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Gabapentin and pregabalin prescribing in Scotland has increased substantially over recent years. Evidence suggests that prescribers may be advocating the use of these medicines off-label to avoid prescribing opioid analgesics. The evidence to support gabapentin and pregabalin use in non-neuropathic pain disorders indicates they are less effective than several other licensed non-opioid analgesics. Notably, patients may not benefit from gabapentin and pregabalin but remain at risk of adverse drug reactions. Furthermore, greater availability has resulted in increased diversion of gabapentin and pregabalin; creating problems within the opioid misuse population and prison service. As a consequence, both gabapentin and pregabalin may soon be controlled under the Misuse of Drugs Act 1971. Prescribers should be aware of the very limited clinical evidence for use of gabapentin and pregabalin outside their licensed indications, as well as their capacity to do harm.

National Institute for Health and Clinical Excellence guidance for the clinical management of hypertension, published last year, proposes a step change in UK clinical practice.1 Although broadly helpful, there are some concerns about its implementation. Ambulatory blood pressure monitoring for diagnosis of hypertension, though logical, will place an additional financial burden on primary care at a time of austerity. Home blood pressure measurement may be a more practical option. Previous guidance recommended the used of thiazide diuretics as a first-line treatment option.2 Five years later, the new guidelines propose a major change, with an initial emphasis on the use of calcium channel blockers and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, moving the use of thiazide-like diuretics to a third-line option. In addition, bendroflumethiazide, the mainstay of treatment in the UK over many years, has been replaced with chlortalidone, the starting doses of which are not readily available in this country. Cost-effectiveness analysis and a presumed risk of metabolic disorders has guided the rationale for these changes to the therapeutic algorithm, however this may not be robust. Importantly, unless there are special circumstances, reducing the blood pressure in hypertensive patients is more important than the means used to lower it. In future, it will be important to ‘personalise’ treatment more effectively and base management on lifetime risk.