Prescribing

Prescribing antihypertensives to people aged 80 years and above is as likely to lead to a serious fall as to prevent a stroke/myocardial infarction

A cohort study used anonymised data from the electronic health records of patients in England, to examine whether patients prescribed antihypertensives were more likely to experience a serious adverse event sooner, compared to those not prescribed them.

Antihypertensive prescriptions were associated with an increased risk of hospitalisation/death from falls, syncope, acute kidney injury, electrolyte abnormalities and gout. However, the absolute risk of these events was low, increasing in frail and elderly patients.

In patients aged 80-89 years, analysis found 1 serious fall would occur each year in every 33 people treated. Other research suggests 1 stroke/myocardial infarction would be prevented for every 38 people treated with antihypertensives aged >85 years.

Suggested WiseGP actions:

1. Share this evidence with your colleagues involved in the holistic care of your frail, elderly population, to support individualised management plans.

2. Recommend colleagues reviewing new admissions to nursing homes/ performing medication reviews for elderly patients in your practice consider deprescribing antihypertensives where appropriate.

3. Consider a quality improvement project for your foundation doctor/ registrar or practice pharmacist, addressing potential over-treatment of hypertension in your frail, elderly patient population- could they review a cohort in one of your nursing homes?

Read more about the research informing this GEM here:

journals.plos.org

Using nationally representative electronic health record data, James Peter Sheppard and team investigate the association between antihypertensives and serious adverse events in individuals aged 40+ in England.

Correlation between antibiotic use and colorectal cancer

• A case-control study aimed to investigate the association between antibiotic use and colorectal cancer (1).

• Almost 8,000 people with colorectal cancer were matched to 5 controls. People with previous cancer, on immunosuppressants and with predisposing conditions, such as polyposis syndromes, were excluded. 

• In people >50 years, antibiotic use was associated with an estimated 9% higher risk of colon cancer. (Adjusted Odds Ratio 1.09 (95% CI 1.01, 1.18), p=0.029) - These statistics mean the true value could be anywhere between 1% and 18%.

• In people <50 years, antibiotic use was associated with an estimated 49% higher risk of colon cancer. (Adjusted Odds Ratio 1.49 (95% CI 1.07, 2.07), p=0.018) - These statistics mean the true value could be anywhere between 7% and 107%. The power of findings was limited by low numbers in this younger cohort.

• An earlier case-control study found antibiotic use was associated with an increased colon cancer risk in a dose-dependent fashion, with risk observed after minimal use, being greatest in the proximal colon and with antibiotics that had anti-anaerobic activity (2).

WiseGP Action

Before the next spike in winter viral illnesses that prompt many antibiotic requests, have a practice educational meeting, where latest antibiotic guidelines for common infections are covered and techniques to manage difficult consultations discussed. You could use the opportunity to update practice texts to be sent to patients to support safety netting and prescribing decisions.

Read more about the studies informing this GEM below.

1. https://www.nature.com/articles/s41416-021-01665-7

2. Oral antibiotic use and risk of colorectal cancer in the United Kingdom, 1989–2012: a matched case–control study

Increased risk of VTE when taking both NSAIDs and hormonal contraception

It’s well established that oral contraceptives can increase venous thromboembolism (VTE) risk. There is also longstanding evidence that NSAIDs are associated with an increased risk of VTE. Have you ever considered their combined risk?

New research has demonstrated that in combination, the risks of hormonal contraception and NSAIDs are additive. Compared with non-use of NSAIDs, the adjusted number of extra VTE events per 100, 000 women over the first week of NSAID treatment was 4 in women not using hormonal contraception, 23 in women taking an NSAID and high risk hormonal contraception* and 11 with concomitant use of an NSAID and medium risk hormonal contraception**.

WiseGP Actions:

• Consider advising against combined use of NSAIDS and moderate/ high risk hormonal contraception, particularly in women who are smokers or have a raised body mass index.

• Consider discussing NSAIDs at a practice meeting/ tutorial.

  • What are your team’s prescribing habits?

    Has the shift away from opiates increased your teams’ reliance on NSAIDs for pain management? (See GEMs on chronic pain for further discussion points)

  • Are clinicians who perform contraceptive reviews advising on the combined risk of NSAIDs with hormonal contraception?

Read more about the evidence informing this GEM here: https://www.bmj.com/content/382/bmj-2022-074450

*High risk contraception - combined oestrogen and progesterone patch, vaginal ring, and tablets containing 50 µg ethinyl oestradiol, or desogestrel, gestodene, drospirenone, or the anti-androgen cyproterone.

** Medium risk contraception - all other combined oral contraceptives as well as the depot injection.