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									              The Script Press
                                                                     Issue 48, September 2007

Duloxetine: marketed as Cymbalta                 Second HPV Vaccination Licensed For
and Yentreve  for different disorders            Use
Duloxetine is indicated for treatment of three    A second HPV vaccination is now licensed for
different disorders – major depressive disorder   use in the UK. Practices are reminded that in
and diabetic neuropathy (marketed as              June the Government agreed in principle that
Cymbalta) and the treatment of stress            girls aged around 12 to 13 years of age should
urinary incontinence (marketed as                 be vaccinated against HPV. The Joint
Yantreve).                                       Committee on Vaccination and Immunisation,
                                                  the body of experts which advises the
                                                  Government on vaccination issues, is expected
Cases of suicidal ideation and suicidal
                                                  to make formal recommendations to Health
behavior have been reported during
                                                  Ministers later this year.
treatment with duloxetine or early on after
stopping treatment. Patients and caregivers
should be asked to monitor and report to their    A decision on whether other age groups should
doctor any distressing thoughts of self-harm if   be able to benefit from a national vaccination
                                                  programme against cervical cancer is still
they occur at any time during or after
treatment with duloxetine.
                                                  Please await further guidance from your
   Cymbalta and Yentreve should be               Prescribing Adviser.
    prescribed for their correct intended use,
    and should not be used together               Also inside This Issue                       Page
   The benefit to the patient of taking          Competition to WIN a Luxury Hamper             2
    duloxetine (Cymbalta) for diabetic            for the best display
    neuropathy should be assessed by a            Advice regarding Ramadan                       2
    doctor at least every 3 months                COMVIBENT® inhaler –                           2
   The benefit of duloxetine (Yentreve) for      discontinuation announcement
    patients with stress urinary incontinence     Brief Advice to Stop Smoking: a                2
    should be assessed regularly                  clinical imperative
   Duloxetine should not be prescribed to        Prescribing low-cost statins                   2
    patients who have: liver disease leading
    to impaired liver function; severe kidney
    impairment; uncontrolled hypertension         Yellow Card Scheme Update
                                                  The Yellow Card scheme collects information from
   Duloxetine should not be prescribed to        healthcare professionals and patients on suspected
    patients who are also taking: non-            adverse drug reactions.
    selective, irreversible monoamine oxidase
    inhibitors for depression; fluvoxamine for    The MHRA encourage healthcare professionals and
    depression or obsessive compulsive            patients, parents and carers to send reports for:
    disorder; or ciprofloxacin. Cymbalta
    should be used with caution alongside            All adverse drug reactions associated with
    other antidepressants or St John’s Wort.          black triangle  drugs and vaccines (ie, those
    The use of Yentreve in combination with           new to the market and monitored intensively)
    antidepressants is not recommended.              All adverse drug reactions in children
   Patients should avoid abrupt withdrawal           associated with a drug or vaccine
    of treatment from duloxetine. Healthcare         All serious reactions associated with
    professionals should prescribe gradually          established drugs and vaccines
    reduced doses over at least 1-2 weeks to         Suspected delayed drug effects; congenital
    minimize withdrawal reactions. If a               abnormalities; and adverse drug reactions
    patient has intolerable symptoms after            associated with herbal remedies
    decreasing or stopping Cymbalta or
    Yentreve, the drug may be re-prescribed       Please continue to send Yellow Cards to the
    or the dose increased; any subsequent         CSM, in line with the guidance above. For further
    reductions in dose may be done more           information, see
Competition to WIN a Luxury Hamper
By now practices and community pharmacies                                 If you win, one suggestion for sharing out the
should have started to receive their support                              goods in the hamper is to use cloakroom tickets
materials to deliver the West Midlands wide                               and stick a ticket to each of the products; the
Medicines Waste Campaign.                                                 other halves of the tickets are then shared out
                                                                          among the members of staff to allocate prizes
For a chance to win a
luxury hamper full of                                                     The closing date for entries is 31st October 2007.
goodies worth £200,
please enter our                                                          COMBIVENT® inhaler – Discontinuation
display competition.                                                      Announcement
All you need to do is                                                     Boehringer Ingleheim Ltd has provided early
create an eye                                                             notification regarding the planned discontinuation
catching display using                                                    of Combivent® Metered Aerosol during 2008. The
the materials provided                                                    company emphasise that the decision is driven
and submit a                                                              solely by the restriction in the use of CFCs. It is in no
photograph of it to                                                       way based on the safety profile, effectiveness or (If you need any                            quality of the product itself. Combivent® UDVs®
help with taking the digital image, please do not                         will continue to be available.
hesitate to contact us and we will be able to help).

Brief Advice to Stop Smoking: a clinical imperative
Brief advice to stop smoking from a clinician is the Gold Standard of prevention interventions.
No other preventive activity produces such significant results from such a small investment in
time. Failure to discuss cessation could be regarded as falling short of good clinical

The following Numbers Needed to Treat (NNT) for various routine preventive interventions
demonstrates why brief advice to stop smoking is called the Gold Standard of preventive

Intervention                                                    Outcome                                                         NNT
Statins1                                                        Prevent one death over five years                                 107
Antihypertensive therapy        2                               Prevent one stroke, MI, death over one year                       700
Cervical cancer screening           3                           Prevent one death over ten years                                  114
GP brief advice to stop smoking < five minutes            4     Prevent one premature death*                                       80
Add pharmacological support 5                                   Prevent one premature death*                                   38-56
Add behavioural support 6, 7                                    Prevent one premature death*                                   16-40

* Over half of all continuing smokers will die prematurely from a smoking-related disease. For every two long
term quitters, one premature death is avoided 8
(1) Statins, NNTs & risk. Bandolier @ (2) Implementing NNTs. Bandolier @ (3) Gates TJ. Screening for cancer: evaluating the evidence. Am
Fam Phys 2001; 63(3):513-522 (4) West R. Smoking and smoking cessation in England: 2006. (5)
Bandolier 2006 @ (6) Levinson et al. Health Educ. Res. 2007(August) (7) Anthonisen et
al. Ann Intern Med, Feb 2005; 142: 233 - 239 (8) Doll & Peto. BMJ, Jun 2004; 328: 1519

The media coverage of the prescribing of low cost statins, especially the recent reports concerning
atorvastatin switches, is making it more difficult for practices to reach and maintain the >75%
target. In recognition of the increased work required by practices to reach target, the Prescribing
Board has secured an additional £400 per 1000 patients for this incentive. Practices reaching the
target will therefore now receive £700 per 1000 patients. The Prescribing Board will also consider
rewarding practices that have made significant progress but have just failed to meet the 75%

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