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CAMHS won't see you now

NICE guidelines on Cox-2s 'are being ignored by GPs'

NICE recommendations on Cox-2s aren't being followed, the British Society for Rheumatology is to be told

GPs are ignoring guidelines from the National Institute for Clinical Excellence on the prescribing of Cox-2 selective inhibitors, which could be putting patient safety at risk, writes Rob Finch.

Three studies, to be presented later this month at the British Society for Rheumatology annual meeting in Edinburgh, show 'worrying' discrepancies between NICE recommendations and what GPs are actually prescribing.

The researchers said although there were huge cost implications in prescribing the more expensive Cox-2s, poor prescribing in these groups could result in large numbers of adverse gastrointestinal problems.

NICE recommends GPs prescribe Cox-2s instead of standard NSAIDs in patients over 65 with osteo- or rheumatoid arthritis, those using other medications with gastrointestinal side-effects, those with co-morbidities, or those requiring long-term use of standard NSAIDs at maximum dose.

But the studies (see box), which comprised 4,264 patients, found between 64 and 92 per cent of patients in one of these categories were taking non-selective NSAIDs, such as aspirin, when they should have been on a Cox-2 inhibitor according to NICE guidelines.

Study leader Dr Ash Samanta, consultant rheumatologist at Leicester Royal Infirmary, said: 'The results reflect the gap between guidelines and what is done in practice.'

Dr Stephen Longworth, past-president of the Primary Care Rheumatology Society and a GP in Leicester, said: 'On the face of it, it sounds worrying. But these [prescribing] decisions can probably be justified. It would be banal to attribute one explanation for this across the board.

'It may be that patients have been on NSAIDs for many years and have not been reviewed. GPs are busy with GMS2 and these sorts of issues go on the back burner.'

Cox-2 differences in practice

Leicester study

l16 practices, 1,152 patients taking Cox-2s for osteo- or rheumatoid arthritis

l22 per cent of patients on Cox-2s had no indication for this on the basis of NICE criteria

l74 per cent of patients over the age of 65 on a standard NSAID had at least one additional criterion for being on a Cox-2

Midlands study

lAudit of NSAID use in 2,846 patients at regional rheumatology clinics

l92 per cent of patients using non-selective NSAIDs should have been prescribed a Cox-2 selective agent

Dorset study

lStudy of change in NSAID prescribing habits in one semi-rural practice over 10 years

l64 per cent of patients currently prescribed NSAIDs fulfil at least one indication for the use of Cox-2s

Shoulder pain actively managed by most GPs

The majority of GPs actively manage patients' shoulder pain but frequently fail to classify symptoms, according to a survey of more than 500 GPs.

The results, to be presented at the conference, showed 85 per cent of GPs thought making an accurate diagnosis was important, but only 48 per cent indicated they normally classified patients into specific syndromes.

GPs questioned were most likely to diagnose rotator cuff tendonitis, capsulitis acromioclavicular pain or rotator cuff pain.

They rated steroid injections, NSAIDs and physiotherapy as similarly effective treatments and preferable to doing nothing, but significantly more male GPs performed shoulder injections.

GPs who were confident in injecting joints had been trained at outpatient or injection clinics, or through specific musculoskeletal courses.

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