Saturday 14 February 2009

Shock news!

You will not be startled to learn the results of the DART-AD trial.

The reason why we've Prescription Only Medicine (POM) is that it's thought to be, ". . . those preparations that are available only on a prescription issued by an appropriate practitioner."

It's the proper stuff. Stuff with risks and benefits. Stuff with real consequences (both good and bad). Rather than Over The Counter (OTC) medicine which anyone can get, over the counter, from a chemist, POM tends to be medication where risks, side effects, treatment emergent adverse events, monitoring, serious interactions or other elements of how the drug works needs careful thought and judgement made.

Hence the legal requirement for not just advice, not just safety netting and input from a manager or a scientist, these proper drugs require, "an appropriate practitioner."

A good turn of phrase, that. "An" suggests one, which pleases me. One GP (not polyclinics and walk in centres). One psychiatrist (not fractured models of a Community one, an Early Intervention one, a Crisis Resolution one, an Inpatient one, a Rehabilitation one etc etc). Optimistic, I know, but having one GP and one Consultant is a model I'm thoroughly wedded to.

"Appropriate" is a handy word, meaning that it's not just a practitioner, it's got to be an appropriate one. The pharmacist in my team's clear on what this means. It means someone who can make valid, rational prescribing decisions. Although, as a pharamcist, there's expertise in the drug's use and interactions, pharmacists don't do out-patient clinics so don't get to see all the consequences of medication used, so don't feel they're experts at prescribing. Sensibly, my pharmacist sees herself as a resource to inform on decisions (and explain medication issues to patients, and manage the governance systems around medicines management), she doesn't see herself as an "appropriate" prescriber.

The word "practitioner" is salient, too. It implies a need for someone in practice, someone practising clinical care. So not just someone who knows a lot about drugs, then. If asked, "Of the last 50 patients you gave advice on medication to, how many had no side effects (and you've documented that), and how many had side effects (which you've documented)?" a "practitioner" should be in a position to answer that, someone just giving advice couldn't. And if that someone's giving prescribing advice but not seeing the consequences of their clinical practice, then I'd suggest they're not "an appropriate practitioner" so should not be issuing prescriptions for Prescription Only Medicine.

Rant over.

POM are medicines that we shouldn't be cavalier with. They're drugs which have real effects, so often need judicious consideration on initiating, continuing, monitoring and withdrawing them.

Which brings me to this study. It's a good study. It's funded by the UK Alzheimer's Research Trust, not a drug company. It's a study that was conducted over an appropriate length of time. Each treatment arm was of a decent size. It's a very relevant research topic.

They looked at folk with Alzheimer's disease, for up to 3 years. They found that patients without antipsychotic medication lived longer than patients with antipsychotic medication. Shock news!

I'm ambivalent about this study, really. On the one hand, it's a well executed bit of credible research that's about a contentious and relevant theme. On the other hand, is it necessary?

In patients with crashing heart failure, with fluid pouring into their lungs, the dread and feeling of drowning, the weakness, then death, life isn't great. Diamorphine can be used to reduce the ghastly symptoms. Diamorphine causes respiratory depression. Stops you breathing. In a patient who's lungs are filling with fluid, reducing their breathing isn't a strategy conducive to a long life. But it's done, rightly, even though life may be shortened, because the clinical condition warrants this palliative care. Is a study necessary to show us that, in heart failure, patients dying without diamorphine live fractionally longer than patients on diamorphine? Probably not. We know diamorphine is a proper drug, a medicine with benefits and side effects that need to be weighed by "an appropriate practitioner."

The DART-AD trial shows us that antipsychotics generate risk in Alzheimer's Disease patients. Although my gut reaction is, "And?!" I do s'pose it's useful to have a well executed study evidencing that what we knew to be the case is actually the case.

So is there anything from this which will change my clinical practice? No. But it's good to know that what I thought (that the drugs were dangerous) is true, and decisions around their use should be very carefully throught through by senior clinicians with expertise in this area.


Gus said...

I don't much care for pedantry but sometimes I just can't resist it.

A 'practitioner' would know that in crashing heart failure, diamorphine reduces preload to the heart and increases survival significantly.

Wholeheartedly agree though.

The Shrink said...

Meh, you've got me :)