Laxative use in adults with intellectual disabilities: development of prescribing guidelines

BACKGROUND

Constipation is overrepresented in people with intellectual disabilities. Around 40% of people with intellectual disabilities who died prematurely were prescribed laxatives. A quarter of people with intellectual disabilities are said to be on laxatives. There are concerns that prescribing is not always effective and appropriate. There are currently no prescribing guidelines specific to this population.

AIMS

To develop guidelines to support clinicians with their decision-making when prescribing laxatives to people with intellectual disabilities.

METHOD

A modified Delphi methodology, the RAND/UCLA Appropriateness Method, was used. Step 1 comprised development of a bespoke six-item, open-ended questionnaire from background literature and its external validation. Relevant stakeholders, including a range of clinical experts and experts by experience covering the full range of intellectual disability and constipation, were invited to participate in an expert panel. Panel members completed the questionnaire. Responses were divided into 'negative consensus' and 'positive consensus'. Members were then invited to two panel meetings, 2 weeks apart, held virtually over Microsoft Teams, to build consensus. The expert-by-experience group were included in a separate face-to-face meeting.

RESULTS

A total of 20 people (ten professional experts and ten experts by experience, of whom seven had intellectual disability) took part. There were five main areas of discussion to reach a consensus i.e. importance of diagnosis, the role of prescribing, practicalities of medication administration, importance of reviewing and monitoring, and communication.

CONCLUSIONS

Laxative prescribing guidelines were developed by synthesising the knowledge of an expert panel including people with intellectual disabilities with the existing evidence base, to improve patient care.

Clinical characteristics of people with intellectual disability admitted to hospital with constipation: identifying possible specific high-risk factors

BACKGROUND

People with intellectual disabilities (ID) die on an average 20 years earlier to the general population. They have higher rates of multimorbidity and polypharmacy. Around 25% of people with ID report chronic constipation. The England Learning Disabilities Mortality Review found that nearly 25% of deaths identified constipation as a long-term health problem. However, the likely risk factors for constipation related harm are poorly enumerated. We sought to identify possible specific high-risk factors by examining the clinical characteristics of people with ID admitted to hospital with constipation.

METHODS

Data of people with ID admitted with constipation in two general hospitals covering a population of 1.3 million from 2017 to 2022 were reported using the STROBE guideline for cohort studies. Collected data included age, gender, intellectual disability severity, recorded medication, presenting complaint and co-morbidities. The medication anticholinergic burden was calculated using the anticholinergic burden scale. Continuous variables were summarised by mean and standard deviation if normally distributed, with categorical variables summarised by the number and percentage in each category.

RESULTS

Of 46 admissions (males 52%), 57% had moderate to profound ID, 37% had epilepsy, 41% prescribed antiseizure medication (ASM) and 45% were on laxatives. Average age was 46 years. The anticholinergic burden score mean was 2.3 and median, one.

CONCLUSIONS

We can hypothesise that people with more severe ID, suffering from epilepsy and on ASM may be more at risk of developing severe constipation. Some admissions may be avoided with earlier use of laxatives in the community.

Chronic constipation in people with intellectual disabilities in the community: cross-sectional study

BACKGROUND

One-third to half of people with intellectual disabilities suffer from chronic constipation (defined as two or fewer bowel movements weekly or taking regular laxatives three or more times weekly), a cause of significant morbidity and premature mortality. Research on risk factors associated with constipation is limited.

AIMS

To enumerate risk factors associated with constipation in this population.

METHOD

A questionnaire was developed on possible risk factors for constipation. The questionnaire was sent to carers of people with intellectual disabilities on the case-loads of four specialist intellectual disability services in England. Data analysis focused on descriptively summarising responses and comparing those reported with and without constipation.

RESULTS

Of the 181 people with intellectual disabilities whose carers returned the questionnaire, 42% reported chronic constipation. Constipation was significantly associated with more severe intellectual disability, dysphagia, cerebral palsy, poor mobility, polypharmacy including antipsychotics and antiseizure medication, and the need for greater toileting support. There were no associations with age or gender.

CONCLUSIONS

People with intellectual disabilities may be more vulnerable to chronic constipation if they are more severely intellectually disabled. The associations of constipation with dysphagia, cerebral palsy, poor mobility and the need for greater toileting support suggests people with intellectual disabilities with significant physical disabilities are more at risk. People with the above disabilities need closer monitoring of their bowel health. Reducing medication to the minimum necessary may reduce the risk of constipation and is a modifiable risk factor that it is important to monitor. By screening patients using the constipation questionnaire, individualised bowel care plans could be implemented.

A review of adherence to nice criteria for initiation and continuation of treatment of dupilumab in atopic dermatitis

Introduction

Atopic dermatitis is a chronic, recurrently flaring, generalised skin condition that can be life-limiting, debilitating and isolating. A typical treatment pathway involves emollients and topical corticosteroids (first line), topical calcineurin inhibitors (second line), phototherapy (third line) and systemic immunosuppressant therapies (fourth line. Dupilumab is recommended by NICE1 as an option for treating moderate to severe atopic dermatitis in adults, only if the disease has not responded to at least one other systemic therapy, such as ciclosporin, methotrexate, azathioprine and mycophenolate mofetil, or these are contraindicated or not tolerated, and the company provides dupilumab according to the commercial arrangement. Dupilumab should be stopped at 16 weeks if the atopic dermatitis has not responded adequately i.e. at least a 50% reduction in the Eczema Area and Severity Index score (EASI, ranges from 0 to 72, with higher scores indicating greater severity) from when treatment started and at least a 4-point reduction in the Dermatology Life Quality Index (DLQI) from when treatment started.

Aim

To ascertain whether dupilumab (a payments by results excluded drug, commissioned by integrated care systems) was used in a teaching district general hospital according to the stated criteria within the NICE technology appraisal.

Methods

Patients prescribed and supplied with dupilumab for more than 16 weeks were identified and Dermatology letters were scrutinised by a pharmacy team member. Ethical review was not required as this was a service evaluation.

Results

Eighty-eight patients had received dupilumab and the records of 30 (mean age 44, range 18-73, 18 male) were reviewed. Most entries were from when NICE first approved dupilumab, though some were chosen from late 2021/early 2022. All but one had been on at least one prior systemic therapy. This one patient was admitted urgently with severe dermatitis and so was referred for dupilumab as it is quicker acting than immunosuppressant therapy and no need to wait for blood tests. One patient did not have a starting EASI score (under a tertiary hospital). Twenty-nine of the 30 patients experienced both the required 50% or more reduction in EASI score at the review meeting and the at least a 4-point reduction in DLQI. The one patient who did not respond had treatment ceased. At approximately week 16, for all patients the ASI score changed from a mean of 29.7 (range 3-66.7) to 3.6 (range 0-27.9), and DLQI from a mean of 18.9 (range 7-30) to 4.4 (range 0-28).

Discussion/Conclusion

This study found that all but one of 30 patients had been on prior systemic therapy, and all but one patient met the NICE criteria at the review period (treatment then ceased). This was a sample of approximately one-third of the patients who had received dupilumab. Acknowledging that the dupilumab NHS price is about £16,000 per patient per year, these reassuring results of NICE compliance have been shared with Dermatology. We recognise the limitations of a single centre, very small-scale study. We do not report prolonged follow up of patients in relation to any improvement in their atopic dermatitis other than what we observed documented in Dermatology letters at commencement and review of treatment.

References

1. National Institute for Health and Care Excellence. Dupilumab for treating moderate to severe atopic dermatitis. (Technology appraisal guidance 534.) 2018 Available from: https://www.nice.org.uk/guidance/ta534

A short survey on GP practices’ approach (structure and process) for managing sepsis

Introduction

Sepsis poses a challenge for general practice, and sepsis awareness raising amongst healthcare professionals is a priority, with general practices expected to have an identified sepsis lead who has updated staff.1 The Royal College of General Practitioners (RCGP) made sepsis a clinical priority to raise awareness of how appropriate GP action could have an impact.2 In September 2020, locality-based prescribing meetings were held focusing on sepsis. For the 2021/22 General Practice Prescribing Quality Scheme it was decided to ascertain what practices had in place to manage suspected sepsis.

Aim

To assess whether GP practices in Cornwall have the structure and processes in place to manage sepsis.

Methods

A pre-piloted paper survey, based on a literature review, was delivered to all practices. There were seven questions (mixture of closed questions and questions allowing expanded answers, and a free text comment option). The sepsis lead GP responded on behalf of the practice. Survey completion, along with completion of other elements of the Prescribing Quality Scheme, generated an incentive payment to practices. This service evaluation did not require ethical approval.

Results

Fifty-one of 57 (89%) surgeries responded. When asked if all practice staff were familiar with the terminology “Red Flag Sepsis’, 36 replied yes, 4 replied only clinical staff, and 11 no. Receptionist training on this topic had occurred in 33 practices, but not in 18. All 51 replied they had the necessary equipment readily available to assess patients with possible sepsis. As regards intravenous antibiotics routinely stocked in the practice, five had none, and for those that kept antibiotics it was a mixture of benzylpenicillin, ceftriaxone, cefotaxime or Tazocin. Thirty-seven were unable to take a blood culture prior to first dose of antibiotics for a patient with Red Flag Sepsis, including one highlighting such a patient would have immediate hospital referral. Fourteen answered yes to this question, including one also highlighting immediate hospital referral. Thirty-five practices had a safety-net resource aligning with NICE guidance3 for giving to adults, parents and carers being managed in the community, whilst ten said no and 5 clarified that they give verbal advice but no written information. Fifteen had implemented change in their practice that they would share with other practices though only 12 provided brief details. Free text comments generated themes around staff training, including administration of IV antibiotics by GPs, and whether practices should be taking blood cultures and associated practical issues.

Discussion/Conclusion

The RCGP states that ideally all staff in a sepsis aware practice will have had education about sepsis.2 We found this had not occurred in 18/51 (35%) practices, and in 11/51 (22%) practices staff appeared unfamiliar with the terminology “Red Flag Sepsis’. The issue of taking blood cultures (73% said they were unable to do this) generated concerns and further discussion with Microbiology colleagues is needed. Practices have identified actions to be taken subsequent to this survey. We recognise limitations of a small survey from late 2021 conducted in a single centre in England, possibly subject to social-desirability bias.

References

1. NHS England. CCG Improvement and Assessment Framework 2017/18: Technical Annex NHS England: Central Analytical team. Available from: https://www.england.nhs.uk/wp-content/uploads/2017/11/ccg-technical-annex-2017-18-v1-1.pdf

2. Royal College of General Practitioners. Sepsis toolkit [Internet]. Available from: https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/sepsis-toolkit.aspx

3. National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management. (NICE guideline 51). 2016. Available from: https://www.nice.org.uk/guidance/ng51

A retrospective observational study of the use of gastroprotection for patients on dual antiplatelet therapy

Dual antiplatelet therapy is recommended for secondary prevention of ischaemic events in coronary artery disease. Some patients, who may be at high bleed risk if other factors are present, should be considered for gastroprotection. In our survey, we assessed whether gastroprotection was prescribed for hospital inpatients, especially high-risk patients, who were receiving dual antiplatelet therapy at discharge, and the type of gastroprotection prescribed. We found that over 13 months, a total of 1,693 patient episodes were prescribed dual antiplatelet therapy at discharge, of which 71% also received gastroprotection. Of the patient episodes who were not prescribed gastroprotection, 46% (223/483) met the criterion of age as a risk factor for gastroprotection. A further 30 episodes met other risk criteria of certain concomitant drugs or prior comorbidity. There is a need among clinicians and pharmacy teams within the hospital for recognition and management of this opportunity to improve the care of these patients.

A retrospective observational study of the use of gastroprotection for patients on dual antiplatelet therapy in an acute trust in England

Introduction

Dual antiplatelet therapy (DAPT), a combination of aspirin and either clopidogrel, prasugrel or ticagrelor, is recommended for secondary prevention of ischaemic events (heart attack and stroke) in people with coronary artery disease. Patients taking DAPT may be at high gastrointestinal (GI) bleed risk if other factors (including advanced age, or concomitant use of medicines that are known to increase the risk of GI bleeds) are present. Such patients should be considered for gastroprotection e.g. a proton pump inhibitor (PPI) or H2 receptor antagonist.

Aim

To assess whether gastroprotection was prescribed for inpatients taking DAPT in a 750-bed acute hospital in England.

Methods

This was a retrospective analysis of existing data. Patient episodes involving prescription of DAPT upon discharge between April 2020 and April 2021 were extracted from the e-prescribing system (WellSky). Electronic records of the identified patient episodes were searched for co-prescription of either PPI or H2 antagonist. We also ascertained if patients on DAPT should have received gastro-protection using age 71 and over, and concomitant drugs as separate risk factors.

Results

Over this 13-month period there were 1693 patient episodes (mean age 72 years, 63% male) when DAPT was prescribed at discharge, of which gastroprotection was also prescribed in 1210 (71%). Of the 483 episodes when gastroprotection was not prescribed, 223 (46%) met the criterion of age as a risk factor for gastroprotection. There were a further 20 episodes of patients aged under 71 years not on gastroprotection but receiving an SSRI, NSAID, prednisolone, nicorandil or an anticoagulant.

Conclusion

We identified that gastroprotection was potentially missing in 243 (14%) of the total DAPT patient episodes. Though there is evidence for the use of PPIs reducing the risk of GI bleeding in patients treated with DAPT after percutaneous coronary intervention or acute coronary syndrome (1), studies have reported that gastroprotection has been missed in the at risk group (2). When considering newly initiated gastroprotection, various factors are considered e.g. any possible interaction with a PPI if one of the antiplatelets is clopidogrel. In addition, PPIs have adverse effects such as low sodium / magnesium, and this may be a reason for consideration of a H2 antagonist. Further work is required to make our prescribers and pharmacy team aware of the importance of considering gastroprotection for this patient cohort. The strength of this study is the extraction of data from our electronic prescribing system for a large cohort of patients prescribed specified antiplatelet medication. Our study has some potential limitations. First, it was conducted in a single centre in England; this might restrict the generalisability of our findings. Second, the retrospective nature of this study may introduce bias or other uncertainties. Third, we did not ascertain the indication for DAPT nor if patients came in on these drugs as opposed to being started during their admission. Fourth, we did not check risk factors for gastroprotection other than age and selected concomitantly prescribed drugs. Finally, we did not check if those not prescribed gastroprotection had significant contraindications other than electrolyte abnormalities.

References

(1) Guo H, Ye Z, Huang R. Clinical outcomes of concomitant use of proton pump inhibitors and dual antiplatelet therapy: a systematic review and meta-analysis. Front Pharmacol. 2021 Aug 2;12:694698.

(2) Sehested TSG, Carlson N, Hansen PW, Gerds TA, Charlot MG, Torp-Pedersen C, et al. Reduced risk of gastrointestinal bleeding associated with proton pump inhibitor therapy in patients treated with dual antiplatelet therapy after myocardial infarction. Eur Heart J. 2019;40(24):1963–70.

UK psychiatrists' experience of withdrawal of antipsychotics prescribed for challenging behaviours in adults with intellectual disabilities and/or autism

BACKGROUND

A high proportion of adults with intellectual disabilities are prescribed off-licence antipsychotics in the absence of a psychiatric illness. The National Health Service in England launched an initiative in 2016, 'Stopping over-medication of people with a learning disability [intellectual disability], autism or both' (STOMP), to address this major public health concern.

AIMS

To gain understanding from UK psychiatrists working with adults with intellectual disabilities on the successes and challenges of withdrawing antipsychotics for challenging behaviours.

METHOD

An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disability (estimated 225).

RESULTS

Half of the 88 respondents stated that they started withdrawing antipsychotics over 5 years ago and 52.3% stated that they are less likely to initiate an antipsychotic since the launch of STOMP. However, since then, 46.6% are prescribing other classes of psychotropic medication instead of antipsychotics for challenging behaviours, most frequently the antidepressants. Complete antipsychotic discontinuation in over 50% of patients treated with antipsychotics was achieved by only 4.5% of respondents (n = 4); 11.4% reported deterioration in challenging behaviours in over 50% of patients on withdrawal and the same proportion (11.4%) reported no deterioration. Only 32% of respondents made the diagnosis of psychiatric illness in all their patients themselves. Family and paid carers' concern, lack of multi-agency and multidisciplinary input and unavailability of non-medical psychosocial intervention are key reported factors hampering the withdrawal attempt.

CONCLUSIONS

There is an urgent need to develop national guidelines to provide a framework for systematic psychotropic drug reviews and withdrawal where possible.

General practitioners' and psychiatrists' attitudes towards antidepressant withdrawal

BACKGROUND

There has been a recent rise in antidepressant prescriptions. After the episode for which it was prescribed, the patient should ideally be supported in withdrawing the medication. There is increasing evidence for withdrawal symptoms (sometimes called discontinuation symptoms) occurring on ceasing treatment, sometimes having severe or prolonged effects.

AIMS

To identify and compare current knowledge, attitudes and practices of general practitioners (GPs) and psychiatrists in Cornwall, UK, concerning antidepressant withdrawal symptoms.

METHOD

Questions about withdrawal symptoms and management were asked of GPs and psychiatrists in a multiple-choice cross-sectional study co-designed with a lived experience expert.

RESULTS

Psychiatrists thought that withdrawal symptoms were more severe than GPs did (P = 0.003); 53% (22/42) of GPs and 69% (18/26) of psychiatrists thought that withdrawal symptoms typically last between 1 and 4 weeks, although there was a wide range of answers given; 35% (9/26) of psychiatrists but no GPs identified a pharmacist as someone they may use to help manage antidepressant withdrawal. About three-quarters of respondents claimed they usually or always informed patients of potential withdrawal symptoms when they started a patient on antidepressants, but patient surveys say only 1% are warned.

CONCLUSIONS

Psychiatrists and GPs need to effectively warn patients of potential withdrawal effects. Community pharmacists might be useful in supporting GP-managed antidepressant withdrawal. The wide variation in responses to most questions posed to participants reflects the variation in results of research on the topic. This highlights a need for more reproducible studies to be carried out on antidepressant withdrawal, which could inform future guidelines.

A structured programme to withdraw antipsychotics among adults with intellectual disabilities: The Cornwall experience

BACKGROUND

Antipsychotic medications are used among 19%-58% of adults with intellectual disabilities to manage challenging behaviour against the NICE guideline recommendations. Studies show that it is possible to completely withdraw antipsychotics in about one third of adults with intellectual disabilities and a dose reduction of 50% or more in another third.

METHOD

In Cornwall, over three years the present authors developed a structured pathway to withdraw antipsychotics among adults with intellectual disabilities which involved people with intellectual disabilities and their carers, GPs, community learning disability team members and pharmacists.

RESULTS

The present authors managed to withdraw antipsychotics totally among 46.5% (33/71) and reduced over 50% of dosage in another 11.3% (8/71) of adults with intellectual disabilities. At three months follow-up no one required hospital admission or change in placement.

CONCLUSION

It is possible to withdraw/reduce antipsychotics in a high proportion of adults with intellectual disabilities if a concerted effort is made involving all stakeholders from the outset.

Valproate MHRA Guidance: Limitations and Opportunities

Recent publication of the Medicines and Healthcare products Regulatory Agency (MHRA) in the United Kingdom has strengthened the regulatory measures for valproate medicines. It highlights the importance of making women of childbearing age with epilepsy aware of the teratogenic risks of valproate and encourages the withdrawal of it from those currently prescribed. While a significant directive, it raises concerns of not having considered the impact on special populations such as women with Intellectual Disability (ID). While it is important that women with ID are not excluded from such safety initiatives, due caution needs to be taken on a case by case basis preferably, to ensure their best interests are central to the decision making. Many women with moderate to profound ID cannot have informed consented sexual relationships not to mention cognitive incapability to make informed choices on medication suitability. These women are at potential risk of having their epilepsy control undermined due to the MHRA directives. Around 30% of people with moderate to profound ID have seizures of which 60% are considered treatment resistant. In this vulnerable population changes to medication without clear clinical and social insights could lead to increased harm levels. This paper enumerates the challenges of application of the new directive to these special populations and proposes a pathway based on individual cognitive ability to provide informed consent to facilitate the continuation or removal of valproate. It is important not to lose sight of individual circumstances and the importance of working collaboratively toward providing person center care.

Improving knowledge of psychotropic prescribing in people with Intellectual Disability in primary care

Purpose

People with Intellectual disability (ID) are likely to be prescribed psychotropic medication particularly antipsychotics without a clear clinical indication. This has given rise to a national initiative in the UK to stop overprescribing medication in this vulnerable population. While the goals are simple it is unclear if specialist ID services or primary care services in the UK should look to lead. Further, it is uncertain if primary care practitioners (GPs) can be systematically educated of the latest good practice developments and concerns in this specialised area. This study surveyed the knowledge level of a sample of GPs in Cornwall UK (county of 538,000) post a structured tutorial on psychotropic medication and people with ID.

Methods

A 21 item questionnaire was delivered in meetings organised for all the county GPs a year after a talk given to the same demographic. The questionnaire conducted an assessment of the knowledge of national guidance on use of psychotropic medication in ID based on the subjects covered in the tutorial.

Results

Of the 60 expected GP participants the tutorial was attended by 44 GPs (73%) and the follow up meeting by 42 (70%). Ninety percent GPs in the follow up meeting filled the questionnaire. For 16 questions, more than 80% GPs gave correct responses whereas five questions attracted a correct answer from less than 80%. Majority of the GPs felt psychotropic medication management in people with ID should be specialist led.

Conclusions

GPs’ knowledge of issues relevant to prescribing in people with ID benefitted from the tutorial. However a clear need for the psychotropic medication management to be delivered via specialist care emerged. This raises issues of resource allocation and debate on whether people with ID require specialist provision due to lack of ability in main stream primary care to manage their needs.

Going down the tubes! Impact on seizure control of antiepileptic medication given via percutaneous feeding tubes

BACKGROUND

Long-term feeding by percutaneous endoscopic gastrostomy tube (PEG) is uncommon but can present significant issues when both nutrition and medication have to be fed down the same tube. This is especially important in people with epilepsy where the dose and bioavailability of antiepileptic drugs are critical to maintain adequate seizure control. This group with long-term PEG tubes is particularly vulnerable and dependent on their carers to provide high standard of care. Indeed, approximately half of the people with long-term feeding tubes suffer from severe intellectual disability which requires careful coordination of all members of the multidisciplinary team. It is all the more important when consideration is given that around 50% of people with severe ID have seizures, mostly treatment resistant.

METHOD

A detailed literature review was conducted with the focus on the numerous factors that can affect medication delivery and absorption with the potential to destabilize seizure control in people with PEG. Issues concerning the site of drug absorption, excipients and dilution, interaction between antiepileptic drugs and the nutritional feed, bioavailability, and problems with the PEG tube are considered.

RESULTS

There is limited research in this area and the studies are often based on small numbers, healthy volunteers or in vitro findings.

CONCLUSION

In the absence of sound research data, seizure control in each patient with a PEG needs to be considered on an individual basis. Establishing a baseline by measuring the serum levels prior to the tube insertion may be helpful, followed by checking the levels after PEG insertion.

Omitted doses as an unintended consequence of a hospital restricted antibacterial system: a retrospective observational study

Objectives

The objective of this study was to determine the frequency of omitted doses of antibacterial agents and explore a number of risk factors, including the effect of a restricted antibacterial system.

Methods

Antibacterial data were extracted from a hospital electronic prescribing and medication administration system for the period 1 January to 30 April 2014. Percentage dose omission rates were calculated. Omission rates for the first dose of antibacterial courses were analysed using logistic regression to identify any correlation between first dose omission rates and potential risk factors, including the antibacterials' restriction status and whether or not they were ward stock.

Results

The study included 90 761 antibacterial doses. Of these, 6535 (7.2%) were documented as having been omitted; omission of 847 (0.9% of 90 761) was due to medication being unavailable. Non-restricted, ward stock antibacterials had the lowest frequency of omission, with 6.2% (271 of 4391) first doses omitted. The prevalence was 10.4% (27 of 260) for restricted, ward-stock antibacterials (OR = 1.6, 95% CI = 1.0–2.4, P = 0.027) and 15.5% (53 of 341) for non-restricted, non-ward stock antibacterials (OR = 2.7, 95% CI = 2.0–3.7, P < 0.001). Restricted, non-ward stock antibacterials had the highest frequency (30.7%, 71 of 231; OR = 6.2, 95% CI = 4.5–8.4, P < 0.001).

Conclusions

Antibacterials not stocked in clinical areas were significantly more likely to be omitted. The prevalence of omitted doses increased further if the antibiotic was also restricted. To achieve safe, effective antimicrobial use, a balance is needed between promoting antimicrobial stewardship and preventing unintended omitted doses.

Postanastomotic transplant renal artery stenosis: association with de novo class II donor-specific antibodies

In this study, we analyze the outcomes of transplant renal artery stenosis (TRAS), determine the different anatomical positions of TRAS, and establish cardiovascular and immunological risk factors associated with its development. One hundred thirty-seven of 999 (13.7%) patients had TRAS diagnosed by angiography; 119/137 (86.9%) were treated with angioplasty, of which 113/137 (82.5%) were stented. Allograft survival in the TRAS+ intervention, TRAS+ nonintervention and TRAS- groups was 80.4%, 71.3% and 83.1%, respectively. There was no difference in allograft survival between the TRAS+ intervention and TRAS- groups, p = 0.12; there was a difference in allograft survival between the TRAS- and TRAS+ nonintervention groups, p < 0.001, and between the TRAS+ intervention and TRAS+ nonintervention groups, p = 0.037. TRAS developed at the anastomosis, within a bend/kink or distally. Anastomotic TRAS developed in living donor recipients; postanastomotic TRAS (TRAS-P) developed in diabetic and older patients who received grafts from deceased, older donors. Compared with the TRAS- group, patients with TRAS-P were more likely to have had rejection with arteritis, odds ratio (OR): 4.83 (1.47-15.87), p = 0.0095, and capillaritis, OR: 3.03 (1.10-8.36), p = 0.033. Patients with TRAS-P were more likely to have developed de novo class II DSA compared with TRAS- patients hazard ratio: 4.41 (2.0-9.73), p < 0.001. TRAS is a heterogeneous condition with TRAS-P having both alloimmune and traditional cardiovascular risk factors.

Morbidity, deprivation, and antidepressant prescribing in general practice

BACKGROUND

Although the link between depression, unemployment, and measures of deprivation and morbidity has been previously documented, the relationship between general practice prescribing of antidepressants, morbidity, and the social demography of general practice populations is poorly understood.

AIM

To consider whether morbidity and the social demography of general practice populations influence the prescribing costs of individual practices.

METHOD

Data were analysed, using a forward stepwise regression procedure, of all 78 practices served by the Cornwall and Isles of Scilly Health Authority. Data on prescribing for antidepressants were provided by the Prescription Pricing Authority for the period from July to December 1995 and converted into defined daily doses (DDDs) to standardize for the variation in prescribing practice between general practitioners.

RESULTS

A significant positive correlation exists between the rates of prescribing DDDs of antidepressants by general practices and the prevalence of permanent sickness in the areas in which these practices serve.

CONCLUSION

Demonstrating an association between morbidity and prescribing rates for depression may prove helpful in setting prescribing budgets.

Survey on repeat prescribing for acid suppression drugs in primary care in Cornwall and the Isles of Scilly

BACKGROUND

Repeat prescriptions for acid suppression therapy represent an important burden on health care resources.

AIM

To determine the prevalence of acid suppression therapy and its indications by general practitioners (GPs) in a larger sample of practices than previous studies.

METHOD

Practices in Cornwall and the Isles of Scilly were invited to identify the number of patients on repeat prescription for acid suppression drugs in their practice, to review the indication for treatment in a sample of 50 patients, and to indicate the mode of review of these patients.

RESULTS

Out of 77 practices, 42 (55%) participated in the study. Overall, 5% of patients were authorized to receive a repeat prescription for acid suppression drugs. Repeat rates varied between practices, from 1.68% to 11.11%. Repeat rates increased with age and were higher in men than in women. Only 41% of patients had a proven diagnosis of gastro-oesophageal reflux disease or peptic ulcer. A review of notes was the most frequent way (36%) stated by GPs to review acid suppression therapy.

CONCLUSION

The repeat rate found in our study was higher than that found in previous studies. A high proportion of older patients in Cornwall, as well as a continuing increase in the prescription of acid suppression drugs, may account for these results.