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GPs go forth

End of year clinical digest

A round-up of 2019’s biggest clinical stories

NICE reverses antidepressant withdrawal position

NICE took the unusual step of delaying it’s update of the depression guidance last April after GP and mental health leaders raised concerns over ‘flawed’ methodology.

In an October update, however, the guideline authority amended statements on withdrawal symptoms, effectively reversing its position on how doctors should advise patients coming off their antidepressants.

The update now includes statements on withdrawal symptoms, clarifying that symptoms may be severe and last for months in some patients.

The original guidance advised that symptoms are generally mild and self-limiting over the course of a week.

The update followed a position statement released by the Royal College of Psychiatrists in May, which recommended that NICE guidelines should acknowledge the potential for severe withdrawal and provide evidence-based guidance for gradual withdrawal from antidepressants.

The full guideline update is still in progress, with a publication date yet to be confirmed.

Genomic testing could worsen workforce problems

Health Secretary Matt Hancock made waves earlier in the year after sharing the results of a commercially available genetic test that he took to find out his risk of developing prostate cancer.

The government has promised that genomic testing will also start to be rolled out to at least five million NHS patients across the UK over the next five years as part of its ‘Accelerating Detection of Disease’ programme.

The programme, announced in July, is set to receive a £160m cash boost from industry supporters and revolutionise how we detect and treat diseases like heart disease, cancer and dementia by identifying genetic markers for the conditions before patients even have symptoms.

GPs have warned, however, that the plans will inevitably increases GP workload and costs.

GP experts voiced concerns about the effect the programme could have on health anxiety and GP workload and called for long-term data on the possible adverse effects of the programme.

Leaders said that specialist pathways would be needed to support those with ‘adverse genetic profiles’, amid fears that such patients would start presenting more frequently to primary care.

A spokesperson for the RCGP overdiagnosis group, chaired by GP Dr Jane Wilcock, commented: ’We do not know the risks of false positive and false negative results, the costs to the NHS of retesting, counselling, onward referrals if needed and relatives testing.

‘As GPs we expect individuals entering ADD will have full counselling for informed consent, understanding possible benefits, risks and options available if information is adverse before participation. We hope there is long-term data collection on possible adverse effects as well as benefits.’

homeopathy getty

If the DHSC decide to follow NHS England’s recommendations, it will mean that homeopathy will no longer be legally prescribed by GPs.

Homeopathy to be blacklisted, say NHS England

NHS England announced plans all the way back in 2017 to stop the prescription of homeopathy in general practice, issuing guidance meant to prevent the prescription of ‘low-priority’ treatments.

The authority amped up its stance in April this year, however, saying that it would be ‘formally requesting’ that the Department of Health and Social Care (DHSC) blacklists homeopathy and diverts available funding towards better uses.

If the DHSC decide to follow NHS England’s recommendations, it will mean that homeopathy will no longer be legally prescribed by GPs.

Although it would be a boon for NHS England if the DHSC followed its advice, the health authority’s challenge against homeopathy prescribing in the UK hasn’t been without its critics. The High Court rejected a legal challenge by the British Homeopathic Association back in 2018 against NHS England plans to no longer routinely fund homeopathy.

Of this year’s blacklisting suggestion, an NHS England spokesperson said: ‘The NHS has issued guidance making it clear to GPs that homeopathy should not be prescribed, and to give further legal force to this we will now be formally requesting that the Department of Health blacklist it so that funds cannot be wasted in this way.’

Half of patients on statins have sub-optimal response

Opinions on the efficacy of statins have gone back and forth for years, but a study published in April has suggested that around half of patients on the medication have a ‘sub-optimal’ response, leading to calls for GPs to tailor statin regimens to individual patients.

The study, published in Heart, was carried out by primary care researchers at the University of Nottingham and looked at just over 165,400 primary care records for patients on statins.

Around half of patients had a sub-optimal response to statin therapy after two years on treatment, meaning that they hadn’t achieved a greater than 40% reduction in LDL-C levels.

Sub-optimal responders were 22% more likely to experience a CVD-related event, such as coronary artery disease or stroke, or peripheral vascular disease than optimal responders.

The authors said in the paper: ‘Currently, there is no management strategy in clinical practice which takes into account patient variations in LDL-C response… Validated clinical decision tools which can predict cholesterol response to statins, or to non-statin drugs, with interventions to help clinicians to tailor and optimise statin treatments for individual patients are needed.’

Heart 2019; available online 15 April

GPs could prescribe cannabis under shared care agreements

Medical cannabis rose to prominence in the public consciousness over the last year, after several high-profile legal challenges by parents whose severely epileptic children were denied it to treat their seizures.

After months of government debate, with GPs seeing a marked increase in patients asking for medical cannabis over the first few months of 2019, NICE released draft guidance in April saying that GPs could be able to prescribe cannabis-based medicinal products as part of a shared care agreement, as long as the initial prescription is made by a specialist doctor.

The guidance said: ‘After the initial prescription, subsequent prescriptions of cannabis-based medicinal products may be issued by another prescriber as part of a shared care agreement under the direction of the initiating specialist prescriber.’

It also said there are ‘potential burdens’ with limiting prescribing and ‘monitoring to tertiary care’.

As a result, the guideline committee highlighted a ‘clear need’ shared care arrangements, involving GPs, other healthcare professionals and non-medical prescribers, adding that moving away from tertiary care could be ‘cost-saving’ for the NHS.

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