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Essentials Correspondance PDF

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Correspondence

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Gender differences in stroke risk in atrial fibrillation

I found the article on atrial fibrillation and flutter most informative, but I was surprised by the five year stroke risk graph on page 15 (Issue 2). Is it correct that women have higher stroke risks than men for ALL age groups? My understanding was that men had a higher risk of IHD and stroke than women irrespective of age. I checked the reference in the NZ Guidelines and this seemed not to be a printing nor transcription error. Could you please clarify this for me? I’m sure other GPs will be wondering the same.

Dr Bruce Sutherland
Warkworth

Bruce is right, other GPs did ask the same question. The risk of ischaemic stroke in atrial fibrillation is higher in women than men in younger and older age groups. Even controlling for known stroke risk factors such as prior cardiovascular disease and diabetes, the risk of ischaemic stroke is greater. A recent study reports a rate ratio of 1.5 (CI, 1.2-1.8).1 We will follow up on this topic in our next issue of best practice journal.

Editor

  1. Fang M, et al, Gender differences in the risk of ischaemic stroke and peripheral embolism in atrial fibrillation. The Anticoagulation and factors in Atrial fibrillation (ATRIA) Study. Circulation 2005; 112:1687-1691.

Use of salbutamol inhalers

In the report section of best practice journal (Issue 2) you discussed the excessive use of salbutamol inhalers. The Waikato Community Pharmacy Group “Dump” campaign found that the group of medications known as inhaled respiratory medication, which included inhaled beta-agonists represented by far the largest proportion of wasted medication in our project. What is being measured as dispensings does not truly represent usage. In fact, the dispensing rules relating to stat dispensing, result in more inhaled beta-agonists being dispensed than pharmacists would prefer.

For example if a prescription is written: Ventolin inhalers, inhale 2 doses prn as directed, 3xop (as is often the case). Pharmacists are obliged to dispense all three inhalers at once, even if the patient does not want or need this. If pharmacists initiate close control dispensing, so that they can give one inhaler plus two repeats, they are accused of colluding to increase the number of dispensing fees they receive.

My point is that I don’t think it is a wise conclusion that medicines are excessively used when this conclusion is based on prescribing patterns. Over prescribed perhaps, over dispensed probably, but I think this is a direct result of the stat dispensing rules which apply to this group of medicines.

Please inform prescribers to be more specific. The best approach is to prescribe accurately to reflect current usage and inform patients they do not have to pick up repeats if they are not needed.

Tom Bennett
Hillcrest Healthcare
Hamilton
(slightly abridged)

We agree with Tom that prescribing is greater than dispensing, which in turn is greater than usage and this probably applies across all medicines. Our reports are usually based on dispensing data as a proxy for prescribing data, which is not available to us.

We can only endorse Tom’s plea for more accurate prescribing.

Editor