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AbstractNPSA issues opioid safety warningThe National Patient Safety Agency (NPSA) has published a rapid response report warning health professionals to take more care with opioid doses. By June, the NPSA had learned of five deaths and 4200 safety‐related incidents involving opioids.The NPSA advises health professionals who prescribe, dispense or administer an opioid to confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient; check where a dose increase is intended, that the calculated dose is safe for the patient; and ensure they are familiar with the characteristics of that medicine and formulation, including the usual dose regimen, adverse effects and symptoms of overdose.Biologicals comparedInfliximab (Remicade) may be the most effective biological agent for the treatment of severe psoriasis, a meta‐analysis suggests (Br J Dermatol 2008; published online ahead of print).In the absence of direct comparative trials, the analysis found that infliximab offered the lowest number needed to treat (NNT) to achieve a 75 per cent improvement in the Psoriasis Area and Severity Index (PASI) score compared with placebo (NNT=2), though etanercept (Enbrel; NNT=3) and efalizumab (Raptiva; NNT=4) were also effective. Safety was comparable for infliximab and efalizumab.NICE recommends etanercept, then efalizumab for severe psoriasis, and infliximab for very severe psoriasis.Volibris for PAHGSK has introduced ambrisentan (Volibris) to improve exercise capacity in patients with class II or III pulmonary arterial hypertension (PAH). The endothelin A receptor antagonist is contraindicated in pregnancy and monthly pregnancy tests are recommended. At a dose of 5mg per day, a month's treatment costs £1651.Outpatient adherenceAlmost a third of dermatology outpatients do not get their prescription dispensed, a Danish study has shown (J Am Acad Dermatol 2008;59:27‐33). Of 322 outpatients prescribed a new treatment, 31 per cent did not cash their prescriptions, and half of patients with psoriasis did not obtain their medicines.Relistor for opioid‐induced constipationMethylnaltrexone (Relistor) is now available for the treatment of opioid‐induced constipation in patients with advanced illness when usual laxatives have failed.Indicated only for patients receiving palliative care, methylnaltrexone is administered as a subcutaneous injection of 8‐12mg on alternate days. Seven 12mg vials cost £147.35.Diclofenac now OTCPharmacists can now supply diclofenac 12.5mg tablets without prescription to adults and children aged 14 and over for the treatment of headache, dental pain, period pain, rheumatic and muscular pain, back‐ache and symptoms of cold and flu.Another varenicline psychiatric warningThe Medicines and Healthcare products Regulatory Agency (MHRA) has published its third warning within a year about the risk of psychiatric disorders with varenicline (Champix).The Agency drew attention to the problem in December 2007 and February 2008. In the latest issue of Drug Safety Update (2008;1:issue 12) it warns that suicidal thoughts and behaviour may occur in people with no known history of psychiatric disorders and while they continue to smoke. A total of 129 yellow cards reporting these problems has now been received. Patients should be warned to stop treatment and seek medical advice if they develop depression or suicidal thoughts, the MHRA advises.This issue of Drug Safety Update also reviews the low risk of atrial fibrillation associated with bisphosphonates and recommends brand prescribing of beclometasone MDI inhalers. New advice from the European Medicines Agency warns of the risk of fibrosis associated with dopamine agonists derived from ergot (pergolide, cabergoline and bromocriptine) and updates prescribing information for etoricoxib (Arcoxia) to require that hypertension should be controlled before beginning treatment, and blood pressure persistently above 140/90mmHg is a contraindication to treatment. Copyright © 2008 Wiley Interface Ltd