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Letters to the Editor
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Prescribing
Drug and Therapeutics Bulletin — muddying the water
From Mr N. J. Staunton, MRPharmS
The PJ recently reported on a Drug and Therapeutics Bulletin which was
rather critical of the use of modified
release (MR) dipyridamole (PJ,
16 July, p74). The Drug and Therapeutics Bulletin has yet again taken
a stance which seems totally out of kilter with clear recommendations
for the use of MR dipyridamole from the two nationally recognised and
endorsed bodies, the National Institute for Health and Clinical Excellence
(NICE) and the National Prescribing Centre (NPC).
NICE guidance says: “The combination of modified-release (MR) dipyridamole
and aspirin is recommended for people who have had an ischaemic stroke
or a transient ischaemic attack for a period of two years from the most
recent event.”1 This advice is endorsed by the NPC’s MeReC
Bulletin of July 2005”.2
I have read the Drug and Therapeutics Bulletin avidly for many years
now but increasingly find that it is negative about almost every drug
launched in living memory.
In order for national drug reviews to be credible it seems fairly logical
that sometimes they should say “yes” and sometimes they should
say “no” (presumably not every new drug is a wonder drug
or totally useless). I believe this is one of the reasons why the Scottish
Medicines Consortium is so well respected, whereas NICE (which pre-2005
seemed to say yes to every drug) has had significant problems.3–5
Both NICE and the NPC now say yes to some drugs and no to others and,
in my view, both individually trump the Drug and Therapeutics Bulletin.
When NICE and the NPC both endorse the use of MR dipyridamole plus aspirin
that is certainly good enough for me. I only wish that the Drug and
Therapeutics Bulletin would work with these national bodies instead of continually
muddying the water.
Noel Staunton
Isle of Wight
References
1. National Institute for Health and Clinical Excellence. Guidance
on vascular disease — clopidogrel and dipyridamole No 90 — May
2005. National Institute for Clinical Excellence, 2005.
2. MeReC Bulletin 2005;15, No 6.
3. Wathen B, Dean T. An evaluation of the impact of NICE guidance on
GP prescribing. British Journal of General Practice 2004;54:103–7.
4. Ryan J, Piercy J, James P. Assessment of NICE guidance on two surgical
procedures. Lancet 2004;363:1525–6.
5. Sheldon TA, Cullum N, Dawson D, Lankshear A, Lowson K, Watt I, et
al. What’s the evidence that NICE guidance has been implemented?
Results from a national evaluation using time series analysis, audit
of patients’ notes, and interviews. BMJ 2004;329:999.
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IKE IHEANACHO, editor, and PAUL MCMANUS, associate editor, Drug
and Therapeutics Bulletin, respond:
Recommendations on the addition of MR
dipyridamole to aspirin for the secondary prevention of stroke hinge
on interpretation of one trial, the European Stroke Prevention Study
2 (ESPS-2).1 This study suggested a marginal advantage with the use
of such combination therapy in preference to either drug alone. Crucially,
other studies have found no benefit in adding standard-release dipyridamole
to aspirin.2 Whether the difference in formulation is sufficient to
account for these different outcomes is, we believe, worthy of further
investigation, a view shared by the NPC in its review of antiplatelet
agents for stroke patients, which states “more studies are needed
to confirm whether adding MR dipyridamole to aspirin is beneficial”.3 In the absence of such studies, we believe that aspirin alone remains
the first-choice antiplatelet therapy for patients with a history of
stroke or transient ischaemic attack. This view is consistent with that
of other bodies that have issued guidance since publication of ESPS-2,
including the Scottish Intercollegiate Guidelines Network,3 the NPC,4 the New Zealand Guideline Group5 and the Royal College of Physicians
Intercollegiate Stroke Working Party.6
This conclusion on dipyridamole might invite questions about how Drug
and Therapeutics Bulletin assesses medicines and other treatments.
For over 40 years, the publication
has provided practice-centred advice, based on rigorous assessment and synthesis
of evidence, including opinions from a wide range of specialist and generalist
commentators, and published independently of industry, government, regulatory
authorities and the medical establishment. For us to recommend a therapeutic
intervention, we have to be convinced that it offers patients clear advantage
over longer-established options, for example, with regards to efficacy, safety
or patient convenience. It is not surprising, therefore, that, at times,
we disagree with other bodies, who may use different criteria in assessing
the
same interventions.
The claim that the Drug and Therapeutics Bulletin is “negative about
virtually every drug launched in living memory” is at odds with reality.
It ignores, for instance, our early calls for NHS-wide access to combination
antiretroviral therapy for HIV infection, sildenafil for erectile dysfunction
and mucolytics for chronic obstructive pulmonary disease. It is further undermined
by, for example, recent Drug and Therapeutics Bulletin recommendations on insulin
analogues in diabetes mellitus, epoetins in cancer-related anaemia and tumour
necrosis factor antagonists in ankylosing spondylitis. On other occasions,
we have exposed fundamental weaknesses in the arguments for using medicines
such as zanamivir, COX II inhibitors, sibutramine, Yasmin and Cerazette. In
addition, Drug and Therapeutics Bulletin articles and events have stimulated
wider changes in policy or practice in areas such as licensing of medicines
for children, greater use of generic drug names, and the safe use of medicines
in schools, while our series of articles on drugs for the doctor’s bag
has become standard advice.
The accusation that the Drug and Therapeutics Bulletin is “continually
muddying the water” lacks evidence and, therefore, credibility.
References
1. Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A.
European Stroke Prevention Study 2. Dipyridamole and acetylsalicylic
acid in the secondary
prevention of stroke. J Neurol Sci 1996; 143: 1–13.
2. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis
of randomised trials of antiplatelet therapy for prevention of death, myocardial
infarction, and stroke in high risk patients. BMJ 2002;324:71–86.
3. Scottish Intercollegiate Guideline Network. Management of patients with
stroke. SIGN 13. Edinburgh, 1997.
4. Antiplatelet agents for stroke patients. MeReC Bulletin 2003;14:5–8.
5. New Zealand Guidelines Group. Life after stroke. New Zealand guideline
for management of stroke. Wellington, 2003.
6. Intercollegiate Stroke Working Party. National clinical guideline for
stroke. Second edition. London: Royal College of Physicians, 2004. |
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