We bring you the latest news from the healthcare about the health care in the United Kingdom.

zondag 14 januari 2018

DTB: An update on the management of gout

An update on the management of gout

Gout is the most common form of inflammatory arthritis and its incidence in the UK has steadily increased from 1.5% in 1997 to 2.5% in 2012.1,2 It is characterised by deposition of monosodium urate crystals in joints and tissues and usually presents with intermittent painful attacks followed by long periods of remission.3 It has been suggested that the management of gout in the UK remains suboptimal.1 In 2004, we concluded that there was a woeful lack of evidence to guide treatment or prophylaxis for gout, particularly with regard to choice of drug or doses.4 The introduction of new drugs and new evidence on the efficacy and safety of treatment options has led the European League Against Rheumatism (EULAR) and the British Society of Rheumatology (BSR) to update their guidelines on the management of gout.2,5 Nevertheless, there are differing views on target serum uric acid (SUA) levels and the role of urate lowering treatment (ULT).2,5–7 Here, we review the latest guidance on the management of gout and consider the role of long-term ULT.

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{blacktriangledown}Patiromer for the management of hyperkalaemia

Hyperkalaemia is a potentially life-threatening condition, in which there is an abnormally high concentration of potassium ions in the blood.1,2 Cation-exchange resins (e.g. calcium or sodium polystyrene sulfonate) that bind potassium in the gastrointestinal tract to increase faecal elimination have been used as part of the management of hyperkalaemia but they have some serious adverse effects, including potentially fatal gastrointestinal necrosis.3,4 Patiromer (Veltassa – Vifor Fresenius) is a cation-exchange polymer that is licensed for the treatment of hyperkalaemia in adults and, unlike other exchange resins, its licence is not restricted to people with anuria, severe oliguria or those requiring or undergoing dialysis.5,6 Here, we review the evidence for the efficacy and safety of patiromer and consider its place in the management of hyperkalaemia.

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Lack of clarity about frequency for monitoring renal function in heart failure guidelines

The optimal frequency for monitoring renal function in people with heart failure is questioned in an extensive review of national and international heart failure guidelines.1 The review describes the two-way link between cardiac and renal function, the association between decline in cardiac function with renal function (and vice versa) and how drugs used to manage heart failure can worsen the situation. Renal dysfunction due to diuretics, particularly in patients with heart failure, is a common cause of hospitalisation for adverse drug reactions in the UK. There is a lack of good evidence to inform heart failure guidelines on the optimal frequency for monitoring renal function. Current recommendations are largely based on expert opinion.

The review found that major guidelines on the management of heart failure (National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, European Society of Cardiology American College of Cardiology Foundation and American...

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Effect of antibiotic stewardship programmes on the incidence of infection

Antibiotic stewardship programmes have been shown to reduce antibiotic use and hospital costs. A systematic review has assessed evidence of the effects of antibiotic stewardship on the incidence of infections and colonisation with antibiotic-resistant bacteria in hospital inpatients.1

The primary outcome was the change in the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infections in hospital inpatients after implementation of antibiotic stewardship. The review's main outcomes were incidence ratios (IRs) of target infections and colonisation per 1,000 patient-days before and after implementation of antibiotic stewardship interventions.1 The meta-analysis included 32 studies (conducted in 20 countries between 1992 and 2014), comprising more than 9 million patient-days and 159 estimates of IRs. Antibiotic stewardship programmes could include heterogeneous interventions, such as auditing, restriction of specific antibiotics, restriction of treatment duration and antibiotic cycling. The most frequently used interventions were audits and implementation of...

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Improving adherence to antidepressant medication in older people

A programme designed to improve adherence to antidepressant medications has been tested in a new study in the US.1 The randomised trial assessed the effectiveness of the Treatment Initiation and Participation Program (TIP), a psychosocial intervention for older patients who have recently been prescribed an antidepressant for depression. The study's authors quoted rates of non-adherence to antidepressants among older adults in the US of 29-40%, with some research suggesting that non-adherence is higher in primary care compared with specialist psychiatry services. They also identified the first 6 weeks of treatment as a particularly critical period for promoting adherence, with increased risks of treatment dropout, relapse, and vulnerability to suicide, among other potential consequences of non-adherence.

The TIP intervention, delivered over three 30-minute sessions during the first 6 weeks of drug treatment, included steps covering review of symptoms and antidepressant regimen, assessing and addressing barriers to adherence, defining...

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Gabapentin and risk of severe respiratory depression

In a recent Drug Safety Update, the Medicines and Healthcare products Regulatory Agency (MHRA) warned about a rare risk of severe respiratory depression with gabapentin, with or without concomitant use of opioids.1 In England, 6.5 million prescriptions for gabapentin were dispensed in 2016.2

A European review of gabapentin was triggered by reports of patients developing respiratory depression without concomitant use of opioids — this reaction had already been recognised with concomitant use of gabapentin with opioids.3 Based on the available evidence, the review recommended that the product information for gabapentin be amended to include warnings for severe respiratory depression, which may affect up to 1 in 1,000 patients.

Healthcare professionals are advised to:1

  • be aware of the risk of CNS depression, including severe respiratory depression, with gabapentin;

  • consider whether dose adjustments might be necessary in patients at higher risk...

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    BP targets for people with CVD

    A Cochrane review has attempted to clarify whether 'lower' blood pressure targets (≤135/85mmHg) are associated with a reduction in mortality and morbidity when compared with 'standard' blood pressure targets (≤140–160/90–100mmHg) in people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease).1

    The authors note that epidemiological studies have found that for BP >115/70mmHg, the risk of cardiovascular events doubles for every 20/10mmHg rise in blood pressure.1 Therefore, it has been suggested that for every 20mmHg reduction in systolic blood pressure (SBP) or 10mmHg diastolic blood pressure (DBP), the risk of a cardiovascular event is reduced by about 50%. While some evidence has suggested that lower targets might reduce cardiovascular mortality and morbidity in people with hypertension and established cardiovascular disease, who are at particularly high risk, they might also increase adverse events and the complications of polypharmacy.


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    NICE: reduce antibiotic prescribing for acute sinusitis

    The National Institute for Health and Care Excellence (NICE) has issued a guideline to tackle over-prescribing of antibiotics for people with acute sinusitis.1 The guideline aims to limit antibiotic use and reduce antimicrobial resistance. In the UK, research has highlighted a high rate of antibiotic prescribing for people with sinusitis.2 In 2011, a study of 568 general practices reported that the median practice issued antibiotic prescriptions at 91% of consultations for 'rhino-sinusitis'.

    The key message of the guideline is that antibiotics are not useful in the vast majority of patients with sinusitis.1 Acute sinusitis is usually caused by a virus, lasts for about 2 to 3 weeks and most people get better without antibiotics. Withholding antibiotics rarely leads to complications. Only about 2% of cases are complicated by bacterial infection, although it is very difficult to identify these.

    For people presenting with symptoms...

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    NHS England: guidance on medicines not to be prescribed

    Following a consultation process earlier in 2017, NHS England has published a list of medicines and other items that it recommends should not be routinely prescribed in primary care.1 The proposed restrictions cover 18 products and include drugs such as co-proxamol, dosulepin, liothyronine, prolonged-release doxazosin, immediate release fentanyl, lidocaine plasters, as well as travel vaccines, homeopathy and some herbal treatments. The annual NHS spend on medicines in primary care in England is about £9 billion and it is estimated that these 18 items cost approximately £141 million per year.2,3

    The guidance is for Clinical Commissioning Groups (CCGs) to use when devising local formularies and prescribing policies.1 However, the guidance does not "remove the clinical discretion of the prescriber in accordance with their professional duties".

    For some items, CCGs are advised that prescribers in primary care should not initiate prescriptions for any...

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    No alchemy for obesity

    A desire to lose weight, exercise more and eat more healthily feature in many people's New Year resolutions, and are ranked higher than stopping smoking or drinking less alcohol.1 Nevertheless, the increase in the number of people who are overweight or obese continues to have a significant impact on the individual, the health service and society. Almost half a century ago, DTB discussed the importance of diet, exercise and psychological support, and noted that "successful management of obesity requires interest, time and enthusiasm on the part of both doctor and patient".2 We also recognised and endorsed the role of programmes and organisations that assist and support people to lose weight. Although exercise, diet and behaviour modification are key elements of obesity strategies, there remains a fascination in the prospect of drug treatment for obesity.3-6 The potential market...

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