of Dermatologists and the Royal College of Physicians reveals. The audit of 100 hospital units found that 39 per cent restricted access to biological therapies because of cost, and over one-third of pharmacies could not supply ,specials' such as topical coal tar preparations. More positively, the units are adequately resourced to provide timely communication with GPs. RCGP responds to Public Accounts Committee The Royal College of General Practitioners has agreed with the Commons Public Accounts Committee that drug package labelling should include the cost of the medication. The suggestion was made by the Committee in its report Prescribing Costs in Primary Care. While recognising the importance of generic prescribing, the RCGP cautions against frequent medication switches because it may unsettle patients. ,Any changes must be carried out for sound clinical reasons with good communication between GPs and their patients,' it adds. Statins for patients with kidney disease? Statins reduce cardiovascular risk in people with chronic kidney disease, a new study suggests, but their effects on renal function remain unclear (BMJ 2008; published online doi: 10.1136/bmj. 39472.580984.AE). The meta-analysis of 50 trials involving a total of 30 144 patients found that statins reduced lipids and cardiovascular events regardless of the severity of kidney disease. However, all-cause mortality was unaffected and, although proteinuria improved slightly, there was no change in the rate of decline of glomerular filtration rate. An accompanying editorial (BMJ 2008; published online doi:10.1136/ bmj.39483.665139.80) suggests that the indications for statin therapy to reduce cardiovascular risk in patients with chronic kidney disease should be the same as for those with normal renal function. New NICE guidance New clinical guidelines from NICE (see New from NICE, pages 14,15) include the diagnosis and management of irritable bowel syndrome in adults in primary care, the care and management of osteoarthritis in adults, and the diagnosis and treatment of prostate cancer. In a public health guideline on smoking cessation services, NICE endorses the use of nicotine replacement patches for 12,17 year olds. Suspect additives in children's medicines The Food Commission (www.foodcomm.org.uk) has drawn attention to the presence in children's medicines of food additives it says are linked with hyperactivity. The Commission, a national nonprofit organisation campaigning for ,the right to safe, wholesome food', says that seven common additives (including tartrazine, sodium benzoate and Ponceau 4R) are associated with hyperactivity in susceptible children. Checking the SPCs, it found that 28 of 70 children's medicines , including formulations of paracetamol, ibuprofen, amoxicillin, erythromycin and codeine phosphate throat linctus , contain at least one suspect additive. Digoxin may increase mortality in AF patients An observational study has suggested that digoxin may increase deaths in patients with atrial fibrillation (Heart 2008;94:191,6). The study was a planned subgroup analysis of a trial evaluating anticoagulant therapy in 7329 patients with atrial fibrillation. Of these, 53 per cent were treated with digoxin. Mortality was significantly higher among digoxin users than nonusers (4.22 vs 2.66 per cent per year); myocardial infarction and other vascular deaths (but not stroke, systemic embolic episodes and major bleeding events) were significantly more frequent with digoxin. Poor communications cause readmission Elderly hospital patients are often discharged with inadequate information or arrangements for care, causing almost three-quarters to be readmitted within a week, say investigators from Nottingham (Qual Safety Health Care 2008;17:71,5). Retrospective review of records for 108 consecutive patients aged over 75 found that readmission was related to medication in 38 per cent and, of these, 61 per cent were considered avoidable. Almost two-thirds had no discharge letter or were readmitted before the letter was typed; two-thirds of discharge letters had incomplete documentation of medication changes. Copyright © 2008 Wiley Interface Ltd [source]

Services for erectile dysfunction in the UK , a 12-month review of referrals to a west Midlands NHS clinic

INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 7 2010
G. Hackett
Summary Introduction:, Few studies have addressed the health economics of the provision of services for sexual dysfunction within the National Health Service. Aim:, To evaluate the referral patterns, workload and prescribing costs in secondary care resulting from government guidance on erectile dysfunction (ED). Method:, A review of 324 consecutive referral letters to the Good Hope Hospital Erectile Dysfunction Clinic was conducted to assess the purpose of referral. Prescribing data and costs were assessed over the same 2-year period. Results:, Severe distress was the main reason for referral in 54% of referrals. Long term prescribing according to government guidance doubled the cost of care and created an unsustainable increase in clinic and pharmacy workload. Conclusions:, Existing regulations designed to control costs of ED therapy have created health inequalities, waste of resources and have increased the overall cost of care. [source]

Comparison of medication-prescribing patterns for patients in different social groups by a group of doctors in a general practice

INTERNATIONAL JOURNAL OF PHARMACY PRACTICE, Issue 4 2005
Mrs. Jenifer Anne Harding Primary care pharmacist
Objective This study was designed to compare medication-prescribing patterns of five general practitioners (GPs) who served patients living in two different communities, one of which is more economically deprived. Method The study focused on cardiovascular and antibiotic prescribing. Practice population data including history of cardiovascular disease and records of medication prescribed were considered with public health and socio-economic statistics for each community. Setting The study practice serves 8300 patients in two clinics, Tipton and Gornal, 4 miles apart. Each has similar numbers of registered patients. Tipton is in one of England's most deprived areas, ranked 16 out of 354 in the Indices of Multiple Deprivation 2004, compared with Gornal which is situated in an area ranked 109. Key findings For each Tipton patient, mean prescribing costs were 37% higher and mean number of prescription items were 16% higher over the study period compared with Gornal. Although a higher incidence might be expected in Tipton, little difference in identified cardiovascular disease (CVD) was found between Tipton and Gornal, and prescribing rates of aspirin and statins were similar. Tipton patients with CVD were less likely to be prescribed antihypertensives especially calcium channel blockers (P = 0.003) and diuretics (P = 0.02). Tipton patients received on average 3.27 different cardiovascular drugs compared with 3.80 in Gornal (P = 0.004). In those aged 65 years and over, this reduced to 3.08 in Tipton compared with 3.82 in Gornal (P = 0.001). Tipton patients generally, and children specifically, were significantly more likely to receive antibiotic prescriptions (P <0.0001). Conclusion This study suggested that some prescribing patterns differed at the two clinics, which may reflect different behaviours by the GPs when prescribing in the two communities of different population need. [source]

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PRESCRIBER, Issue 3 2008
Article first published online: 26 FEB 200
Higher risk of CV events in aspirin resistance More than one in four patients may have aspirin resistance, a new metaanalysis shows, and they face a four-to sixfold increased risk of a major cardiovascular event or death compared with aspirin-sensitive patients taking low-dose aspirin (BMJ online: 17 Jan 2008; doi:10. 1136/bmj.39430.529549.BE). The analysis included 20 studies involving a total of 2930 patients with cardiovascular disease. Of these, 28 per cent were defined as having aspirin resistance (according to the various definitions in each study). Compared with aspirin-sensitive patients, the odds ratio of any cardiovascular event or acute coronary syndrome was about 4 and the odds ratio of death was 6. Aspirin-resistant patients did not benefit from other antiplatelet treatment. ADOPT: rosiglitazone fracture risk in women A new analysis of the ADOPT trial (N Engl J Med 2006;355: 2427-43) has found that the risk of fractures during treatment with rosiglitazone (Avandia) is approximately twice as high as with metformin or glibenclamide, but mainly in women (Diabetes Care online: 25 Jan 2008; doi: 10.2337/dc07-2270). The study found a significant difference in risk between the drugs only for women, with a cumulative incidence of 15.1 per cent with rosiglitazone, 7.3 per cent with metformin and 7.7 per cent with glibenclamide after five years. No risk factors were identified although the incidence of fractures was higher among postmenopausal than premenopausal women. New from NICE Infliximab for the treatment of adults with psoriasis. Technology Appraisal Guidance No. 134, Jan 2008 Infliximab (Remicade), a monoclonal antibody against TNF-alpha, should be an option for treating very severe plaque psoriasis in adults, NICE recommends. Using its fast-track single technology appraisal procedure, NICE concluded that infliximab should be considered when standard therapies,methotrexate or ciclosporin (Neoral), or PUVA , have failed or are unsuitable. The criteria for disease severity are defined by the Psoriasis Area Severity Index (PASI) score (,20) and the Dermatology Life Quality Index (DLQI) score (>18). Treatment response is also defined by these measures and infliximab should be continued for longer than 10 weeks only when predefined thresholds are met. Infliximab costs an average of £11 750 annually. In 2006, NICE recommended etanercept (Enbrel) and efalizumab (Raptiva) for patients with severe psoriasis (PASI ,10 and DLQI >10). Commons committee wants tougher targets Most GPs get full QOF points for medicines management even though there is inexplicably large variation in good prescribing practice between PCTs, the Public Accounts Select Committee points out in its latest report, Prescribing Costs in Primary Care. The Committee wants to see tougher QOF targets among several initiatives to reduce prescribing costs. Although most publicity centred on its endorsement of the National Audit Office claim that GPs could save £200 million by prescribing lower-cost drugs, the report contains some more far-reaching proposals. GPs should prescribe generic alternatives within a therapeutic category, so when a brand is not available generically, eg Lipitor, a different drug that is, eg simvastatin, should be used when clinically appropriate. Further, this form of substitution should be rewarded via QOF targets. There should be greater uniformity in the appearance, labelling and packaging of generic and branded equivalents. The Department of Health should consider raising awareness of the value of medicines by printing the cost on packaging, and to reduce the £100 million wasted annually in dumped medicines, it should investigate which drugs aren't used and why patients won't take them. Strategic health authorities should work with the National Prescribing Centre to develop more prescribing indicators with which to measure PCT performance and support PCTs to promulgate best practice. They should also collaborate on promoting joint primary-secondary care formularies and increase the consistency of prescribing, not only between hospital specialists and GPs but also between PCTs. To monitor the influence of the pharmaceutical industry, PCTs should keep a record of gifts and hospitality and publish a register. Questions to ask about mental health treatment The Department of Health has published a booklet designed to raise awareness of medicines management issues affecting people using mental health services and their carers, and professionals in the health and social services. Although one aim of Medicines Management: Everybody's Business is to empower people with mental health problems to ask about their medication, its formal style is better suited to staff who need to improve their person-centred approach to care. It covers what information people should expect and what questions to ask when drug treatment is being considered, what to expect at review and issues to consider when contemplating stopping treatment. Copies can be downloaded at www.dh.gov.uk. Consider statins for all patients with diabetes Treatment with a statin should be considered for all patients with diabetes unless their risk is low, say the authors of a new study (Lancet 2008;371:117-25). Their meta-analysis of 14 randomised trials involving 18 686 people with diabetes and an average follow-up of 4.3 years found that statins reduced vascular events and vascular mortality as much as in nondiabetic populations. The overall benefit was 42 fewer major events per 1000 people treated for five years. This was independent of a history of vascular disease or other baseline characteristics. No evidence for OTC cough medicines There is no evidence that over-the-counter cough medicines for adults and children are effective in relieving acute cough, a new Cochrane review has concluded (Cochrane Database of Systematic Reviews 2008, Issue 1). The review of 17 randomised trials involving 2876 adults and eight involving 616 children reported conflicting findings of uncertain clinical relevance. The trials were heterogeneous and of low quality. Copyright © 2008 Wiley Interface Ltd [source]