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1 Απριλίου 2020, 19:41:57

Αποστολέας Θέμα: Don’t be bullied into prescribing Tamiflu.  (Αναγνώστηκε 4300 φορές)

0 μέλη και 1 επισκέπτης διαβάζουν αυτό το θέμα.

30 Ιανουαρίου 2015, 00:54:37
Αναγνώστηκε 4300 φορές
Αποσυνδεδεμένος

Argirios Argiriou

Moderator
Views & Reviews

No Holds Barred

Margaret McCartney: Don’t be bullied into prescribing Tamiflu

BMJ 2015; 350 doi: Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος (Published 22 January 2015)

Cite this as: BMJ 2015;350:h417

Margaret McCartney, general practitioner, Glasgow
margaret@margaretmccartney.com



I have recurrent thoughts about times when doctors felt adamant about the benefit of interventions—putting babies to sleep on their front, for example, or giving steroids to people with head injury, or bloodletting—that turned out to be lethal.

Now we have guidelines, hundreds of them. Good guidelines would distil evidence cautiously, making clear what we know and where the gaps are. They would say how many people would get what benefit from a treatment, while identifying the cost in terms of harm. But guidelines are not always applicable to our patients,1 and they are meant to guide practice; rarely should they dictate it.

The medical director and the centre director for the Thames Valley area of NHS England have recently written to GPs about the prophylactic use of oseltamivir (Tamiflu) for flu in nursing homes. They wrote, “It is concerning that doctors may be deterred from prescribing antivirals and this could be putting lives at risk.”

They noted “differing interpretations of the evidence base” but added that the Medical Defence Union has identified an “expectation on the part of the public and the legal profession that NICE [National Institute for Health and Care Excellence] guidance and PHE [Public Health England] advice would be followed.” They also said “it is expected” that GPs “would make a decision to prescribe based on the needs of their patient and the evidence of best practice and guidance from national bodies such as NICE and PHE,” adding, “There is also an expectation defined in the GMC’s [General Medical Council] Good Medical Practice that a doctor will respond to an organisation advising on public health.”

This reads as a veiled threat: if GPs decide not to prescribe oseltamivir for all patients in a nursing home, lawyers and the GMC could dust down their robes and eviscerate the doctor for not following orders. In a no blame, patient centred NHS, things might be different.

Why might doctors hesitate with their prescription pads? It could be because 33 people have to be treated prophylactically to prevent one case of flu. (2) One in 20 will vomit, and one in 100 will have neuropsychiatric side effects. Or maybe it’s because NICE didn’t include a negative trial in its calculations. (3) And PHE cites serial relative risks, but it remains unclear whether the data apply to multimorbid people in nursing homes. (4)

All of this leaves us with a drug of uncertain, probably marginal benefit—and difficult choices. The architects of mass public health interventions still don’t grasp that populations are made up of individual patients. Each person offered antivirals needs not just an assessment of dose but also a discussion of risk and harm. Without extra resources what work would PHE suggest that primary care staff stop doing to fit this in?

Doctors must question what they are told to do, speak up, and point out flaws in arguments when asked to prescribe drugs of questionable benefit. Prescribing because of fear is toxic to patient care and safety.

Notes
Cite this as: BMJ 2015;350:h417

Footnotes
Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I’m an NHS GP partner, with income partly dependent on Quality and Outcomes Framework points. I’m a part time undergraduate tutor at the University of Glasgow. I’ve written two books and earn from broadcast and written freelance journalism. I’m an unpaid patron of Healthwatch. I make a monthly donation to Keep Our NHS Public. I’m a member of Medact. I’m occasionally paid for time, travel, and accommodation to give talks or have locum fees paid to allow me to give talks but never for any drug or public relations company. I was elected to the national council of the Royal College of General Practitioners in 2013 and am chair of its standing group on overdiagnosis. I have invested a small amount of money in a social enterprise, Who Made Your Pants?

thebmj.com Blog: The BMJ Today: Should I prescribe anti-virals to prevent flu for nursing home patients? (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)

The BMJ’s readers can buy Margaret’s new book, Living with Dying, for £7.99 (RRP £11.99) including UK delivery from Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος with checkout code BMJ799.

Provenance and peer review: Commissioned; not externally peer reviewed.

References
↵Steel N, Abdelhamid A, Stokes T, Edwards H, Fleetcroft R, Howe A, et al. A review of clinical practice guidelines found that they were often based on evidence of uncertain relevance to primary care patients. J Clin Epidemiol2014; published online 5 Sept; doi:10.1016/j.jclinepi.2014.05.020.
↵Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan C. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ2014;348:g2545.Abstract/FREE Full Text
↵Cohen D. GPs are told to treat with scepticism advice on anti-flu drugs from Public Health England. BMJ2015;350:h258.FREE Full Text
↵Phin N, Moll R. GPs are told to treat with scepticism advice on anti-flu drugs from Public Health England. BMJ Rapid response 16 Jan 2015. Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος.

Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος
« Τελευταία τροποποίηση: 30 Ιανουαρίου 2015, 22:42:29 από Argirios Argiriou »
Before ordering a test decide what you will do if it is (1) positive, or (2) negative. If both answers are the same, don't do the test. Archie Cochrane.

6 Φεβρουαρίου 2015, 09:35:42
Απάντηση #1
Αποσυνδεδεμένος

Argirios Argiriou

Moderator
February 5, 2015

New Meta-Analysis Clarifies Oseltamivir's Benefits and Risks


Bruce Soloway, MD reviewing Dobson J et al. Lancet 2015 Jan 30.


A patient-level meta-analysis confirms this drug's modest antiviral activity and substantial side effects.


In a 2014 Cochrane meta-analysis of eight manufacturer-conducted, placebo-controlled, influenza treatment trials in adults, researchers concluded that oseltamivir (Tamiflu) “modestly reduces” duration of symptoms but causes nausea and vomiting and, possibly, adverse psychiatric effects. The report pointedly questioned the antiviral activity of oseltamivir and “its use in clinical practice as an anti-influenza drug” (NEJM JW Gen Med May 15 2014 and BMJ 2014; 348:g2545). However, the analysis was based on aggregate rather than patient-level data.

Researchers now report a meta-analysis of patient-level data from the same trials plus one recent addition (total of 4328 adult patients with flu-like illness). In all trials, patients with fever and at least two influenza symptoms of shorter than 36 hours' duration were treated with oseltamivir (75 mg) or placebo twice daily for 5 days. Roche provided all data and unrestricted funding for the analysis.

Among 2893 patients with confirmed influenza, median time to alleviation of all symptoms was significantly shorter in those who received oseltamivir than in those who received placebo (98 vs. 123 hours), and oseltamivir patients experienced significantly fewer lower respiratory complications and hospitalizations (1 fewer per 100 treated patients). Among all patients with flu-like illness, the difference between groups in time to symptom alleviation was attenuated but still statistically significant. Among patients who were found to be uninfected with influenza, outcomes were similar for the oseltamivir and placebo groups. Patients taking oseltamivir experienced significantly more nausea and vomiting (5 more patients with vomiting per 100 treated patients) but no excess psychiatric symptoms.

Comment

This analysis confirms oseltamivir's antiviral activity, its modest effect on duration of influenza symptoms, and its substantial side effects. Ideally, treatment with oseltamivir should be limited to patients with confirmed influenza, with careful evaluation of potential benefits and harms.

Editor Disclosures at Time of Publication

Disclosures for Bruce Soloway, MD at time of publication Nothing to disclose

Citation(s):

    Dobson J et al. Oseltamivir treatment for influenza in adults: A meta-analysis of randomised controlled trials. Lancet 2015 Jan 30; [e-pub ahead of print]. (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)

- See more at: Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος
Before ordering a test decide what you will do if it is (1) positive, or (2) negative. If both answers are the same, don't do the test. Archie Cochrane.

16 Ιανουαρίου 2020, 23:48:21
Απάντηση #2
Αποσυνδεδεμένος

Argirios Argiriou

Moderator
Psychiatric Symptoms in a Patient with Influenza A (H1N1) Treated with Oseltamivir (Tamiflu): A Case Report

Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος
Before ordering a test decide what you will do if it is (1) positive, or (2) negative. If both answers are the same, don't do the test. Archie Cochrane.

Λέξεις κλειδιά: Tamiflu oseltamivir οσελταμιβίρη 
 

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