MeReC Monthly No. 23: Reducing the use of antipsychotic drugs in dementia, Selective outcome reporting identified in industry-sponsored trials of gabapentin, Hospital and primary care prescribing of ‘NICE appraised’ and ‘low cost’ medicines, What’s new on NPCi?

The UK Government has accepted the findings and recommendations of an independent report¹ on prescribing of antipsychotics in people with dementia. The report identifies an unacceptable level of people with dementia dying as a result of being prescribed an antipsychotic. There is clear evidence that antipsychotics are currently being over prescribed. Alternative non-pharmacological approaches to dealing with anxiety and behavioural problems are available and should be used.

Action
Healthcare professionals should follow the NICE/SCIE guideline on dementia for the management of non-cognitive symptoms and behaviour that challenges. In line with this guidance, antipsychotic drugs should be prescribed only when a person is a risk to themselves or others, and where all other methods have been tried. This should be for a short period of three months only, while a care plan is put in place.

Prescribers should note that risperidone^▼ is the only antipsychotic indicated for a behavioural problem in people with dementia, i.e. short-term treatment (up to six weeks) for persistent aggression in patients with moderate to severe Alzheimer’s dementia.

NICE has developed an audit support tool for assessing the use of medications and non-pharmacological interventions for non-cognitive symptoms, behaviour that challenges and behavioural control in people with dementia.

Why is action necessary?
The report¹ identifies limited benefits and significant harms in treating behavioural symptoms of dementia with antipsychotics. It estimates that there are 180,000 people with dementia treated with antipsychotic medication in England per year. Of these, up to 36,000 may derive some benefit from treatment but, as a result of antipsychotic treatment, an additional 1,800 may die and an additional 1,620 may suffer a cerebrovascular adverse event (around half of which may be severe) per year. The report suggests that if support was available to provide alternative methods of managing behavioural problems, prescribing of antipsychotics could be reduced by two-thirds in people with dementia.

What is proposed?
The report¹ includes a list of recommendations for prioritisation, improvements in leadership, audit, training of staff and improvements in the services offered to people with dementia. All of these recommendations have been accepted by the UK Government and, if adopted, will facilitate a reduction in the unnecessary prescribing of antipsychotics to people with dementia. For details see the full report that was considered in MeReC Stop Press Blog No. 847.

Further information on the management of dementia can be found on the relevant floor of NPCi. This includes a patient decision aid to assist healthcare professionals in consultations with patients with dementia (and their family/carers) for whom treatment with an antipsychotic is being considered for the treatment of behavioural and psychological symptoms of dementia.

Selective outcome reporting identified in industry-sponsored trials of gabapentin

A study has found evidence of selective outcome reporting in industry-sponsored reports of randomised trials of off-label use of gabapentin.¹ For eight of the twelve published trials, the primary outcome differed from that described in the original protocol. Trials that presented findings that were not significant for the protocol-defined primary outcome were either not reported in full or were reported with a changed primary outcome.

Action
Healthcare professionals should be aware of reporting bias and base their prescribing decisions on evidence-based information from organisations with a public sector ethos such as NICE, CKS, SIGN, Cochrane, CRD, Clinical Evidence, DTB and the NPC. It is important not to merely rely on the claims made in individual publications or reports, but to consider the entire body of evidence.

Hospital and primary care prescribing of ‘NICE appraised’ and ‘low cost’ medicines

The NHS Information Centre has issued a report¹ on the use of medicines in hospitals in 2008 and compares their use in primary care. The report includes a table focusing on medicines positively appraised by NICE as well as comparing use of ‘low cost’ medicines, which are subject to Better Care, Better Value Indicators, between Strategic Health Authorities.

Action
Although the data have many limitations, the report provides useful information for service providers who may wish to assess their prescribing of these medicines.

The NPC has produced National Support Materials (available on NPCi) for the Better Care, Better Value Indicators (statins, proton-pump inhibitors [PPIs] and renin-angiotensin [RAS] drugs). These materials include online and downloadable resources, and cover policy and guidance, therapeutics, and implementation and monitoring at a local level.

What did the report find?
The overall NHS expenditure on medicines in 2008 was £11.6 billion, with hospital use accounting for 28.7% of the total cost, up from 25.8% in 2007. The cost of medicines rose by 3.4% overall but by 15.2% in hospitals. Of those medicines positively appraised by NICE, the greatest overall cost within the NHS was for atorvastatin (total estimated cost about £340 million, with £334 million in primary care), but etanercept incurred the greatest cost in hospitals (total estimated cost about £152 million with £145 million in hospitals).

The report identified considerable variation among Strategic Health Authorities in both primary care and in hospitals with regard to the proportion of lower cost statins, PPIs and RAS drugs (i.e. ACE inhibitors plus angiotensin-2 receptor antagonists) prescribed. For example, the prescribing costs for ACE inhibitors ranged from 28.1% (London) to 39.3% (North East) as a proportion of the overall RAS drug costs in primary care. In hospitals, this proportion ranged from 35.5% (Yorkshire and the Humber) to 60.4% (North East). Other, more recent data (Figure 1) demonstrates the wide distribution in the proportions of ACE inhibitors prescribed across individual practices in England.

Figure 1. Variation in RAS drug prescribing (items) at practice level (year to September 2009). Figure prepared with data kindly supplied by, and with the permission of, NHSBSA Prescription Services

We have added and updated some new resources on the therapeutics section of NPCi recently — why not take a look?

New floors
Three new floors in the information mastery suite, which complement the existing Information mastery 2 – skills floor, and one on wound management have been opened. The new floors currently have <60 minute eLearning events and extra resources are being prepared.

Information mastery 1 – overview: How can busy practitioners keep up to date with the evidence and use it to make better decisions with their patients? This floor provides a summary of the philosophy of the three elements of information mastery and how this can help busy practitioners practice modern evidence-based healthcare.

Information mastery 3 – making decisions better: More depth on the psychology of how humans (including health professionals) really make decisions, and how we can make decisions better, even with our busy everyday lives.

Wound management: This floor contains sections covering general aspects, pressure ulcers, leg ulcers and management of the diabetic foot.

The National Institute for Health and Clinical Excellence (NICE) is associated with MeReC Publications published by the NPC through a funding contract. This arrangement provides NICE with the ability to secure value for money in the use of NHS funds invested in its work and enables it to influence topic selection, methodology and dissemination practice. NICE considers the work of this organisation to be of value to the NHS in England and Wales and recommends that it be used to inform decisions on service organisation and delivery. This publication represents the views of the authors and not necessarily those of the Institute.

NPC materials may be downloaded / copied freely by people employed by the NHS in England for purposes that support NHS activities in England. Any person not employed by the NHS, or who is working for the NHS outside England, who wishes to download / copy NPC materials for purposes other than their personal use should seek permission first from the NPC.
Email: copyright@npc.nhs.uk Copyright 2010

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