Clinical Posters 414 – 420
414 Identifying and managing interactions in commonly prescribed medications
Aim of study Antidepressants and non-steroidal analgesics are amongst the most commonly prescribed medications in the UK. The significantly increased risk of upper gastrointestinal bleeding for patients taking both is well established (de Jong et al, 2003) and the addition of a proton pump inhibitor reduces this risk (de Abajo et al, 2008). The aim of our work was to investigate how well GPs were managing the interaction between these very commonly prescribed medications.
Method We undertook an audit, using EMIS searches of all registered patients in one practice (n=3688) to identify patients who had an SSRI and an NSAID on repeat prescription, last issued within the preceding 6 months. For those on both, we recorded if they had been prescribed gastroprotection and, if not, whether a reason was documented.
Outcomes 43 patients had a repeat prescription for an SSRI and an NSAID. Only 27 (63%) were prescribed gastroprotection or had a documented reason why it had not been prescribed. The remaining 36% patients were invited for an appointment to review their medications, and within 1 month most patients had been reviewed.
Relevance and discussion 36% patients, in a GP teaching practice, were taking regular NSAIDs and SSRIs without gastroprotection. Identifying and managing interactions between commonly prescribed medications can be a challenge for GPs with multiple demands on their time. Clinicians need regular updates on important drug interactions, dedicated time for medication reviews and meaningful IT systems for highlighting significant interactions. This is also an example where community pharmacists could help support the primary care workforce.
415 C reactive protein point-of-care testing to reduce antibiotic usage in primary care
Aim To assess whether using a point-of care CRP test prior to prescribing for suspected infections presenting in Primary CAre (excluding urinary tract) would lead to a reduction in prescription of antibioticsContent of presentation-Practicalities of protocol we devised and implemented. Practice Data collected that shows levels of antibiotic prescribing and CCG level data comparing local practices.
Relevance/Impact Many studies have demonstrated the worth of CRP testing to distinguish between viral and bacterial infections and thus reduce antibiotic prescribing,but we wanted to see if it would be practical in a busy General Practice in the depths of winter. Antibiotic resistance is an increasing problem and ‘poses a catastrophic threat’, according to Chief Medical Officer, Professor Dame Sally Davies, so all means to reduce unnecessary antibiotic prescribing should be sought.This test is not to replace communication skills and clinical accumen of a clinician but to augment robustness for not prescribing antibiotics
Outcome We found CRP testing was straight-forward to integrate with our clinical work and provided a 26% reduction in antibiotic prescribing over the same period last year
Discussion To reduce unnecessary antibiotic prescribing and thus the development of antimicrobial resistance would be of great benefit.Our experience of point-of care CRP testing suggests it is cheap and easy in modern day General Practice and could be rolled out to GP practices, Walk In centres, even Accident and Emergency departments.
416 The use of centor score in prescribing antibiotics for patients with sore throat
Ha Phuong Do Le
Aims To determine if and how centor criteria was being adopted at the GP practice and to review choices of antibiotics.
Content Population reporting tool was used to search for all patients who presented with either ‘tonsillitis’ or ‘sore throat’ over a three-month period (N=97). Where no centor score was documented, a retrospective centor score was calculated based on recorded clinical features of the patients. The subsequent clinical decisions were noted and matched with the centor score.
Relevance Patients who score 3 or 4 on centor criteria have higher risk of Group A Beta-Hemolytic Streptococcus (GABHS) infection. Antibiotics can reduce the risk of complications associated with GABHS in these patients. Low risk patients may not benefit from antibiotics. Overprescribing antibiotics may contribute to antibiotics resistance.
Outcomes: A centor score was recorded for only 4 out of 97 patients. The percentage of patients receiving antibiotics for Centor score of 0, 1, 2, 3, and 4 were 21, 43, 78, 92 and 100% respectively. Eighteen out of 45 patients were prescribed penicillin V as first line, however 19 out of 45 were prescribed amoxicillin.
Discussion: The infrequent use of the centor criteria at this practice may explain relatively high rates of antibiotic prescribing amongst the low centor score patients. Following discussion with the clinical team, it was established that amoxicillin was prescribed by some clinicians to avoid the high cost of penicillin V oral solution. It was agreed that the recommended first line antibiotic should be used.
417 A Literature Review on the Views of Patients, General Practitioners and Healthcare Professionals in the Prevention of Diabetes using Lifestyle Interventions
Background Weight loss has been found to be the dominant predictor to reduce diabetes incidence making this a key prevention strategy. Being diagnosed with an impaired glucose tolerance (IGT) has been found to have an increased risk of transitioning into type 2 diabetes, making this an important group to target any prevention strategies. The majority of type 2 diabetes is managed in Primary Care making it important to evaluate the views of all parties involved in such interventions.
Aim To review research carried out to date in the UK, which has analysed the views of patients, GPs and their allied health professionals on the prevention of diabetes by lifestyle intervention in patients diagnosed with IGT.
Methods The literature search set out to identify studies published between 1995-2015. Studies were selected if they considered the prevention of diabetes by means of lifestyle interventions. The studies were critically appraised using the CASP tool. Themes were extracted and then compared across the studies to form conclusions. The sources used were OVID Medline, Cochrane and Google Scholar.
Results Eight studies met the inclusion criteria. Patients feel that more practitioner time and advice would be helpful and motivating, reducing confusion over the diagnosis of IGT. GPs and healthcare professionals felt that guidelines for delivering such interventions would be useful. Barriers to providing this intervention were found to be; time, lack of resources and negative attitudes towards the intervention.
Conclusion The findings form the foundations for future research to be conducted, in the form of focus groups/questionnaires on a larger scale, which would provide findings to design an interventional service, which would take into account the views of all involved.
418 Analgesic Efficacy and Safety of Nonprescription Doses of Naproxen Sodium in the Treatment of Osteoarthritis of the Knee or Hip
Background To evaluate the analgesic efficacy and safety of nonprescription doses of naproxen sodium (NS) in patients with osteoarthritis (OA) of the knee or hip.
Methods In 4 identical multicentre, randomised, double-blind, placebo-controlled, multidose, parallel-design studies, patients aged ≥25 years with at least moderate pain from OA of the hip or knee were randomised to daily doses of NS 660 mg (or 440mg in patients ≥65 years) or placebo for 7 days. At baseline and post-treatment, investigators assessed pain at rest, pain on passive motion, and pain on weight bearing; patients assessed stiffness after rest, day pain, night pain and completed timed 50-foot walks. Patients reported any adverse events (AEs) that occurred during the study period. Changes from baseline were analysed with parametric techniques.
Results Across the 4 studies, 409 patients received NS (440mg/660mg), and 409 patients received placebo; of whom, 356 were ≥65 years. NS (440/660mg) provided significantly greater (p≤0.05) improvement compared with placebo for all efficacy parameters. Twenty-seven percent of patients who received NS 440/660mg and 28% of patients who received placebo reported at least 1 AE. Four percent of the AEs in the NS group were considered severe, compared to 15% in the placebo group. The incidence of gastrointestinal AEs was similar: 14% in the NS 440/660mg group, and 11% in the placebo group. A similar safety profile was seen in those ≥65 years.
Conclusion Nonprescription doses of NS (440/660 mg) effectively relieve pain in patients with mild to moderate OA of the hip or knee. At such doses, NS had a similar safety profile to placebo, regardless of the age of the population.
419 ‘The NHS will need to be ready to use genomics as part of its routine care’ What does this mean for primary care
Whilst Genetics focuses on DNA coding for single functional genes, Genomics is the study of the entirety of our DNA with the recognition of the crucial regulatory role of non-coding DNA and of complex interactions between multiple genes and the environment. The transformational 100,000 Genomes Project is funded by the Department of Health to sequence 100,000 genomics, aspiring to kick-start a UK genomics industry and set up a genomics medicine service within the NHS. Patient demand, advancing technology and better affordability are also driving integration of genomics information into clinical care, with potential for significant patient benefit.
This poster aims to provide an overview and demonstrate how genomic medicine is likely to impact on primary care by illustrating the following clinical examples pictorially: Cancer: precise diagnosis and treatment based on genomic testing of both patient’s DNA and their tumour DNA; Familial Cancer: testing of the patient’s genome in order to predict risk and tailor screening and further management; Rare disease: Increased genomic and clinical diagnosis; Pharmacogenomics: genomic variants influencing drug safety and efficacy incorporated into routine prescribing (e.g. variants which affect statin metabolism); Common complex disease: genomic variants integrated into risk tools to refine accuracy of risk prediction and disease management according to sub-type; Genomic testing to risk-stratify patients within population screening programmes.
Raising awareness of the potential impact for primary care is crucial; implementation into routine clinical practice will demand a responsiveness in commissioning, informatics and education at all levels in order for primary care to become truly ‘genomics-ready’.
420 A Case of Antisynthetase syndrome
A 54 year old male presented to the GP with a cluster of signs and symptoms including muscle fasciculation, fluctuating violaceous rash, thoracic aortic aneurysm, aortic stenosis, chronic progressive respiratory condition which was latterly diagnosed as bronchiectasis; persistently sore fingertips with nail shards and continual fatigue and myalgia.The finding of a thoracic aneurysm, initially thought to be an incidental finding on chest CT for chronic respiratory disease combined with the myriad of symptoms experienced over the preceding 10 years led to the consideration of a diagnosis of antisynthetase syndrome.
Case studies report an increase in malignancies within 6 to 12 months of diagnosis. Screening is necessary in people with this condition, as indeed it is for dermatomyositis.The muscle enzymes which are tested for are creatinine kinase (CK) and aldolase. There are 9 serum autoantibodies (aminoacyl-tRNA synthetases) which are cellular enzymes of protein synthesis. The most commonly detected muscle autoantibody is Anti-Jo-1 which denotes the disease as Anti-Jo1 syndrome.
The diagnosis is confirmed in people with the characteristic signs and symptoms (and exclusion of other diseases) with an antisynthetase antibody plus 2 of the following features; inflammatory myopathy, interstitial lung disease (ILD) and/or inflammatory polyarthritis. Antisynthetase syndrome is a chronic disease hence the long-term outlook depends on long-term treatment and physiotherapy for rehabilitation. The severity and type of lung involvement determines the prognosis as progressive interstitial lung disease results in respiratory failure. A poorer prognosis is noted in people with disease onset after the age of 60 years, confirmed malignancy and/or a negative Jo-1 antibody test.