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Clinical round-up - news and drug updates in April

The latest information for GPs

depression in adults 3x2

 

Child antidepressant scripts rise 54%

Prescriptions for antidepressants in children rose 54% between 2005 and 2012 in the UK, an international study has revealed.

The study, led by King’s College London academics, looked at data from The Health Improvement Network primary care database and found the proportion of children aged up to 19 years who had received an antidepressant prescription went up from 0.7% in 2005 to 1.1% in 2012.

This was mainly down to increases in SSRI use, with prescriptions for tricyclic antidepressants showing a relative decline. Around 90% of the SSRIs were started between the ages of 15 and 18.

The figures follow research suggesting increases in suicide risk and aggressive behaviour with antidepressant use may be more widespread than previously thought, with SSRIs and SNRIs linked to the increase.

RCGP chair Dr Maureen Baker said the ‘vast majority of antidepressants for children and young people are prescribed in secondary care’, but added that ‘with such long waits for patients to see a specialist or to get a psychological therapy referral, drug therapy is sometimes seen as the only option for GPs to best support patients, who may be in extreme distress.’

Eur Neuropsychopharmacol 2016, online 8 Feb

GP antibiotics ‘drive resistance’ in children

Routine GP prescribing of antibiotics to treat UTIs in children and young people is contributing to antimicrobial resistance and should be reviewed, research has concluded.

Countries within the Organisation for Economic Cooperation and Development (OECD), including the UK, had lower levels of resistance than less developed nations, but it was still high to many first-line treatments, including ampicillin, trimethoprim and co-amoxiclav.

The study also found UTI resistance to antibiotics was 13 times more likely in children prescribed antibiotics within the preceding six months.

It led the team from Bristol to conclude that ‘ampicillin, co-trimoxazole and trimethoprim are no longer suitable first-line treatment options for UTIs in many OECD countries,’ and that ‘as a result, many guidelines, such as those published by NICE, might need updating’.

BMJ 2016, online 15 Mar

‘Difficult’ patients raise misdiagnosis risk

Patients displaying disruptive behaviour increase GPs’ risk of getting a diagnosis wrong, according to Dutch research.

The study concluded that GPs devote so much mental resource to dealing with their patients’ emotional behaviour that their decision making may become impaired.

It said doctors were 42% more likely to misdiagnose a ‘difficult’ patient than a ‘neutral’ one in a complex case, and 6% more likely to do so in a simple case.

Researchers presented GPs in their last year of medical training with six vignettes depicting three diagnostically simple cases and three complex cases. The patients were a mix of ‘difficult’ – displaying distressing behaviours – and ‘neutral’. Spending longer on diagnosis or reflecting on it later did not make up for the impact of difficult behaviour.

The study concluded: ‘Disruptive behaviours displayed by patients seem to induce doctors to make diagnostic errors.’

BMJ Qual Saf, online 7 Mar

‘Check depressed patients for ADHD’

GPs with patients diagnosed with major depression should consider whether they have underlying, undiagnosed ADHD, research has suggested.

Using data from self-reported questionnaires from more than 2,000 patients, researchers found those with current depression were four-and-a-half times more likely to have ‘probable ADHD’ than those not currently depressed or with no history of depression.

They also found that the more severe the depression, the greater the likelihood of underlying, undiagnosed ADHD.

Patients with mild depression had a greater than two-fold increase in risk of having ADHD symptoms, while those with moderate and severe depression had eight- and six-fold increases, respectively, compared with non-depressed patients.

The authors suggested the low levels of stimulant use in this group ‘may suggest ADHD symptoms are overlooked in depression, due to referral for depressive disorders instead of undiagnosed ADHD.’

J Affect Dis 2016, online 28 Feb

Therapeutics update

• Flu jab coverage falls across target groups

The latest official figures for this year’s flu campaign suggest a markedly lower vaccine uptake across all cohorts of patients, compared with last season.

According to figures up until the end of January, uptake is down among elderly people and the under-65s in at-risk groups, pregnant women and all the target age groups in children.

This appeared to be most marked among under-65s in clinical risk groups, where coverage fell from 50% last year to 45% this year. Coverage fell by 4% and 3% in all two- and three-year-olds respectively.

Public health chiefs told Pulse the latest data were unlikely to change, but Public Health England recently warned GPs to retain vaccine stocks ‘due to the recent arrival of cold weather’, which they say could mean a ‘late surge in demand for flu vaccinations’.

• Ulipristal acetate (Esmya) approved by SMC

The SMC has approved ulipristal acetate (Esmya) for use in women with moderate to severe uterine fibroids, potentially reducing the number of women choosing to have surgery.

• Guanfacine (Intuniv) available in the UK for childhood ADHD

Guanfacine (Intuniv), a non-stimulant tablet for children aged 6-17 years old with ADHD, has become the second medication of its type to be made available in the UK.

CPD tip of the month: Brandt-Daroff exercises for vertigo

If you are not confident in performing the Epley manoeuvre, or the patient does not want it done, you can advise them to do Brandt-Daroff exercises at home. They’ve been found to succeed in 95% of cases.

• Sit upright on the edge of the bed. Turn head 45° to left

• Lie on right side for 30 seconds

• Sit up, turn head back to the middle

• Turn the head 45° to right

• Lie on left side for 30 seconds

• Sit up, turn head back to the middle

• Repeat this four more times.

Case-based learning: vertigo

1.5 CPD hours

pulse-learning.co.uk

 

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Readers' comments (3)

  • SSRI,s and SNRI's do not prevent suicide, they cause it.
    They cause akathisia in those who are metabolically vulnerable, - i.e. CYP 450 genomic variant, slow metabolisers of all ages, and children in particular. It is unforgivable to induce a toxic prescription medication adverse drug response which is analogous to an overwhelming fight or flight reaction and which causes extreme changes in behaviour.
    It is Akathisia which compels suicidality and other extreme violence including homicidality. As akathisia is rarely identified, albeit easily recognised, it is not "yellow carded".
    Hence the deaths caused by these psychotropic medications are inevitably more common than currently appreciated.

    Unsuitable or offensive? Report this comment

  • Dear Doctor,
    at 9.42am, may I ask for clinical references I am aware that certain SSRI should not be prescribed to adolescents , and should be prescribed with a great deal of caution. I would find it helpful if you could reference any clinical papers?

    Regards

    Clinical Pharmacist

    Unsuitable or offensive? Report this comment

  • Clinical Pharmacist,
    Perhaps the most compelling starting point is: -

    The relevance of cytochrome p450 polymorphism in forensic medicine and akathisia related violence and suicide.

    Selma Eikelenboom-Schieveld. Yolande Lucire, and James Fogelman.

    Journal of forensic and legal medicine. April. 2016.

    Unsuitable or offensive? Report this comment

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