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HDR PLANNING & HOT TOPICS. Nov 3 rd 2010. This Afternoon. HDR Planning 14.00 – 15.15 Tea break 15.15 Hot topics 15.30 – 17.00. Planning. Hot Topics. Pub quiz style Split into 3 groups Question and answers Discussion Top team each round will win a prize. Aims.

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this afternoon
This Afternoon
  • HDR Planning 14.00 – 15.15
  • Tea break 15.15
  • Hot topics 15.30 – 17.00
hot topics
Hot Topics
  • Pub quiz style
  • Split into 3 groups
  • Question and answers
  • Discussion
  • Top team each round will win a prize
slide5
Aims
  • To consider the latest studies and how they influence our prescribing in relation to:

- Aspirin

- Glucosamine

  • To review the latest research into the use of PSA in screening for prostate cancer
1 aspirin
1) Aspirin
  • Who do you think needs to be prescribed aspirin?

(as currently under debate....ignore diabetic patients, focus on those with cardiovascular risk)

aspirin the study
Aspirin – the study
  • Lancet 2009: 373: 1849
  • Antithrombotic Trialists Collaboration (ATTC) meta analysis looked as use of aspirin in primary and secondary prevention.
  • A large study
  • All compared aspirin to placebo
  • The outcomes were CV events and the rate of harm
primary prevention
Primary prevention
  • Aspirin DOES NOT reduce the CV MORTALITY
  • Aspirin DOES reduce CV EVENTS – but the risk reduction v small (NNT 1666)
  • HARMS for every 3333 treated over 12m there would be one additional GI/extra cranial bleed (NNH 3333)
  • DTB agree, current practice is recommended that:
    • Aspirin shouldn’t be started for primary prevention
    • In those already taking it – explain current evidence to patient.
secondary prevention
Secondary Prevention
  • Aspirin prevents 1 CV event per year for every 66 people treated (NNT 66)
  • Aspirin prevents 1 vascular death for every 344 people treated
  • There was insufficient data to report on GI/extra-cranial bleeds or haemorrhagic CVAs
  • DTB
    • Secondary prevention 75mg aspirin/day
    • (no evidence of improved protection with increase dose – but increased dose does increase GI haemorrhage risks)
aspirin questions and answers
Aspirin – Questions and Answers
  • Who do you think needs to be prescribed aspirin?
  • Not for primary prevention
  • Secondary prevention require 75mg OD
  • Secondary prevention would include those with TIA/stroke, previous MI, angina.
2 glucosamine
2) Glucosamine
  • Who should be prescribed glucosamine?
  • What advice should you give a patient when commencing treatment?
  • In which patients is the use of glucosamine contraindicated?
glucosamine
Glucosamine
  • Glucosamine is only indicated in patients with knee OA (DTB 2008; 46:81-4)
  • NICE does not support the use of glucosamine in OA (NICE, 2008)
derbyshire medicines management may 2010 advice
Derbyshire Medicines Management May 2010 Advice
  • A trial of glucosamine sulphate 1500mg once daily is recommended as a treatment option in patients suffering from osteoarthritis of the knee, after trying, or in conjunction with paracetamol.
  • Use may mean that potentially toxic NSAIDs or coxibs need not be used.
  • It may take several weeks for the full effect to be seen.
  • If prescribed generically – the community pharmacy chooses the brand to supply. Expensive brands cost up to £90 for a thirty day supply
  • Medicines Management recommends that glucosamine sulphate is prescribed as the brand Valupak. Thirty days supply of the 1500mg strength costs only £2.83.
what should we tell patients
What should we tell patients?
  • None of the clinical trails have shown glucosamine is particularly effective
  • It may reduced pain in some people
  • It probably won’t improve function
  • It’s unclear whether it has any long term effects (slowing disease progression)
  • Glucosamine in safe in most people – but there are CIs
  • Glucosamine may take several weeks to work – trial for 3 months, if pain is no better, consider stopping
glucosamine questions and answers
Glucosamine - Questions and Answers
  • Who should be prescribed glucosamine?
  • Only those with knee OA
  • What advice should you give a patient when commencing treatment?
  • May improve pain, probably won’t improve function, long term effects unclear, if no improvement at 3 months – consider stopping
  • In which patients is the use of glucosamine contraindicated?
  • Pregnant, breast feeding, allergic to shellfish and those on warfarin
psa testing questions
PSA Testing Questions

1) What percentage of men with a normal PSA have clinically significant prostatic cancer?

2) What percentage of men with raised PSA will not have prostate cancer?

3) List 3 advantages and 3 disadvantages of the PSA test

slide18
PSA
  • PSA is a glycoprotein produced by the prostate
  • The amount produced can increase due to malignant and benign processes
slide19
PSA
  • PSA has long been used in general practice.
  • There is currently lots of debate over whom should have a PSA test, there is no agreed criteria for testing.
  • But, questions to consider;
    • Could the PSA be a useful screening tool?
    • Would screening reduce mortality?
bmj 2009 339 b3537
BMJ 2009;339:b3537
  • Looked specifically at how well PSA performs as a screening test depending on cut off values chosen.
  • The authors concluded that additional biomarkers would be needed before population screening should be introduced.
systemic review of psa screening bmj 2010 34 c4543
Systemic review of PSA screening – BMJ 2010; 34:c4543
  • Systemic review of PSA screening – BMJ 2010; 34:c4543
  • Pooled results from 6 major PSA screening studies (inc. PLCO and ERSPC)
  • Meta-analysis of 387,286 men showed:
  • Screening increased your risk of being given a diagnosis of prostate cancer
  • Screening had no impact on death from prostate cancer or overall mortality
plco screening trial nejm 2009 360 1310 0
PLCO Screening Trial (NEJM 2009; 360: 1310-0)
  • 76,000 men (aged 55-74) were randomised to usual care or annual screening for prostate cancer
  • 40-52% of the men in the control group had screening each year
  • Screening picked up more cancers than usual care
  • Mortality from prostate cancer was not reduced in those who had been screened
  • Screening did not appear to pick up earlier tumours (similar rates of all stages in control and screening group)
erspc nejm 2009 360 1320 8
ERSPC (NEJM 2009; 360:1320-8)
  • RCT 180,000 men aged 50-74 in 7 European countries.
  • Randomised to “no screening” or to “PSA once every 4 years”
  • Twice as many cancers were diagnosed in the screening group compared to the control group
  • Those who had undergone screening were 20% less likely to die of prostate cancer
  • Benefit of screening only seen in those aged 55 or more, not in those 50-54
  • There was a significant rate of over diagnosis (detecting tumours that would never become clinically significant)
erspc continued
ERSPC (continued)
  • 1410 men would need to be screened to prevent one death from prostate cancer
  • 48 additional cases of prostate cancer would need to be treated to prevent one death from prostate cancer.
comparing erspc and pclo
Comparing ERSPC and PCLO
  • Different cut-off values for action (3ng/ml v 4ng/ml)
  • Study population selection
  • Improved prostate cancer treatment over the course of the PCLO trial
  • Follow up of PCLO may not have been long enough.
what do these trials mean to our practice
What do these trials mean to our practice?
  • National Screening Committee have recommended that a prostate cancer screening programme should not be introduced in the UK
  • Men who ask for a PSA should continue to be offered the full range of information to allow them to make an informed decision
psa summary
PSA Summary
  • PSA test has significant failings
  • Screening MIGHT save lives, but we don’t know whether it actually does any good...which is a far more important question.
  • Treating men with clinically unimportant cancers exposed them to harm with no benefits
  • PSA should not be done routinely without discussing risks and benefits with the patient
  • A single PSA <1ng/ml in a man’s 60s largely rules out the risk of clinically significant prostate cancer.
psa answers 1
PSA Answers (1)

1) What percentage of men with a normal PSA have clinically significant prostatic cancer?

  • 20%

2) What percentage of men with raised PSA will not have prostate cancer?

  • 66%
psa answers 2
PSA Answers (2)

3) List 3 advantages and 3 disadvantages of the PSA test

  • Advantages
  • Reassurance if result is normal
  • May indicate cancer before symptoms present
  • May find cancer at an early stage
  • If treated may avoid worse outcomes, e.g. death
  • Even if aggressive/advance cancer, treatment may prolong survival
  • Disadvantages
  • False negatives
  • May have unnecessary tests and anxiety
  • Cannot differentiate slowly growing ‘v’ aggressive cancers
  • May cause unnecessary anxiety if it’s a slow, clinically insignificant ca
  • 48 men will undergo treatment to save one life
the end
The End
  • Questions?
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