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Recent eLetters

Displaying 1-4 letters out of 4 published

  1. GPs 'wasting millions of pounds' prescribing gluten free foods

    The February issue of the Drugs and Therepeutics Bulletin, a BMJ journal,has an editorial entitled "Prescribing foods?". I regret that despite my forty years of BMA membership and BMJ readership, I can only read an abstract, as I am considered a 'non-subscriber': http://dtb.bmj.com/content/51/2/13.extract

    So I must also link to a Daily Telegraph article. It is by the DT's Medical Correspondent, who I can assume HAS read the editorial: http://www.telegraph.co.uk/health/healthnews/9868852/GPs-wasting-millions- of-pounds-prescribing-gluten-free-foods.html

    It appears that the D&TB editors have taken exception to the cost of treating coeliacs in the UK, quoted at £27M/year. They claim that prescription "inhibits competition meaning a loaf of Gluten-free bread can cost more than £5, compared with £3 in Tesco". They further claim that prescribing gluten-free foods is unnecessary as they are freely available in shops.

    I would ask if these two male editors, for surely, like the PM who did not know what milk cost, if they have any idea how much an ordinary loaf costs in comparison? (£1.40) Or why they consider that coeliacs, with an unpleasant, lifelong diesease that can be complicated by osteoporosis, infertility, dermatitis, lactose intolerance, other autoimmune diseases and Hodgkins lymphoma or adenocarcinoma, and is successfully treated at relatively low cost should not have that treatment on the NHS? And why coeliacs should be singled out against diabetics (annual cost to the NHS ?9.6BILLION) or asthmatics (?1 billion)?

    I do not defend the provision of 'pizza bases', nor that anyone who makes a 'life-style choice' to go gluten-free should get their chosen diet on the NHS. I just plead that clinically diagnosed coeliacs, who have to work hard to avoid the gluten that creeps into foods of many types, may be provided with a palatable gluten-free bread, Glutafin Fresh, that is NOT available without a prescription.

    Dr.John Davies, FRCA Albert House Haverbreaks Lancaster LA1 5BN

    Conflict of Interest:

    First, I must declare an interest. My partner is a coeliac, who must rigorously avoid gluten because otherwise she suffers severe symptoms, abdominal pain, and diarrhoea.

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  2. Prescribing perfectly

    DTB Vol. 50, No. 9, September 2012 - Prescribing perfectly

    In your leading article on this subject you ask reactions. As a retired pharmacist with a long standing experience in community pharmacy I recommend the following:

    There is no perfect prescribing as long as this is left to humans. Computers may be of help but their output is as good as their input may be. Humans are never perfect, even doctors are not. The circumstances in which they prescribe leave all chances for mistakes.

    For that reason as early as the XIth century an independent and separate task was given to the prescriber and the dispenser. In my opinion this measure is the best safeguard to ensure good prescribing.

    With to-day's many new drugs known as biologicals, it is almost impossible for the prescriber to know all side effects or interactions. Hence a close cooperation between prescriber and dispenser is very necessary. This can be done over the telephone but sometimes it is preferable that the two have a personal contact. The computer is not always a reliable source of information. All side effects and interactions and, eventually, the contra-indications will always be introduced later than they got known.

    In this country -the Netherlands- nearly everybody is linked to one specific pharmacy. The advantage is that the pharmacist knows his patients almost as well as their doctor. Through the regular FTOs (pharmacotherapeutical meetings) organised by most pharmacists there is a regular contact between the two groups. This is the base of a confidential and professional relationship required for regular consultations.

    This will in the long term result in far less prescription errors than any highly advanced computer. Both groups nowadays cannot function anymore without its help. But however advanced it is the human factor which renders it successful.

    And what applies to primary care should be copied in secondary care in the same manner.

    Wolfheze (NL), September 14, R.M. Ulmann

    Conflict of Interest:

    None declared

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  3. Neuropathic pain and pregabalin

    The recent DTB update on the drug treatment of neuropathic pain. Part 2: antiepileptics and other drugs (DTB 2012;50:126-129) is a welcome summary of prescribing, and a reminder of the poor quality of the evidence behind the guidance.

    However, it may be prudent to add a warning about pregabalin.

    The Summary of Product Characteristics (SPC)(1) states: Cases of abuse have been reported. Caution should be exercised in patients with a history of substance abuse and the patient should be monitored for symptoms of pregabalin abuse.

    A review(2) carried out in Canada concluded that while pregabalin was not likely to be abused by non-drug abusing subjects, it does have euphorigenic activity and may be subject to abuse in susceptible populations.

    In recent years, it has become apparent that pregabalin is used recreationally, with initial reports that it is widely traded in prisons. This has resulted in prison prescribing guidance(3) cautioning against its routine use. Recent local reports suggest that street use has now become widespread, pregabalin is increasingly offered as an alternative to heroin, and overdoses have been reported. It is discussed in detail in online drug users' forums - www.bluelight.ru has a "Wonders of Pregabalin" thread.

    There are also increasing concerns regarding the difficulty in withdrawing pregabalin. The SPC(1) warns of withdrawal symptoms which include insomnia, anxiety, flu like symptoms and convulsions.

    Prescribers should be aware of these issues when considering prescribing pregabalin for neuropathic pain. Consideration could be given to the off label use of duloxetine as an option for patients with a history of substance misuse, as recommended in the prison prescribing guidance(3).

    1. Summary of product characteristics http://www.medicines.org.uk/EMC/medicine/14651/SPC/Lyrica+Capsules/ 2. Canadian Agency for Drugs and Technologies in Health: Abuse and Misuse Potential of Pregabalin: A Review of the Clinical Evidence; April 2012 http://www.cadth.ca/media/pdf/htis/april- 2012/RC0348%20Pregabalin%20draft%20report%20Final.pdf 3. Royal College of General Practitioners & Royal Pharmaceutical Society: Safer Prescribing in Prisons Nov 2011 http://www.rcgp.org.uk/news/2011/november/~/media/Files/News/Safer_Prescribing_in_Prison.ashx

    Conflict of Interest:

    None declared

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  4. Mole checks on the high street

    Dear Sir,

    As a dermatologist involved in skin cancer management I read with interest your article on mole checks on the high street and the concerns raised by the All Party Parliamentary Group on Skin (APPGS). I gave evidence to the APPGS and shared their concerns regarding the lack of training in skin cancer diagnosis, for staff performing the clinical examination in such clinics. The high street mole screening clinics were invited to give evidence of their governance standards by the APPGS in 2008 and were criticised in the report for failing to do so. To highlight the potential prevalence of misdiagnosis on the high street I would like to give evidence about two cases seen within a month, to support the concerns raised by the APPGS.

    Case 1. A 46 year old lady presented requesting excision of a lesion on her chin. She had recently visited a high street mole screening clinic, where she was diagnosed with a suspected basal cell carcinoma (BCC). A clinical and dermoscopic image had been taken and was sent for an overseas tele-dermoscopic opinion. She received a phone call and a report 24 hours later which confirmed a lesion suspicious for a BCC, and advised to have surgery. Having prepared herself for surgery she attended my clinic where a benign intradermal naevus was confirmed and she was reassured that no surgery was required. This case does illustrate the limitations of tele- dermoscopy when the referring ‘clinician’ is not medically trained, which therefore gave false suspicion on a very benign lesion. Additionally teledermoscopy for pink lesions has been shown to be less accurate than face-to face diagnosis even for experienced dermatologists. 1

    Case 2. A 32 year old man with a previous history of BCC sought skin cancer screening as he had moved to the UK. He had a 12 month history of a persistent pink macule on the right side of his neck at the edge of the scar of his BCC excision. He was screened by a non-medically qualified practitioner and a SIAScopic image was taken and sent for a remote (within the UK) expert diagnosis. He received a report 3 weeks later stating that all was well. The pink area remained and he sought a second opinion. On examination he had an obvious clinical recurrence of his BCC. This was completely excised and confirmed on histology. There were a number of errors in his management. Firstly the history of previous BCC excision at this site would make a diagnosis of recurrence highly suspicious on clinical history alone. Secondly too much weight was placed upon a SIAScopic image alone and not in the context of the history, leading to misdiagnosis and mismanagement. The blood vessel patterns of BCCs can be non-specific, from simple erythema to the typical arborizing telangiectasia; the pressure applied for image acquisition may also impair vascular structures. Thus the importance of an expert making the clinical diagnosis face to face of pink lesions in patients at risk for skin cancer should not be underestimated. 1 Additionally SIAScopy, a diagnostic tool not routinely used by dermatologists, has been independently shown to be less accurate than dermoscopy, which is the standard diagnostic tool for skin lesion diagnosis. 2-3A large study, assessing the role of SIAScopy as a diagnostic tool in primary care, is due to conclude in 2010.4 However, until the results are available one cannot assume that this technology is validated as a diagnostic test, without the support from evidence of this study. Therefore the use of this technology at the present time is contrary to the UK National Screening Committee recommendations for screening where there should be ‘ a simple, safe, precise and validated screening test’.4

    These two cases reflect the potential for misdiagnosis of skin cancer that may occur when commercial organisations and non-experts are involved in skin cancer diagnosis, namely a false positive or a false negative diagnosis. Sadly these two cases may be the tip of the iceberg as I have additional cases and I am aware of other dermatologists having similar experiences, although with an absence of a central database for reporting such activity formal evidence may be lacking. These cases do however support the concerns raised by the APPGS on the standard of diagnosis at these clinics and additionally give evidence towards poor standard of care as illustrated. Further evidence should be sought to answer or dispel the concerns of the APPGS more thoroughly. With the evidence supplied, the continuing expansion of high street clinics offering skin cancer screening is a concern particularly as many such clinics promote themselves to the public as the experts in mole diagnosis and skin cancer screening; the public should be made aware that firstly there is no evidence to support this claim and secondly evidence to the contrary exists.

    References 1. Fabbrocini G et al. Telediagnosis and face-to-face diagnosis reliability for melanocytic and non-melanocytic 'pink' lesions. J Eur Acad Dermatol Venereol. 2008 Feb;22(2):229-34

    2. Haniffa MA, Lloyd JJ, Lawrence CM. The use of a spectrophotometric intracutaneous analysis device in the real-time diagnosis of melanoma in the setting of a melanoma screening clinic. Br J Dermatol. 2007 Jun;156(6):1350-2 3 Glud M, Gniadecki R, Drzewiecki KT. Spectrophotometric intracutaneous analysis versus dermoscopy for the diagnosis of pigmented skin lesions: prospective, double-blind study in a secondary reference centre. Melanoma Res. 2009 Jun;19(3):176-9 4. MoleMate™ UK Trial: The management of suspicious pigmented lesions in primary care

    5. UK National Screening Committee. Criteria for appraising the viability, effectiveness and appropriateness of a screening programme (see www.library.nhs.uk/screening)

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