Prescribing Advice for GPs

Cost-efficacy of blood glucose monitoring

February 5, 2010 at 4:40 pm | In Prescribing Extra - Other |  Print | No Comments

The Journal of the Canadian Medical Association has published a cost-efficacy analysis of self-monitoring of blood glucose in patients with type 2 diabetes mellitus managed without insulin.

Data from the United Kingdom Prospective Diabetes Study (UKPDS) was used to forecast diabetes-related complications based upon a modest reduction of 0.25% in HbA_1c that could be expected in patients using testing strips.

The analysis identified an increment cost utility ratio of Can$113,643/QALY (quality adjusted life-year). The analysis also reports the number needed to treat (NNT) to prevent specified diabetes related complications over a 40 year period. The lowest NNT reported is 266 for myocardial infarction, based on the reported cost of $0.40 per strip this intervention would cost Can$1,553,440.

The authors conclude that, “use of blood glucose test strips for frequent self-monitoring is unlikely to represent efficient use of finite health care resources“. They also note that less frequent monitoring or a reduced test strip price would improve cost-effectiveness.

This study details some limitations such as the use of HbA_1c as a surrogate for diabetes-related complications, the limitation of using the UKPDS data to model potential health benefits and the lack of a measure for hypoglycaemia.

Action: This study is consistent with existing analyses. Clinicians should continue to discourage regular and frequent self monitoring in patients with non-insulin treated type 2 diabetes.

Lancet retracts Wakefield paper

February 4, 2010 at 11:26 am | In Prescribing Extra - Other |  Print | No Comments

The Lancet has issued a full retraction of the Early Report title “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children“. This is the paper widely credited with raising concerns with the safety of the MMR vaccination.

The paper was partly retracted in 2004 when 10 of the 12 original authors wished to “make it clear that in this paper no causal link was established between MMR vaccine and autism as the data were insufficient“.

This full retraction has been made in light of the information considered by the General Medical Council (GMC) during a Fitness to Practice hearing that has identified that several of the claims made in the original article, in particular the method of referral to the clinic and ethical approval for the investigations, were false. It should be noted that the GMC investigation only reviewed how the research was conducted, not whether the findings were valid. It would seem that The Lancet now has sufficient concerns about the conduct of the study to retract it completely.

The retraction has also been reported around the world in the general media (BBC, NYTimes, LATimes and Sydney Morning Herald).

Action: Clinicians should be aware of this retraction. Papers making reference to this study should be viewed cautiously.

Smokefree future

February 1, 2010 at 1:26 pm | In Prescribing Extra - Other |  Print | No Comments

The Department of Health (DH) has announced an ambitious strategy to halve the number of smokers by 2020.

More than 80,000 deaths each year are linked to smoking and smoking related illnesses costs the NHS £2.7 billion a year. Additionally, the DH notes that research has shown that 7 in 10 smokers want to quit.

The DH has made the following commitments:

• Stopping young people being recruited as smokers by cracking down on cheap illicit cigarettes. Immediate investment in extra overseas officers will stop 200 million cigarettes entering the UK every year
• Every smoker will be able to get help from the NHS to suit them if they want to give up – new types of support will be available at times and in places that suit smokers
• The Government will carefully consider the case for plain packaging
• Stopping the sale of tobacco from vending machines – a significant source of tobacco for young people
• Protecting everyone, especially children, from the harms of second-hand smoke by promoting smokefree homes and cars and reviewing smokefree law. This review will include, for example, whether to extend legislation from enclosed public places and workplaces to areas like entrances to buildings

Action: Clinicians should be aware of this strategy. These changes, if realised, will likely results in greater demand on smoking cessation services.

Cohort analysis of HbA1c

January 29, 2010 at 11:50 am | In Prescribing Extra - Other |  Print | No Comments

The Lancet has published the results of an observational retrospective cohort study that aimed to assess the relationship between HbA_1c and all-cause mortality. The study is accompanied by a comment article that discusses the findings further.

The study collected data from the UK General Practice Research Database for 27,965 individuals aged 50 years and older with a diagnosis of type 2 diabetes. The data were analysed for HbA_1c and all-cause mortality. A secondary analysis looked at “large-vessel disease” which was defined as any record of myocardial infarction, stroke, coronary revascularisation, carotid or peripheral arterial revascularisation or angina.

The analysis found an association between low and high mean HbA_1c and increased risk of all-cause mortality and cardiac events. The lowest risks were associated with an HbA_1c of 7.5% which provides some support to the current treatment targets recommended by the National Institute for Health and Clinical Excellence (NICE) for patients on more than one glucose lowering agent.

The study acknowledges the limitations of using real world observational data. Corrections were made for age, sex, smoking status, cholesterol, cardiovascular risk and general morbidity but remaining confounding factors may still bias the results. Additionally, this analysis relies on practice level data and must accept that there may be errors and omissions in the data. Finally, the accompanying article notes that observational studies cannot demonstrate cause and effect.

The authors note that their results need independent confirmation but conclude that if confirmed “diabetes guidelines might need revision to include a minimum HbA_1c value“.

Action: Clinicians should be aware of the continue research in this area. Clinicians should aim for the blood glucose treatment goals specified in the current NICE Guideline and resist the temptation to treat to lower levels.

NICE Guidance – January 2010

January 27, 2010 at 10:51 am | In Prescribing Extra - Other |  Print | No Comments

The National Institute of Health and Clinical Excellence has published new guidance for the month of January 2010.

There is one guidance document that has an impact in primary care. The clinical guideline for venous thromboembolism – reducing the risk (QRG) has been updated. The scope of the previous guideline has been extended to cover all patients being admitted to hospital. This may be of relevance to primary care clinicians who may be asked to prescribe or administer continued treatment following discharge.

Action: Clinicians should be aware of this updated guideline. It is a useful resource to those involved in the provision of preventative treatments for venous thromboembolism.