Safety
Use of both the generic and proprietary names
From Professor D. H. Cousins, MRPharmS
In the letter from Bruce
Burnett and Uttamlal Chouhan (PJ, 22 September,
p326) the National Patient Safety Agency’s “Rapid response
report 2”, concerning risks with confusing different formulations
of intravenous amphotericin, was highlighted. The authors indicate that
one way of reducing the risk of prescribing and administration errors
is to prescribe by brand name.
The information in the NPSA report does not actually recommend this.
The report alerts users of the potential risks of wrong dosing with different
formulations of amphotericin injection and recommends that health care
organisations undertake an immediate risk assessment of amphotericin
products and procedures in accordance with NPSA’s “Patient
safety alert 20: promoting safer use of injectable medicines” and
take action to reduce the risks.
Background information concerning the rapid response report is available
on the NPSA’s website
In
a section listing potential action to reduce risks with amphotericin
injections,
health care organisations are recommended
to review local systems and consider actions to reduce areas where risks
exist. Safer practice recommendations based on guidance issued by the
Institute of Safe Medication Practice Canada following similar incidents
are listed for local consideration.1
ISMP Canada recommends: “When prescribing, communicating and dispensing
amphotericin products use both the complete generic name and the proprietary
name: ‘non-lipid amphotericin (Fungizone)’ or ‘liposomal
amphotericin (AmBisome)’ or ‘lipid complex amphotericin (Abelcet)’.”
I hope this helps to clarify the information presented in the NPSA report.
The use of both the generic and proprietary names for certain products may
help to minimise miscommunication in practice. David Cousins
Head of Safe Medication Practice
National Patient Safety Agency
References
1. Institute For Safe Medication Practices Canada. Safety Bulletin.
Warning: prevent mix-ups between conventional amphotericin B (Fungizone)
and
lipid based amphotericin B products (Ambisome and Abelcet). Institute
For Safe Medication Practices Canada. June 2002, volume 2, issue
6.
Interaction between paracetamol and coffee taken out of context
From Dr G. Brandon
The recent newspaper reports of an interaction between paracetamol and
coffee are another example of science being taken out of context by the
lay media.
The research, reported in Chemical Research in Toxicology (26
September 2007) is a nice piece of protein chemistry which showed that
caffeine binds
to the same site on the cytochrome P450 enzyme as does paracetamol, therefore
slowing its oxidation. This work was done in Escherichia coli cells with
large amounts of caffeine used to swamp the P450 enzyme.
We contacted the principal author and he stressed to us that the concentrations
of caffeine used in this in vitro study were much greater than what would
be achieved by drinking coffee or taking caffeine-containing drugs.
The study has no relevance to the everyday use of paracetamol products,
including those with caffeine, or of taking paracetamol products with
coffee, despite the exaggerated headlines in many newspapers.
Geoffrey Brandon
Director
Paracetamol Information Centre
Cranberry juice and warfarin interaction
From Dr B. A. Warner, MRPharmS and others
In response to the letter from Alisdair
Thomson (PJ, 15 September, p291)
we are grateful for his comments and would like to make the following
points.
In March 2007 the National Patient Safety Agency issued “Patient
safety alert 18”, which describes nine recommendations to make
the use of anticoagulants safer. The NPSA worked closely with the British
Society
for Haematology, clinicians, patients and other stakeholders to develop
these recommendations, which have been generally well received by the
NHS. Part of this work included revising the information for patients
contained in the “yellow book”.
The issue of an interaction
between cranberry juice and warfarin was considered by the expert advisory
group, which included haematologists and other experts in the field.
The advice of the group was that the amount of cranberry juice reported
to cause a significant interaction with warfarin was too great to be
considered for inclusion.
Many other food and herbal products can also
potentially cause problems in anticoagulated patients and the advice
was to restrict those listed in the yellow book to those interactions
that were likely to cause significant clinical problems when consumed
in normal amounts. Cranberry juice was not considered to fall into
this category.
Recently further discussions have taken place between the NPSA and
the BSH on this topic and a decision has been reached that the wording
in
the yellow book is likely to be revised for future editions to include
reference to the Medicines and Healthcare products Regulatory Agency
and BNF advice [which recommend avoidance of cranberry juice].
Bruce Warner
Senior Pharmacist
National Patient Safety Agency
Rhona McLean
Consultant Haematologist
Sheffield Teaching Hospitals
Trevor Baglin
Consultant Haematologist
Addenbrooke’s Hospital,
Cambridge
Title and review of clinical paper may prompt inappropriate use of erythropoietin
From Mr R. A. Williams, MRPharmS, and Mr S. Pegler, MRPharmS
With reference to the news article “Deaths
among critically ill cut by epoetin alfa” (PJ, 22
September 2007, p318), we would suggest that the title and review of
the clinical paper (New England
Journal of Medicine 2007;357:965) is misleading and may prompt
inappropriate use of erythropoietin in critically ill patients.
The news article suggests that the trial demonstrates that patients treated
with erythropoietin have a greater increase in haemoglobin concentration
and a decrease in mortality, particularly in trauma patients.
The trial studied medical, surgical and trauma patients admitted to intensive
care. The primary end point was the percentage of patients receiving a
red-cell transfusion. Secondary end points were the number of red-cell
units transfused, mortality and the change of haemoglobin concentration
from baseline.
The study found no difference in the primary outcome but did report a reduction
in mortality in trauma patients who had been in intensive care for at least
48 hours. Although this benefit was only demonstrated in one sub-group
for a secondary end point, the authors emphasised this result when reporting
the trial and this emphasis is also given to the news coverage in the PJ.
As readers will be aware, results from sub-group analysis should be interpreted
extremely cautiously in trials in which the primary outcome has proved
non-significant. The implications for practice from this trial is that
the use of erythropoietin in all critically ill patients should be restricted
to prospective randomised, controlled trials, with independent examination
of fatal and non-fatal clinically important outcomes.
Readers may be interested in the contrast in coverage given to the same
trial by the BMJ (2007;335:537)
in an article titled “Erythropoietin
not recommended for most critically ill patients”. Furthermore, the
warning conveyed in its coverage endorses the findings of an early release
editorial in the journal of the Canadian Medical Association, based on
the findings from a meta-analysis of nine randomised, controlled trials
and a commentary on the use of in erythropoietin in critically ill patients
(available on the journal’s website). The editorial asks doctors
to be vigilant about the off-label use of erythropoietin to treat anaemia
in critically ill patients.
This is also covered by the BMJ in “Off-label
use of erythropoietin may be harmful, doctors told” (BMJ 2007;335:532). Roger Williams
Pharmacy Manager
Scott Pegler
Medicines Information Manager
Morriston Hospital,
Swansea NHS Trust |
The
Pharmaceutical Journal