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At the heart of general practice since 1960

GPs may face scrutiny on gaps in H. pylori testing

Nerys Hairon reports on the latest crisis to engulf arthritis care

After the crisis over cox-2 inhibitors and the withdrawal of co-proxamol, the last thing GPs needed was another scare over a popular class of painkillers.

But that is exactly what they got last week, as a media storm blew up around the cardiovascular safety of conventional NSAIDs.

Worried patients have been flocking to surgeries after a trio of studies ­ from the UK, the US and Canada ­ all

suggested the drugs posed significant cardiac risks (see box below).

In April the European Medicines Agency began a review of the cardiovascular safety of conventional NSAIDs on top of its existing evaluation of cox-2s.

But even the researchers responsible for the UK study are warning against a panicked reaction to their results.

Professor Julia Hippisley-Cox, professor of clinical epidemiology and general practice at the University of Nottingham, cautioned: 'I do not think it should change practice at the moment, but I do think it should focus the mind on the safety of these drugs.'

RCGP prescribing spokes-person Dr Jim Kennedy believes drug regulators have already overreacted in their restrictions on cox-2s. He is concerned that a 'flurry' of studies on NSAIDs could lead to further limits on GPs' treatment options.

He said: 'The researchers have got on a bit of a bandwagon on this. There is a danger there will be a flurry of research activity because it's topical rather than because it improves our understanding. We need good-quality research, not just quantity.'

Dr Peter Fellows, chair of the GPC prescribing subcommittee, also warned against a swathe of new prescribing controls.

'There is no drug without risk. We are fully aware that NSAIDs carry risks and need to be treated with caution. We have found new risks we weren't aware of, but it does not mean the drugs shouldn't be prescribed.'

He added: 'On the basis of current figures the risk does not justify stopping treatment. It's just additional warnings would be in order.'

For Dr Fellows, the new research highlights the folly of this year's withdrawal of coproxamol: 'I don't think that made a lot of sense and a lot of people will go for ibuprofen. I hope there will be a rethink on co-proxamol.'

Dr Iain Gilchrist, a member of the Primary Care Rheumatology Society and a GP in Hatfield Heath, Essex, also called for regulatory bodies to exercise restraint, arguing GPs needed to inform patients about risks and benefits.

Dr Gilchrist said some patients, including those with rheumatoid arthritis, gout and ankylosing spondilitis, usually needed anti-inflammatories, as ordinary painkillers were less effective. But he advised that for patients with osteoarthritis or soft-tissue lesions, GPs should be more active in using options such as analgesics and local injections.

Dr Gilchrist said: 'For patients on anti-inflammatories, we need to actively look for other risk factors of heart disease, and hopefully reduce the absolute risk of the patient developing it. What we do not need is a complete withdrawal of all anti-inflammatories, as they still are very useful drugs.'

But while GPs do not want withdrawals, they are adamant that the UK's Medicines and Healthcare Products Regulatory Agency needs to provide clear treatment guidelines.

RCGP chair Dr Mayur Lakhani has demanded drug regulators 'settle the matter once and for all' through the review of NSAIDs.

But he added: 'There is no need for undue concern. Traditional NSAIDs like ibuprofen have a satisfactory overall track record.'

Trio of studies that have thrown NSAID use into doubt

UK study

Compared 9,218 patients with a first myocardial infarction and 86,349 controls using data from 367 GP practices

MI risk increased by 24 per cent for current use of ibuprofen, 55 per cent for diclofenacs and 32 per cent for rofecoxib

Published in last week's BMJ

Canadian study

Analysed 2,256 patients prescribed rofecoxib, celecoxib or a conventional NSAID after admission for congestive heart failure

Combined risk of death and recurrent congestive heart failure 26 per cent higher with conventional NSAIDs and 27 per cent higher with rofecoxib than with celecoxib

Published in last week's BMJ

US study

Matched 15,343 cases of acute MI in arthritis patients with controls

Risk increased by 71 per cent with indomethacin, 41 per cent with sulindac and 11 per cent with ibuprofen

Presented at European Congress of Rheumatology in Vienna last week

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