Top ten drugs in Australia


Top 10 drugs
(Aust Prescr 2011;34:172)
These tables show the top 10 subsidised drugs for the year July 2010 – June 2011.
Table 1
Top 10 drugs supplied by DDD/1000 pop/day *, 
Drug PBS/RPBS 
1. atorvastatin 82.87
2. irbesartan 33.02
3. rosuvastatin 32.37
4. perindopril 29.94
5. paracetamol 26.88
6. ramipril 26.16
7. candesartan 25.25
8. simvastatin 23.90
9. esomeprazole 21.32
10. amlodipine 19.92
DDDs in this table include use in combination products
Table 2
Top 10 drugs by prescription counts 
Drug PBS/RPBS 
1. atorvastatin 11 020 969
2. esomeprazole 6 099 877
3. rosuvastatin             5 975 902      
4. paracetamol             4 840 331      
5. simvastatin             4 245 616      
6. perindopril             3 995 257      
7. pantoprazole 3 549 374
8. metformin hydrochloride             3 383 078      
9. irbesartan             3 098 162      
10. atenolol             3 070 515      


Table 3
Top 10 drugs by cost to government 
Drug Cost to government DDD/1000/day * Prescriptions
($A) PBS/RPBS  PBS/RPBS 
1. atorvastatin 637 426 978 82.87 11 020 969
2. rosuvastatin 334 168 383 32.37             5 975 902      
3. ranibizumab 310 399 773 –  146 272
4. esomeprazole 184 167 326 21.32 6 099 877
5. clopidogrel 173 946 446 10.94             2 774 567      
6. salmeterol and fluticasone 173 934 061 – §             3 065 047      
7. adalimumab 173 892 033 0.33 97 834
8. olanzapine 161 933 986 2.99 950 386
9. simvastatin 139 642 087 23.90             4 245 616      
10. etanercept 122 729 015 0.24 69 742


* The defined daily dose (DDD)/thousand population/day is a more useful measure of drug utilisation than prescription counts. It shows how many people, in every thousand Australians, are taking the standard dose of a drug every day.
Based on date of supply. Does not include private prescriptions or prescriptions under PBS co-payment.
PBS Pharmaceutical Benefits Scheme, RPBS Repatriation Pharmaceutical Benefits Scheme
The World Health Organization has not allocated a DDD for this drug
§ This combination does not have a DDD allocated
Source: Drug Utilisation Sub-Committee (DUSC) Database, as at September 2011. © Commonwealth of Australia.


FDA Is Petitioned To Add Black Boxes For PPIs


Diagram depicting the major determinants of ga...Image via Wikipedia

nexium-flickrThe widely used class of drug known as proton pump inhibitors that are used to treat acid reflux can cause dependency and, therefore, are likely to increase various serious risks, some of which are not specified in product labeling, according to Public Citizen. And so the consumer watchdog is petitioning the FDA to upgrade labeling for these meds with Black Box warnings.
In making its case, Public Citizen notes that patients who use PPIs for at least a month, but then stop taking the med can have even more stomach acid, which is called rebound acid secretion. As a result, patients may return to the meds, creating what the watchdog group calls a “long-term dependence.” Yet some patients may not need the meds in the first place, Public Citizen argues.
“PPIs are often prescribed outside of their approved uses, for purposes such as stress ulcer prophylaxis in noncritical hospitalized patients and long-term treatment of conditions such as GERD past the approved time frame. It has been estimated that up to two-thirds of all people on PPIs do not have a verified indication for the drug. In addition, even in many people with presumed GERD on PPI therapy, less intense acid-suppressive therapies are effective in relieving symptoms, and in other cases, the medical problem does not even involve acid reflux,” the group writes in its petition.
“Compounding the problem of massive inappropriate use, recent evidence has documented several serious new safety problems with long-term PPI use. For some of these risks, current FDA-approved PPI labels do not mention the adverse effect at all, including the potential for developing dependence on the drugs, which results in rebound hypersecretion of stomach acid and recurrence of symptoms after stopping PPI use. For other risks, even if mentioned, the label does not adequately explain or emphasize them. There are currently no black box warnings in the label of any PPI” (you can read the petition here).
To bolster its cause, Public Citizen enlisted Helge Waldum, who heads of the Department of Digestive and Liver Diseases at Trondheim University Hospital in Norway and has authored dozens of medical journal articles on PPIs, including what is said to be the first trial to show patients could become dependent on the meds through the so-called rebound effect. He signed on as a co-petitioner (and you can read his statement here).
In response, a spokeswoman for AstraZeneca, which sells Nexium, Prilosec and Vimovo, wrote us this: “We work with the FDA to ensure the benefit/risk profile of our products are reflected appropriately in the prescribing information so that health care professionals can weigh the risk and benefit of medicines when making treatment decisions. PPIs have been available in the US for over 20 years and are among the most widely-studied class of medicines.
“The data referred to by Public Citizen is in the public domain and available to regulators and physicians across the world. Ultimately, it’s up to doctors to prescribe these medicines based on individual patient need. We encourage ongoing communication between physicians and patients concerning individual medical needs. AstraZeneca is confident in the positive benefit-riskand safety profiles of NEXIUM, PRILOSEC and VIMOVO.”

Antipsychotics Increase Adiposity, Insulin Resistance in Children


Source: http://www.familypracticenews.com

SAN DIEGO – Significant increases in adiposity and insulin resistance quickly became apparent in a 12-week study of low-dose antipsychotics to treat mainly nonpsychotic disorders in 144 children.
Newer, “atypical” antipsychotics increasingly are being used to treat mood and disruptive behavior disorders in children, Dr. John W. Newcomer said at the annual meeting of the American Diabetes Association
“It’s a topic of increasing concern in a number of state Medicaid” systems, he said. Concerns have been generated in part by data showing premature mortality in people with mental disorders that’s related primarily to cardiovascular disease but also to cardiometabolic risk.
Children in the open-label study were randomized to flexibly dosed treatment with risperidone, olanzapine, or aripiprazole. It was their first use of antipsychotics.

Dr. John W. Newcomer
    
These were “very low doses,” he emphasized. “These are not doses that would be used to treat a psychotic disorder,” said Dr. Newcomer, who led the study while at Washington University, St. Louis. He now is a professor of psychiatry and behavioral sciences at the University of Miami.
The 5-year Metabolic Effects of Antipsychotics in Children (MEAC) study targeted symptoms of aggression and irritability in patients aged 6-18 years. “Typically, they had been suspended from school,” he said.
The main primary diagnosis was treatment-refractory attention deficit hyperactivity disorder (ADHD) in 57% of patients. “This is what clinicians are using these drugs for in this type of public-sector population – kids who fail two or three courses of stimulants who then are looking for some other treatment.”
Other main diagnoses included oppositional defiant disorder in 22%, pervasive developmental disorder in 6%, bipolar disorder in 4%, and major depression in 3%. Smaller proportions of patients were diagnosed with other mood disorders, Asperger’s syndrome, autism, obsessive-compulsive disorder, or Tourette’s syndrome.
Mean doses were 1 mg/day in the 49 patients on risperidone, 6.3 mg/day in the 46 patients on olanzapine, and 6 mg/day in the 49 patients on aripiprazole. Approximately half of patients also were on stable doses of stimulants for ADHD.
Total body percentage of adiposity increased 2.4% after 12 weeks on antipsychotics – slightly less than a standard deviation, and a highly significant change, Dr. Newcomer and his associates reported. Mean total fat increased 2.3 kg, they added.
The percentage body fat increased the most in the youngest children. Greater changes were seen with olanzapine than with risperidone or aripiprazole. About a fourth of patients on risperidone or aripiprazole showed little change in body fat, but three-quarters on those drugs and nearly all patients on olanzapine showed increases.
Whole-body insulin sensitivity decreased approximately from 8 mg/kg per minute to 7 mg/kg per minute, a significant reduction. Olanzapine produced the greatest reduction in whole-body insulin sensitivity.
Importantly, scores for irritability and aggression improved in all groups, he added.
“I’m not a child psychiatrist. I was not terribly sympathetic to this at the beginning” of clinicians’ use of antipsychotics for these indications, said Dr. Newcomer, who chaired the Drug Utilization Review Board for Missouri Medicaid for 14 years. “But I was educated by the psychiatric outcome. There was really profound psychiatric symptom improvement, with kids going back to school and [behaving differently],” he said. The psychiatric response was similar among treatment groups in the study.
As early as 6 weeks after starting therapy, significant changes could be seen on adiposity. Children with the biggest changes in body fat showed effects within the first month of treatment.
Height, weight, waist circumference, body mass index, and BMI percentile were measured at all visits. At baseline and at 12 weeks, investigators performed dual-energy x-ray absorptiometry (DEXA) scans and MRI to assess changes in adiposity, hyperinsulinemic euglycemic clamp with isotopomers to assess changes in insulin sensitivity, plasma sampling (such as oral glucose tolerance test or measuring fasting glucose and lipids), ECG, and psychiatric ratings. At the 6-week follow-up, patients underwent DEXA, oral glucose tolerance testing, and lab measures of fasting status.
A previous nonrandomized study of 272 antipsychotic-naive children and adolescents reported weight gains of 4-8 kg and increases in BMI percentile for patients taking any of four atypical antipsychotics for a median of 11 weeks, compared with a control group (JAMA 2009;302:1811-2).
The study’s design raised concern that the effects could be larger than reported, however, because overweight or obese children were assigned to drugs considered to have the lowest risk for weight gain, Dr. Newcomer said.
In a post-hoc analysis, Dr. Newcomer showed that at the start of the current study, the children had similar rates of overweight or obesity as did children in the general population, but rates were higher in the cohort by the end of the study. The rate of overweight or obese children in the cohort increased from about 33% to 48%.
“I’m personally skeptical about the idea that it’s the psychiatric disorders themselves that are the metabolic challenge, rather than the treatment being the primary effect,” he said.
Medicaid data suggest that 43% of prescriptions for atypical antipsychotics are for indications that are not backed by evidence justifying use, he said. Visits to U.S. physicians that included prescriptions for antipsychotics to patients aged 20 years or younger more than doubled between 1997 and 2002, to a rate greater than 1,400 per 100,000 visits, a separate study reported (Arch Gen. Psych. 2006;63-681).
The National Institutes of Health funded the study. Dr. Newcomer has been a consultant for or received grants from Janssen Pharmaceuticals Inc., Pfizer Inc. , AstraZeneca, Bristol-Myers Squibb, Otsuka Pharmaceutical Co. Ltd., Schering/Merck, Vivus Inc., Obecure Ltd., Biovail Corp., Lundbeck A/S, Sanofi, and Dainippon Sumitomo Pharma Co. Ltd./Sepracor Inc.
Use Judiciously, Monitor Carefully

We know from a variety of studies in adults using atypical antipsychotics that there is a range of potential weight gain seen with this class of agents. With these agents also being used in children for major mental health concerns, it’s important to have information from studies like Dr. Newcomer’s on the metabolic effects in that age group.
The challenge is finding the balance between selecting the agent that works best for the child and monitoring very carefully for things like rapid weight gain, higher blood glucose values, and issues that may be associated with these metabolic disturbances such as high levels of triglycerides or increases in appetite.

Dr. David M. Kendall
    
Weight gain is part and parcel of our environment, and in many cases is attributed to the availability of calorie-dense foods and decreased physical activity. If we have medications that add to that, in this case the atypical antipsychotics, we have to be judicious about using these medications. Clinicians need to be very attentive, both the in specialty setting and the primary care setting, to watch for changes such as rapid weight gain, and then offer alternative therapies if they are available.
As we’ve learned with adults, anyone who is considering prescribing this class of medications should carefully monitor body weight, plasma glucose (an obvious measure of changing glucose tolerance), and other associated risk factors like blood pressure and blood lipids, which can change as adiposity changes. I think it would be critical to monitor all of those in a situation like this.
Dr. David M. Kendall is chief scientific and medical officer for the American Diabetes Association, Alexandria, Va. He said he has no relevant conflicts of interest.
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Epidemiología de los factores de riesgo cardiovascular en España


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Grau M, Elosua R, Cabrera de León A, Guembe MJ, Baena-Díez JM, Vega Alonso T et alFactores de riesgo cardiovascular en España en la primera década del siglo xxi : análisis agrupado con datos individuales de 11 estudios de base poblacional, estudio DARIOS. Rev Esp Cardiol 2011; 64: 295-304.   TC   PDF

Introducción

Los estudios publicados sobre la epidemiología de los factores de riesgo cardiovascular en España han obtenido resultados discrepantes y la Encuesta Nacional de Salud únicamente ofrece información sobre la prevalencia previamente diagnosticada de los mismos.

Objetivo

Analizar la prevalencia conjunta de facotres de riesgo en 11 estudios desarrollados en 10 comunidades autónomas en la primera década del siglo XXI y determinar el grado de variabilidad geográfica en su distribución.

Perfil del estudio

Tipo de estudio: Metaanálisis
Área del estudio: Prevención
Ámbito del estudio: Comunitario

Métodos

Se incluyeron en el estudio DARIOS 10 estudios epidemiológicos que incluían individuos de 35-74 años (excepto uno que incluía personas de 49 a 74 años). Todos ellos utilizaron la encuesta estandarizada de la OMS, que recoge datos sobre variables sociodemográficas, consumo de tabaco y antecedentes de HTA, hipercolesterolemia y diabetes. Asimismo en todos ellos se habían tomado medidas antrompométricas (talla, peso, IMC, PA) y de laboratorio (glucemia y perfil lipídico).
A partir de estos datos se calculó la prevalencia de HTA conocida y real, diabetes mellitus (DM) conocida y real e hipercolesterolemia conocida y real (con cifras de colesterol total ≥250, ≥240 y ≥190 o de colesterol LDL ≥115 o ≥160).

Resultados

Se incluyó en el estudio a casi 29.000 individuos de 10 comunidades autónomas que representan el 70% de la población española. La edad media fue de 54 años y un 54% de los participantes eran mujeres. Se encontró una heterogeneidad significativa entre estudios para muchas de las variables analizadas.
Las prevalencias reales y conocidas para los diferentes factores de riesgo se recogen en la figura 1. La prevalencia de factores de riesgo fue superior en varones que en mujeres para todos los analizados con la excepción del perímetro abdominal.
Figura 1Prevalencias estandarizadas reales y conocidas de diferentes factores de riesgo.

Conclusiones

Los autores concluyen que la prevalencia de los factores de riesgo cardiovascular en España es elevada con escasa variabilidad entre comunidades autónomas.

Conflictos de interés

Ninguno declarado. Financiado por Astra-Zeneca.

Comentario

La principal fortaleza de este estudio es que permite estimar la prevalencia actual de los principales factores de riesgo cardiovascular en España, dado que la población cubierta por las poblaciones en las que se han llevado a cabo los estudios de los que se han analizado los resultados cubren un 70% de la población estatal. Otras fuentes de datos, como la Encuesta Nacional de Salud se basan en las declaraciones de los individuos sin que se hayan validado con medidas objetivas, por lo que son más bajas y no permiten conocer cuál es la proporción de morbilidad no diagnosticada (fig. 2). En cualquier caso, las diferencias son inferiores a las que se habían detectado en estudios previos, lo que se interpreta como un reflejo de un mayor cribado de la población.
Figura 2Prevalencia de los factores de riesgo cardiovascular en el estudio DARIOS y en la Encuesta Nacional de Salud 2006.
Otro dato interesante es la prevalencia de la hipercolesterolemia en función de cuál sea el punto de corte elegido. Si el punto de corte se establece en 250 mg/dL, aproximadamente el 40% de la población entraría dentro de la definición de hipercolesterolemia, mientras que si se reduce a 190 mg/dL, la proporción es de 80%. Si tenemos en cuenta que la mortalidad por enfermedades cardiovasculares en España es relativamente baja, supondría medicalizar a una parte muy importante de la población para obtener un beneficio escaso. Por lo tanto, estas cifras que aparecen en algunas guías de práctica clínica de prevención cardiovascular deben tomarse más como un objetivo ideal al que tender que un punto de corte para la actuación médica.

Bibliografía

  1. Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R et alEuropean guidelines on cardiovascular disease prevention in clinical practice: executive summary: Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J 2007; 28: 2375-2414.   TC (s)   PDF (s)
  2. Bambs C, Kip KE, Dinga A, Mulukutla SR, Aiyer AN, Reis SELow Prevalence of `Ideal Cardiovascular Health´ in a Community-Based Population: The Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) Study. Circulation 2011; 123: 850-857.    TC (s)   PDF (s)
  3. Villar Álvarez F, Banegas Banegas JR, Donado CJ, Rodríguez-Artalejo F. Las enfermedades cardiovasculares y sus factores de riesgo: hechos y cifras. Informe de la Sociedad Española de Arteriosclerosis 2007. Madrid: Sociedad Española de Arteriosclerosis. 2007.

Autor

Manuel Iglesias Rodal. Correo electrónico: mrodal@menta.net.
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