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Journal digest – papers you should know about in March

Anticoagulants ‘raise stroke risk in CKD’

GPs should weigh up risks and benefits before initiating anticoagulants as they may increase risk of ischaemic stroke and haemorrhage in chronic kidney disease patients, advise researchers. 

A study in UK primary care looked at 2,400 over-65s with CKD and a new atrial fibrillation diagnosis. Those taking anticoagulants were matched with those who were not, with 72% taking warfarin. 

The researchers followed these patients for just over 500 days and found those on anticoagulants were almost three times more likely to suffer a stroke as those who were not, and more than twice as likely to experience a haemorrhage. 

But they noted that all-cause mortality was reduced in CKD patients on anticoagulants, suggesting the drugs may lead to a lower rate of fatal strokes or a reduced number of myocardial events. 

They concluded: ‘For the general population, overwhelming evidence supports oral anticoagulation in the context of atrial fibrillation… and this has been universally adopted in clinical practice guidelines. 

‘However, this may not apply in patients with atrial fibrillation and concurrent chronic kidney disease.’

BMJ 2018;360:k342

‘Register high opioid use patients’ GPs told

GPs should add data to a national register of patients who have a high use of opioids, researchers have suggested, after a study identified an overall increase in opioid prescribing in England between 2010 and 2014.

The researchers found an overall increase in prescribing of buprenorphine, codeine, morphine, oxycodone and tramadol, with tramadol the most prescribed.

They also found more opioids were prescribed in the north of England than in the south, and in areas of greater social deprivation.

The researchers concluded that ‘a national registry of patients with high opioid use would improve patient safety for this high-risk demographic, as well as provide more focused epidemiological data regarding patterns of prescribing’.

Br J Gen Pract, online 12 Feb

E-cigarettes ‘should be available on NHS’

An updated evidence review by Public Health England has concluded e-cigarettes could be contributing to at least 20,000 people successfully quitting smoking a year, although it also found thousands of smokers still ‘incorrectly believe’ vaping is as harmful as smoking and around 40% of smokers have never tried an e-cigarette.

PHE said the updated research showed vaping was associated with improved quit success rates and an with accelerated drop in smoking rates across the country last year.

PHE director for health improvement Professor John Newton said: ‘Our new review reinforces the finding that vaping has a fraction of the risk of smoking, at least 95% less harmful, and of negligible risk to bystanders. Yet over half of smokers either falsely believe that vaping is as harmful as smoking or just don’t know.’

The update also said the regulation of e-cigarettes as medicines needed review.

A summary published by PHE went further, suggesting there is ‘compelling evidence that e-cigarettes be made available to NHS patients’.

Public Health England, 2018. 

Few GPs follow new bronchiolitis guideline

Only 7% of GPs say they have changed their practice for treating viral bronchiolitis as a ‘direct result’ of NICE guidelines, a study has reported. 

The study compared GP responses to a questionnaire before and after the guidelines and found 25% of GPs said they had changed their practice, although only 7% stated this was as a direct result of the guidelines.

NICE guidelines, published in June 2015, included the recommendation that children should not be prescribed antibiotics, systemic or inhaled corticosteroids, or a combination of systemic corticosteroids and nebulised adrenaline for the treatment of bronchiolitis.

The study found 24% of the respondents still prescribed corticosteroids, of which a large proportion were oral.

However, the researchers did note a decrease from 7% to 5% in prescription of oral antibiotics.

Oxfordshire GP and Primary Care Respiratory Society UK policy lead Dr Duncan Keeley said: ‘The main issue is the prescription of oral corticosteroids, as there’s no evidence of effectiveness.

‘The problem is that it is for some doctors a change in practice, which is always difficult to achieve.’

BMJ Thorax, online 9 Jan

Cold homes guideline ‘unrealistic’ for GPs

NICE guidelines that recommend GPs use existing data to identify patients who may be at risk of ill health from living in cold homes have been labelled ‘unrealistic’.

A recent study concluded there was ‘no evidence’ to suggest such identification was possible.

Researchers analysed the records of almost 35,000 patients who had died between April 2012 and March 2014, across 300 practices.

While they found that every 1°C decrease in temperature was associated with a 1.1% increase in deaths, using the data available to GPs, they were unable to establish with certainty any groups that were predominantly affected.

Study author and professor in medical statistics at the University of Bristol Professor Richard Morris said: ‘Primary care data does not routinely include information about whether patients’ homes are cold, so there is no simple way for GPs to identify patients most at risk.

‘Primary healthcare professionals, especially GPs, may also have little opportunity to visit people’s homes, which means that they are reliant on the patient disclosing a cold home problem or on other professionals sharing that information.

‘NICE’s recommendation therefore appears unrealistic.’

Br J Gen Pract, online 29 Jan


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