Medication changes implemented during medication reviews and deprescribing
A new study published in the British Journal of Clinical Pharmacology has aimed to provide post-hoc analyses of a clinical trial that reported beneficial effects of medication reviews on health-related quality of life. Specifically, to describe the medication changes with a focus on deprescribing, and to explore patient- and medication-related factors that may identify patients most likely to benefit from medication reviews.
Post-hoc analyses of data from a pragmatic, non-blinded, randomised clinical trial investigating a medication review intervention (NCT03911934) in 408 geriatric outpatients treated with ≥9 medicines. In the medication review group (n=196), 26% of the medicines prescribed at baseline were discontinued with 82% still being discontinued after 13 months.
The most common reason for discontinuation was lack of indication (72% of discontinuations). The medicines most often discontinued in the medication review group compared with usual care included: metoclopramide (11/15=73% discontinued vs 1/12=8% in usual care), acetylsalicylic acid (20/48=42% vs 2/47=4%), simvastatin (18/48=38% vs 2/58=3%), zopiclone (23/59=39% vs 4/54=7%), quinine (9/14=64% vs 6/16=38%), citalopram (4/18=22% vs 0/20=0%), and tramadol (18/37=49% vs 8/30=27%).
Factors associated with number of deprescribed medicines included: number of prescribed medicines, Drug Burden Index, patient motivation for medicine changes, and prescriptions of metoclopramide, iron preparations, antidepressants other than Selective serotonin reuptake inhibitors (SSRIs), Non-steroidal anti-inflammatory drugs (NSAIDs) or drugs for urinary incontinence.
Physician-led medication reviews resulted in persistent deprescribing of medicines in older polypharmacy patients treated with ≥ 9 medicines. Motivation for having their medicine changed, treatment with more medicines, and a higher burden of sedative and anticholinergic medicines characterized the patients most likely to benefit from physician-led medication reviews. The most frequent medicine change was discontinuationdue to lack of indication and most of the discontinued medicines were medicines that may cause adverse effects in older patients. A higher number of medicines, higher sedative and higher anticholinergic burden of the medicines, if the patient was motivated for medicine changes orhada prescription of metoclopramide, an iron preparation, other antidepressant(i.e. not selective serotonin reuptake inhibitors), non-steroid anti-inflammatory drug, ordrug for urinary frequency and incontinence were allassociated witha highernumber of deprescribed medicines.
It is concluded that these patient- and medication-related factors could aidinidentifying patients that will benefit most from medication reviews.
Crackdown on rogue firms targeting children with free vapes
A loophole that allows the vaping industry to give free samples of vapes to children in England is set to be closed under new plans announced by the Prime Minister. Recent NHS figures for 2021 showed that 9% of 11 to 15 year old children used e-cigarettes, up from 6% in 2018.
Selling vapes to under 18s is illegal, however the recent rise in teenage usage of vapes and the recent surge in the use and promotion of cheap, colourful products that businesses are targeting children, which has prompted the action to crack down on this. The government has also announced today that there will be a review into banning the vaping industry selling ‘nicotine-free’ vapes to under 18s. This will ensure our rules keep up with the way that vaping products are being used.
The news comes as the Prime Minister and Chief Medical Officer visited Kent Scientific Services in West Malling where e-cigarettes can be analysed for their content, to ensure manufacturers are complying with government regulations.
Manufacturers must notify the Medicines and Healthcare Regulatory Agency (MHRA) before vape products are placed on the market, including disposables. The MHRA has recently taken steps to improve their notification processes and crack down on non-compliant vapes. Chief Medical Officer Professor Chris Whitty said:
‘While vaping can be an effective quitting tool for smokers, it is important that non-smokers are not encouraged to start vaping. There has been a particularly worrying rise in the number of children using vapes, with companies clearly marketing these products at children using colours, flavours and cheap disposable options.
‘Closing the loophole that allows companies to give out free samples of vaping products to under 18s is a very welcome step in tackling some of the harms caused by the vaping industry.’
Rabies: the green book, chapter 27 updated May 2023
Rabies: the green book, chapter 27 has been updated to include changes to categories of exposure, post-exposure treatment, and advice relating to immunosuppressed individuals; updated contact details for specialist advice; and removal of Sanofi Rabies BP due to discontinuation.
Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The disease may be caused by rabies virus genotype 1 (classical rabies) or less commoly by rabies-related lyssaviruses.
The presentations are clinically indistinguishable. Rabies-related lyssaviruses implicated in human disease include European bat lyssaviruses (EBLVs) and Australian bat lyssavirus (ABLV).
On rare occasions, transmission of the virus has occurred through bodily fluids from an infectious animal coming into contact with an individual's mucous membranes.
Exposure through mucous membranes has a low probability of infection but must be managed as a significant event. Infection does not occur through intact skin.
Virus is present in some tissues and fluids of humans with rabies, but person-to-person spread of the disease has not been documented other than in exceptional circumstances.
Cases have occurred rarely outside the UK through corneal grafts and other transplanted tissues taken from individuals with rabies.
There is currently one rabies vaccine licensed for intramuscular use in the UK – purified chick embryo cell rabies vaccine (PCEC, 2.5 IU/ml) (Rabipur®).
Rabies Vaccine BP (human diploid cell vaccine) was discontinued in August 2022.
Other WHO approved cell culture-derived vaccines are available in other countries and may contain different concentrations of rabies antigen.
The UK licensed products (Rabipur®) contains 2.5IU rabies antigen in a 1ml dose; other products should be used as recommended by the manufacturer.
145 000 people in England to have further treatment choice for preventing migraine attacks, says NICE
In final draft guidance published on 31 May 2023, NICE has for the first time recommended an oral treatment for preventing migraines.
Rimegepant (Vydura made by Pfizer) is recommended as an option for preventing episodic migraine in adults where at least three previous preventive treatments have failed, opening the way for up to 145 000 people to choose it on the NHS in England.
Episodic migraine is where a person has fewer than 15 migraine days each month. The draft guidance recommends rimegepant for adults who have at least four migraine attacks per month but less than 15. The clinical trial evidence shows that rimegepant works better than a dummy treatment for reducing the number of episodic migraines in people who have already tried three preventive treatments.
Over 5.6 million people in England are thought to have episodic migraines in England and it is estimated around 190 000 migraine attacks are experienced every day in England. Rimegepant is taken as a wafer which dissolves under the tongue. It works by stopping the release of a protein around the brain called calcitonin gene-related peptide (CGRP). CGRP causes intense inflammation in the coverings of the brain (the meninges) and is responsible for the severe pain associated with migraine attacks.
Helen Knight, Director of Medicines Evaluation at NICE, said: ‘Each year the lives of millions of people in England are blighted by migraine attacks. They can be extremely debilitation and can significantly affect a person's quality of life. In comments received during consultation on the previous draft guidance, patients and carers described migraine as an invisible disability that affects all aspects of life including family, social activities, mental health, finances and education.
‘Rimegepant is the first oral treatment for migraine to be recommended by NICE and for many thousands of people it is likely to be a welcome and more convenient addition to existing options for a condition that is often overlooked and undertreated. Today's draft guidance demonstrates our commitment to focusing on what matters most and getting the best care to people while ensuring value for the taxpayer.’
Current treatment options for preventing migraine include drugs that are used for treating other conditions, such as beta-blockers, antidepressants and epilepsy medications.
These treatments can have significant side-effects and can be ineffective for some people. Treatments offered after these have been tried include NICE-recommended erenumab, fremanezumab or galcanezumab, all of which are given as injections.
The draft guidance says if rimegepant is considered to be 1 of a range of suitable treatments, after discussing the advantages and disadvantages of all the options, the least expensive should be used.
Registered consultees, including the company and patient and professional groups, now have the opportunity to appeal against the draft guidance. If no appeals are received final guidance is expected to be published next month.