At 12:54 PM 8/27/98 +0100, you wrote:
>I have had major problems getting hold of good evidence concerning th
frequency
>of tests for patients on 2nd-line drugs, lithium, etc. A local
rheumatologist
>(in Bristol) is now asking for *monthly* checks for salazopyrine, including
>LFTs; and a local psychiatrist for 3-mthly lithium checks incl
TSH/creatinine.
>Has anyone researched this whole issue - if so who, when & with what
>conclusions?
>
Tim,
About 5 - 6 years ago I was involved in looking at this as a MAAG project
with a number of GP colleagues. As I recollect we looked at Lithium,
Salazopyrine, Diuretics, Digoxin, ACE inhibitors, Warfarin,
anti-convulsants and perhaps 1 or 2 others (papers not to hand at present).
There was a lot of literature in some areas but even where it existed it
was often of poor quality.
Obviously the detail of the work we did should be considered out of date
but I'd suggest two principles.
1) Broadly the same criteria applied to a screening test in a healthy
population should be applied to this kind of screening drug surveillance.
Although one can argue that because drugs are being prescribed we should be
somewhat more interventionist there are still questions about whether the
monitoring
detects problems sooner than they would detected clinically
allows effective changes of treatment to alter the outcome
is based on tests with a high degree of specificity and sensitivity
is cost benefit effective
is acceptable to patients.
If one applies this to Warfarin the answers are at least moderately well
worked out.
As I recollect Salazopyrine caused more S/Es in rheumatoid sufferers than
in patients with UC so the general clinical picture is also important.
2) It is up to the consultant to provide you with the evidence if he / she
wants you to do the test. He can make his own clinical decisions. If he
wants to persuade you it's his job to find persuasive enough evidence.
Given that this kind of monitoring is not (in my view) core GP work if
you're in doubt you can simply leave him to do all the tests himself.
Patient acceptability may then become an issue, especially if they find out
that his imposition on them is not evidence based.
However he may have excellent reasons and just not have communicated yet.
He / she is the one paid to know, if he / she doesn't and still insists
there may be a larger problem with patient care.
HTH
JB
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