Clinical Pharmacy News summary

Practice pharmacists can help general practitioners meet national recommendations for secondary prevention of coronary heart disease (CHD), the findings of a new study have shown...[more]

The latest Merec Bulletin reviews drug treatment of depression in primary care...[more]

Concern over the potential for medicinal cannabinoid preparations to be abused has led to the development of “anti-diversionary” packaging...[more]

Rofecoxib (Vioxx) might be more likely to cause oedema and changes in blood pressure than celecoxib (Celebrex), according to researchers from America...[more]

Eradication of Helicobacter pylori is as effective as omeprazole in preventing recurrent upper gastrointestinal (GI) bleeding in patients taking low-dose aspirin, according to Dr Francis Chan (Chinese University of Hong Kong) and colleagues...[more]

Bisphosphonates, currently used to treat osteoporosis, might form the basis of treatment of parasitic diseases in the future, say researchers...[more]

Pretreatment with paroxetine minimises depression induced by interferon-alfa, an American study has shown...[more]

Women are particularly prone to drug-induced QT interval prolongation during the first half of their menstrual cycle, say researchers from the United States...[more]

Improving secondary prevention of CHD

Practice pharmacists can help general practitioners meet national recommendations for secondary prevention of coronary heart disease (CHD), the findings of a new study have shown.

Kevin Rothnie (practice pharmacist, Angus Local Health Care Co-operative, Forfar) conducted an audit of the prescribing of lipid lowering drugs in patients aged over 75 years who had suffered a myocardial infarction.

He compared the number of patients whose care matched the recommendations of joint British guidelines (ie, how many had had a total cholesterol level measured in the past year and who had a total cholesterol level below 5mmol/L) before and after making the practice partners more aware of the recommendations.

In the baseline audit, about 47 per cent of patients had had a total cholesterol test in the past year. One year later, this had increased to about 88 per cent. In addition, 41 per cent of patients had a total cholesterol level of less than 5mmol/L at baseline, which rose to about 76 per cent after one year.

Mr Rothnie concludes that this kind of audit can “improve the clinical effectiveness of coronary heart disease secondary prevention” but adds that prescribing costs rose as a result of increased use of lipid lowering drugs. This study is published in Primary Care Pharmacy (2001;2:8).

PCP is available through the Pharmaceutical Press and appears on PJ Online, the website of The Pharmaceutical Journal (www.pharmj.com).

Correction The patient group in this study was under 75 years of age, not over 75 years.

Other articles in the March 2001 issue of PCP

Management of change in prescribing (C. Lowe), PDF* file, 20K

POM to P — implications for practice pharmacists (C. Bond), PDF* file, 25K

Providing prescribing support for PCGs (G. Speak), PDF* file, 30K

Monitoring and screening for diabetes (N. Dixon), PDF* file, 20K

Prescribing indicators (I. Bishop), PDF* file, 25K

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Treating depression in primary care

The latest Merec Bulletin reviews drug treatment of depression in primary care. The bulletin says that depression is often unrecognised and that many patients do not receive optimum treatment. It concludes that tricyclic antidepressants, related drugs and selective serotonin-reuptake inhibitors are suitable first-choice agents for most patients and that there are no significant differences in efficacy between them (Merec Bulletin 2000;11:33).

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“Anti-diversionary” packaging for cannabinoids

Concern over the potential for medicinal cannabinoid preparations to be abused has led to the development of “anti-diversionary” packaging.

Speaking at a one-day symposium on April 5, Dr Philip Robson (medical director, GW Pharmaceuticals Ltd) described a sublingual spray device for delivery of cannabinoids that GW Pharmaceuticals was developing. The electronic device was the size of a mobile telephone. It comprised a medical canister (containing the cannabinoids for delivery), a tamper-evident membrane, and a microchip that stored data such as the frequency and size of dose for a particular patient. The device required the patient to enter a personal identification number correctly before the dose could be administered. Dr Robson said that it had “enormous potential” beyond its obvious use for anti-diversionary tactics. Its real merit was its potential for use as a research tool. The device could be used to record doses electronically and to transmit these data to a remote site. In addition, outcome measures, such as visual analogue scales for pain, could be incorporated into the device.

The symposium was organised by the Academy of Pharmaceutical Sciences, the Multiple Sclerosis Society and the British Pharmacological Society. — Contributed.
See also Forum

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More side effects with rofecoxib than with celecoxib?

Rofecoxib (Vioxx) might be more likely to cause oedema and changes in blood pressure than celecoxib (Celebrex), according to researchers from America. However, questions have been raised over the equivalence of the doses used in the study.

Dr Andrew Whelton (Johns Hopkins University School of Medicine, Baltimore) and colleagues conducted a six-week study to compare the effects of celecoxib and rofecoxib on the heart and kidneys of patients aged over 65 years who had hypertension and osteoarthritis.

They say that, although both drugs caused significant oedema and changes to blood pressure, these side effects were more likely to occur in patients treated with rofecoxib. “The finding that celecoxib was associated with a lower incidence of cardiorenal events compared with rofecoxib, especially with regard to hypertension, should be considered when selecting a cyclo-oxygenase 2-specific inhibitor for the treatment of osteoarthritis,” they say.

The trial involved 811 subjects, 412 of whom received celecoxib 200mg daily and 399 rofecoxib 25mg daily. The British National Formulary states that the recommended doses for osteoarthritis for celecoxib is 200mg (maximum 400mg) daily and for rofecoxib is 12.5mg (maximum 25mg) daily.

Significant oedema occurred in 9.5 per cent of patients who received rofecoxib compared with 4.9 per cent of those taking celecoxib. In addition, 16.5 per cent of patients treated with rofecoxib experienced an increase in systolic blood pressure of more than 20mmHg compared with 10.9 per cent of those taking celecoxib. However, more patients in the celecoxib group were also receiving angiotensin converting enzyme inhibitors than in the rofecoxib group, although the authors say this did not affect blood pressure changes.

The overall number of patients who experienced side effects was similar in both groups and the number of withdrawals from the study because of adverse events was the same (9 per cent). The paper is published in the American Journal of Therapeutics 2001; 8:85).

A spokeswoman for Merck, Sharp & Dohme, manufacturers of rofecoxib, told The Journal on April 11 that the study compared rofecoxib's highest dose for osteoarthritis with celecoxib's lowest dose. In addition, the oedema endpoint was assessed using a non-validated technique, with no baseline measurements. The potential for changes in renal function, including sodium retention, oedema and increased blood pressure was reflected in the prescribing information for rofecoxib, celecoxib and other non-steroidal anti-inflammatory drugs, she said.

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H pylori eradication and GI bleeding: new findings

Eradication of Helicobacter pylori is as effective as omeprazole in preventing recurrent upper gastrointestinal (GI) bleeding in patients taking low-dose aspirin, according to Dr Francis Chan (Chinese University of Hong Kong) and colleagues. However, they say that in suscepible long-term users of other non-steroidal anti-inflammatory drugs (NSAIDs), eradication of H pylori alone is not sufficiently preventive.

Four hundred patients with H pylori infection who had had an upper GI bleed were given omeprazole 20mg daily for eight weeks to promote ulcer healing. Once the ulcers were healed, patients with coronary heart disease or stroke were given aspirin 80mg daily and those with arthritis were given naproxen 500mg twice daily, for six months. Each group of patients was then randomly assigned to receive either omeprazole 20mg daily for six months or a one-week course of eradication therapy (bismuth subcitrate 120mg, tetracycline 500mg and metronidazole 400mg) given four times daily.

The researchers say that omeprazole was superior to H pylori eradication at preventing recurrent bleeding in patients taking naproxen. They suggest that in long-term users of NSAIDs other than aspirin, ulcers might be induced by NSAIDs rather than by H pylori infection, whereas, H pylori might need to be present for aspirin to induce substantial GI bleeding. They further comment that, in light of the increasing use of aspirin for cardiovascular prophylaxis, patients at risk of bleeding from ulcers should be tested for H pylori infection and treated if it is found. The study is published in the New England Journal of Medicine (2001;344:967).

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Bisphosphonates for parasitic diseases?

Bisphosphonates, currently used to treat osteoporosis, might form the basis of treatment of parasitic diseases in the future, say researchers. A team of scientists from the United Kingdom, America and Venezuela have found that, in vitro, this class of drugs appears to kill Plasmodium falciparum, Leishmania and Toxoplasma gondii. The researchers are now testing the efficacy of the drugs in animals and say that results to date have been promising. Journal of Medicinal Chemistry (2001;44:909).

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Paroxetine reduces depression induced by interferon-alfa

Pretreatment with paroxetine minimises depression induced by interferon-alfa, an American study has shown. It also reduces interferon-alfa-associated symptoms of anxiety and neurotoxicity, and decreases the incidence of major depression linked with high doses, the researchers say.

Dr Dominique Musselman (Emory University School of Medicine, Atlanta) and colleagues randomly assigned 40 patients with malignant melanoma to receive either placebo or paroxetine 10mg daily (one tablet) for one week, followed by 20mg daily thereafter, two weeks before initiation of treatment with interferon-alfa 2b. Two weeks after starting interferon-alfa 2b therapy, the dosage of paroxetine (or placebo) could be increased up to four tablets per day. The researchers found that in the paroxetine group, two patients developed major depression, compared with nine in the placebo group.

Severe depression necessitated discontinuation of interferon alfa-2b in one patient in the paroxetine group compared with seven patients taking placebo. They suggest that paroxetine might enhance endogenous feedback pathways that regulate the production of cytokines such as interferon-alfa. The study is published in the New England Journal of Medicine (2001;344:961).

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QT prolongation and the menstrual cycle

Women are particularly prone to drug-induced QT interval prolongation during the first half of their menstrual cycle, say researchers from the United States.

Dr Ignacio Rodriguez and colleagues (Georgetown University Medical Centre, Washington DC) gave infusions of an antiarrhythmic drug, known to cause QT prolongation, to 20 healthy women during menses, ovulation and the luteal phase of their menstrual cycle. They found that low progesterone levels were associated with an increase in mean corrected QT but there was no correlation with estradiol levels. The researchers say that women had the greatest corrected QT response during the menstrual and ovulation phases of their cycle. High progesterone levels may have a protective effect, they add.

“Physicians caring for patients who are receiving drugs with potential actions on cardiac repolarisation currents should closely monitor the QT interval and beware of other risk factors for the development of torsades de pointes,” they say (JAMA 2001;285:1322).

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