May 17, 2013
In what they say is the first UK randomised controlled trial of pharmacist prescribing, UK researchers have concluded that there may be benefits for people with chronic pain from pharmacist prescribing, and that larger trials are now needed. The authors comment that despite the increasing number of pharmacists and other non-medical prescribers, rigorous outcome comparisons are lacking.
The trial assigned 196 patients from six practices with prescribing pharmacists in England and Scotland, all of whom used repeat prescriptions for pain medication (excluding certain groups such as those serious mental illness), to three groups at random - two groups received pharmacist medication review, with and without pharmacist prescribing (the former with a face to face consultation; the lattter with feedback to the GP), and one group received treatment as usual. One of the reasons for this exploratory trial was to select the best outcome measures for a larger multi-centre trial - four were used here, including both pain and generic health outcome measures.
The authors highlight the paucity of the evidence base for pharmacist prescribing using validated outcome measures, rather than the reported experiences of healthcare professionals and patients. The results suggest that pharmacist prescribing, and perhaps pharmacist medication review alone, is “feasible, acceptable and may lead to improvements in pain and other measures”, conclude the authors.
Bruhn H et al. Pharmacist-led management of chronic pain in primary care: results from a randomised controlled exploratory trial. BMJ Open 2013;3:e002361
May 17, 2013
Nurses in a London emergency department were providing appropriate medication under the different mechanisms of independent nurse prescribing and Patient Group Directions (PGDs), with some notable differences, according to this cross-sectional review.
The researchers reviewed notes from 617 episodes of care, 382 using independent nurse prescribing and 235 using PGDs. Analysis of the results revealed more frequent prescribing by the prescribing nurses, with appropriate medication given in all but one case (where penicillin was prescribed for an allergic patient, highlighting the importance of history-taking). All medications received by patients in the PGD group were appropriate, although documented less consistently, but over 10% were not covered within the PGD - it was not clear how a prescription was obtained for these from the patient notes. This highlights the limitations of PGDs. The nurses in this department managed a wide range of conditions, with pain relief being the most common type of medication supplied.
Black A and Dawood M. A comparison in independent nurse prescribing and patient group directions by nurse practitioners in the emergency department: A cross sectional review. Int. Emerg Nurs 2013; published online 6 May.
May 17, 2013
Some rather ‘overexcited’ media coverage followed publication of a study in which antibiotic treatment of one particular type of chronic lower back pain was found to be more effective at one year than placebo in reducing back pain and disability, according to NHS Choices, which cautions that further research is needed and that the research certainly does not mean that everyone with lower back pain should be offered antibiotics.
All the patients in the trial had ‘Modic type 1 changes’ - signs of bone swelling in the lower back confimed with MRI scans - and had been in pain for six months or more after a slipped disc. The possibility that the swelling could be caused by bacterial infection and therefore treatable with antibiotics was tested in this randomised controlled trial. The NHS Choices commentary also highlights some limitations in the research.
May 17, 2013
NICE now expects to publish the new good practice guidance for patient group directions (PGDs) in June, it has announced, and some organisations have published information about their responses to the consultation, which closed at the end of April.
The Guild of Healthcare Pharmacists is recommending that pharmacy technicians be added to the list of professionals who can use PGDs, arguing that their clinical roles in the NHS have developed in recent years and that this would improve patients’ access to medicines. The Guild is clear that PGDs should only be used for “distinct patient episodes”, as otherwise they may end up being used for rare indications “as cover” by some providers that do not have a doctor or referral mechanism. This use of PGDs as a substitute for non-medical prescribing in these situations is not in patients’ interests.
Pharmacy Voice highlights what it sees as the benefits of PGDs, for example how community pharmacy NHS ‘flu vaccination services may help reach under-65 at risk groups. It argues that there have been only limited opportunities for community pharmacists to become independent prescribers, although service redesign does offer further potential.
May 17, 2013
NICE has issued several updates recently, including an update to the guidance on omalizumab, recommended as an additional treatment for severe persistent allergic asthma in adults and children over 6 who need continuous or frequent treatment with oral corticosteroids.
In the ‘Evidence summaries: new medicines’ series, there are summaries on the use of lisdexamfetamine dimesylate in children and young people with attention deficit hyperactivity disorder, linaclotide for irritable bowel syndrome with constipation in adults, and lurasidone for schizophrenia, among others.
In the ‘Evidence summaries, unlicensed/off-label medicines‘, series, new entries include modafinil for fatigue in multiple sclerosis, and oral desmopressin for nocturia and nocturnal polyuria in men with lower urinary tract symptoms.