How can GPs best decide if a new medication is right to prescribe?

Doug Hendrie

8/06/2018 1:49:49 PM

Almost 800 new medications came onto the Australian market between 2001 and 2011.

Which medication is the best fit?
Which medication is the best fit?

Many of the new medications that hit the Australian market in the decade from 2001–11 were highly specialised.
However, some are of use to GPs, and might even replace an existing medication for specific conditions. But which ones? And how do you know if a new medication is safe – and better than the existing options?
It is for this reason that Dr Jill Thistlethwaite, GP, academic and NPS MedicineWise spokesperson, researched the best methods of assessing new medication.
In a new study published in the June issue of the Australian Journal of General Practice (AJGP), ‘Evaluating and prescribing new medicines in general practice,’ Dr Thistlethwaite and her co-author Dr Lynn Weekes, CEO of NPS MedicineWise, outline the available sources of reliable information.  
‘[GPs] can’t know all of the new medications, and many of those will be highly specialised,’ Dr Thistlethwaite told newsGP. ‘What GPs need to be aware of are those they’re likely to prescribe in the community. Focus on those medicines more directly applicable to their practice demographic.’
Dr Thistlethwaite recommends reading journals such as Australian Prescriber and signing up to online news items.
Importantly, she said, it is crucial to bring clinical experience to bear on the question of a new medication.
‘Evidence-based medicine and practice is around evidence and a clinician’s experience, and those two things, as well as your patient’s beliefs and health expectations, help you make those decisions [on what to prescribe],’ Dr Thistlethwaite said.
‘Is this a medicine in a class where medications are already available? What is this adding? Is it superior to what I already prescribe, or very similar? Can I carry on prescribing those I’m familiar with?
‘Or is this a medication, which is completely new, doing completely new things which might be beneficial to my patient population and those it has been marketed for?’
Dr Thistlethwaite stresses the need to employ a healthy scepticism about claims of efficacy.
‘When I was a very young doctor in the UK, a medication came out which was advertised as the new answer to osteoarthritis. But it was only out for 12 weeks before it was withdrawn,’ she said. ‘It always makes you a little bit sceptical about the claims of the pharmaceutical company.
‘You’re just thinking, do I need to prescribe this? Is there not anything else I can use? And if you look at clinical trials, GPs might say their patient would have been excluded from this trial because of their multimorbidity and polypharmacy.
‘So we do need to be careful.’
It is also important to flag adverse events for any new medications a GP does trial, according to Dr Thistlethwaite.
‘It’s only by this post-marketing surveillance that concerns may be raised that there are issues which didn’t come to light in pre-marketing surveillance, or may not have been reported,’ she said.
‘Often in a busy day you might forget, but it’s really, really important to encourage prescribers to flag up those potential issues with a new medicine.’
What should patients be told?
Dr Thistlethwaite believes it is crucial to be upfront about the fact they are receiving a new medication.
‘It’s important to say this is a new medication that’s only been here so long, this is what the evidence suggests it does, and this is why I think it would be good for you,’ she said. ‘Having that discussion, and having space for the patient to ask questions [is important].
‘Often people say, “My condition is so bad I’m prepared to try it”. Or they might say they’d rather stick to something else. It’s that shared decision making, which is so important.’
While Dr Thistlethwaite concedes that staying on top of new medications often feels like just one more job for a busy GP, she feels there are rewards when a new drug yields positive results.
‘I’m acknowledging it’s difficult – as a practising GP – to keep on top of it, but it’s our responsibility as prescribers to be aware as possible of factors around new medicines,’ she said.
‘It’s part of our role, our business.’

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Philip Dawson   14/06/2018 2:33:20 PM

the problem we have with nearly all trials of new medications is none of the trials are being conducted against the current market leader for that condition, they simply compare their trials against placebo against the other already available trials. It should be mandatory that all new drugs should conduct a trial against the current market leader to prove both effectiveness and cost effectiveness before listing. The arthritis drug quoted is not the first to come with glowing recommendations only to later be shown to either not work, cause harm or to not work "very much". In many cases placebo seems more cost effective than the drug!