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Clinical round-up: July

Give PPIs with aspirin in over-75s, GPs told

GPs should prescribe PPIs to over-75s who are on a daily dose of aspirin to prevent gastrointestinal bleeds.

New research from the University of Oxford found that, among patients aged 75 or over, the overall risk of developing serious bleeding was 10 times higher than in those aged under 75.

When investigating the role of co-prescribed PPIs, they found the estimated NNT to prevent one fatal upper GI bleed over five years fell from 338 in patients younger than 65 to 25 for those 85 or older.

Current NICE guidance on NSAID prescribing recommends co-prescription of PPIs in patients at increased risk of adverse GI effects, with those aged 65 and over included in this group, but this advice is not routinely applied.

Experts are now calling for guidance to be updated so that patients over 75 on long-term antiplatelet therapy are routinely co-prescribed PPIs.

GPSI in cardiology Dr Ahmet Fuat told Pulse: ‘This study provides robust evidence that we should be routinely co-prescribing PPIs with aspirin in all patients over 75 to reduce the risk of major or fatal GI bleeding.’

Lancet 2017, online 13 Jun

ß-blockers ‘may not cut post-MI mortality’

Beta-blockers may not reduce the likelihood of death when prescribed following an MI, a new study says.

In patients who had suffered an MI without heart failure, there was no significant difference in death rates between those who were and those who were not taking β-blockers.

The results come from data gathered from nearly 180,000 survivors of acute MI in England and Wales, just under 95% of whom were prescribed a β-blocker during the six-year study period.

The researchers suggested β-blockers could potentially be removed as a secondary prevention drug for MI patients being discharged from hospital; however, NICE guidelines recommend these patients are offered the drugs for 12 months post-MI.

Dr Ahmet Fuat, a GPSI in cardiology in Darlington, said: ‘There is little evidence for using β-blockers long term after acute MI, unless the patient has heart failure or angina symptoms.

‘We need a trial that addresses the mortality and morbidity benefits, but in the meantime, GPs should tailor β-blocker use to individual patients.’

J Am Coll Cardiol 2017, online 29 May

Fewer talking therapy referrals in elderly

Older patients with mental health issues are far less likely to be referred to talking therapy than younger patients, according to official NHS research .

After analysing 80,000 referrals, the South West of England Improving Access to Psychological Therapies Evaluation Project found the percentage of patients referred significantly reduced with age, from 23% of 20- to 24-year-olds to 6% of those aged 70-74.

The researchers concluded this could be partially explained by a greater reluctance among older people to accept being referred to talking therapy, due to a perceived stigma, but they also pointed to the attitudes of professionals and mobility issues as potential barriers.

Lead author Professor Richard Byng, GP and professor in primary care research at Plymouth University, said: ‘We would suggest that GPs should do more to discuss mental health problems with their older patients and increase awareness of the different therapy options available’.

Br J Gen Pract 2017, online 5 Jun

Consider falls risk ‘with ß-blockers’

GPs should take falls risk into account when prescribing β-blockers, new research has warned.

A team from the Netherlands, looking at just over 10,000 patients taking the drugs, found that non-selective β-blockers, such as carvedilol and propranolol, were associated with a 22% increased risk of falls over a two-year period, compared with those not taking the drugs.

Those taking selective β-blockers did not have any increased risk of falls, compared with non-users.

The researchers conclude: ‘Falls risk should be considered when prescribing a β-blocker in this age group, and the pros and cons for β-blocker classes should be taken into consideration’.

Br J Clin Pharmacol 2017, online 7 Jun

GP reminders ‘boost bowel screen uptake’

GPs can help boost the uptake of bowel cancer screening in the over-60s by sending them a personal reminder letter.

A trial involving 25 GP practices in Wessex with low uptake of screening saw more than 3,000 reminder letters, signed by a GP, sent to patients who had been invited for screening and sent a 28-day reminder by the NHS, but had not returned their kit.

Uptake was three percentage points higher in patients who received a letter than those who did not receive one. The researchers said that, extrapolated across England, that could mean 123,000 more people being screened each year.

Br J Can 2017, online 18 May

Prescribing update

Strontium ranelate to be discontinued

French drug company Servier, which produces the only form of strontium available in the UK, will stop producing the drug in August, citing a reduction in the number of prescriptions. Patients are being advised to ‘contact their GP or hospital doctor to discuss their options’.

WHO updates antibiotics advice

The World Health Organization has updated its essential medicines list, with advice on antibiotic prescribing. Its ‘watch’ list – drugs that should be used with caution and ‘dramatically reduced’ in order to reduce the development of resistance – now includes ciprofloxacin. Their ‘reserve’ list – only to be used in life-threatening situations – includes colistin and some cephalosporins. 

CPD tip of the month - vaccinating pregnant women

There are a number of things to consider when managing pregnant women who request vaccinations, but the main issue is to balance the risk of any recommended vaccine against the risk posed by the disease for which it is given.

If you decide to go ahead and vaccinate, the following can be given to pregnant women, where indicated:

  • Hepatitis A
  • Hepatitis B
  • Meningococcal ACWY
  • Tetanus

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