10 e-Letters

  • Patient Centred Approaches to the Prescribing of Anti-depressants

    I find it concerning that the authors pay no attention to the use of Shared Decision Making regarding the use of anti-depressants. Many patients have and continue to benefit from being prescribed an anti-depressant. It is important within prescribing that patients' views, experience and preferences are given due regard.

  • Response to Jauhar S, et al.

    We appreciate the interest in our article by Jauhar and colleagues and welcome the opportunity to address a number of misleading points in their letter.  


    No argument they raise undermines our central points: antidepressants do not demonstrate a clinically important difference from placebo according to any suggested threshold, including that proposed by NICE, empirical correlation with clinician evaluation or other means. There is no conclusive evidence of an above-average response sub-group so far demonstrated. The evidence for relapse prevention properties is highly problematic because of confounding by withdrawal effects. Common adverse effects are well-established, a...

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  • Response to: Horowitz M, Wilcock M. Newer generation antidepressants and withdrawal effects: reconsidering the role of antidepressants and helping patients to stop. Drug and Therapeutics Bulletin 2022;60:7-12.

    We read with interest the opinion piece by Horowitz and Wilcock [1], which highlights ‘considerable uncertainty about the benefit of antidepressant use in the short- and long-term’ and ‘the uncertain balance of benefits and harms’ with antidepressants, within its key learning points. We wish to counter these and address other assertions within their narrative review.

    In the section ‘Questions relating to efficacy’, the authors mention meta-analyses with newer generation antidepressants (principally the selective serotonin reuptake inhibitors [SSRIs] and serotonin-noradrenaline reuptake inhibitors [SNRIs]) which show a difference from placebo of around 2 points on the Hamilton Depression Rating Scale (HDRS), noting this does not meet thresholds of 3-, 5- or even 6-point differences, regarded by some as indicating a minimally clinically important difference.

    This is taken from data on the antidepressant mirtazapine (neither an SSRI nor SNRI) plotting change in HDRS against clinically important difference [2]. This does not have any relevance for SSRIs or SNRIs, as mirtazapine, by its effects on sleep and somatic symptoms, will exert large effects on HDRS without necessarily affecting low mood. The selection of a point on this graph was not made by authors of the original paper [3], and within-group changes from that selected study cannot be extrapolated to placebo-drug differences: a point made explicit by experts in this area [4], and by us in response to Dr H...

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  • Flawed methodology leading to flawed conclusion

    Dear D&T team,

    Thank you for highlighting this paper which attempts to answer an important clinical question.
    I read the DTB summary which reflects the published abstract and the authors' conclusions. Unfortunately this paper has a major flaw as the main CYP "interaction" seen in the study group and therefore studied was Atorvatsatin / Rivaroxaban .
    It has been well established that there is no clinically significant interaction between atorvastatin and rivaroxaban whatever the "clinical practice research database" might say.

    Therefore this study finds mainly that there is no interaction between two pairs of drugs that do not interact- atorvastatin and rivaroxaban and digoxin and rivaroxaban.
    The authors incorrectly extrapolates this finding to actual CYP 3a4 inhibitors although there is an exploratory finding of enhanced bleeding risk with these agents.
    In our busy world people may not have time to delve beyond the abstract and key points and may make an erroneous prescribing decision based on this.
    The finding related to SSRI use is very valuable and should be born in mind.

  • Yes, an important place for depot triamcinolone in hay fever!

    We commend the author’s endeavours to present an unbiased review concerning depot triamcinolone. However, this review cannot be judged a total success; there are numerous flaws that cry out to be corrected. The most important issue is the excessive focus on potential side effects, that are generally regarded as of minor significance.
    We understand that this is a somewhat lengthy comment, but since the journal states that ‘critique and disagreement are important features of science’, we hope that we are allowed to express our opinion in order to be able to promote further debate.

    The title, negatively framed, states ‘Still no place for depot triamcinolone in hay fever?’ and we get the feeling that the author already skipped the question mark and directly continued with the key learning point that ‘in 1999, Drug and Therapeutics Bulletin (DTB) noted that despite the likelihood that a single injection of triamcinolone will relieve hay fever symptoms, there was uncertainty about the efficacy and safety of repeated administration’.1
    This notion is too easily repeated in the current conclusion. The first part of the first sentence of the conclusion section informs us again that a single injection of triamcinolone has likelihood that it will relieve hay fever symptoms. The fact that it probably causes symptom reduction should be enough reason to explore the possible indications for this therapy.
    Therefore, the only logical conclusion should have been that...

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  • Mucopleurastasis: A description of the phenomena of patients reporting the symptom of being ‘caught in the chest’.

    Medicine has a long history of having its own technical and discriptive language.

    This has often developed from observations of medical phenomena being explored and cataloged scientifically, presented in a way that is descriptive and useful for clinicians.

    Ireland is a country defined by it literature. It is famous for its coloquial language and linguistic idiosyncrasities. From Joycian ‘chamber music’ to Wildes’ wit and Irish idioms like ‘being away with the fairies’, it is clear that we more than most have our own way with words.

    This is not disimilar to many parts of the world where dialects have evolved to better represent the cultural nuiances of the given area. In many ways language evolves out of a need to communicate amongst each other.

    In Ireland, specifically the geographically isolated West coast, many patients present to their family doctor reporting that they are ‘caught in the chest’. For some, particularly as you move away from the West and certainly out of Ireland, this may seem an unusual symptom or at least an unusual turn of phrase, but for a GP from the West of Ireland, this presentation occurs at least several times a day and more frequently during the winter months.

    So what exactly is the message that these patients are trying to convey and why indeed is it such a common presentation?

    This description of the sensation they are experiencing generally refers to patients with respiratory tract type infections. M...

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  • Mole checks on the high street
    Jonathan C Bowling

    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 screeni...

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  • Neuropathic pain and pregabalin
    Barbara Pawulska

    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 b...

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  • Prescribing perfectly
    Robert M Ulmann

    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 a...

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  • GPs 'wasting millions of pounds' prescribing gluten free foods
    John R. Davies

    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 ass...

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