The Lancet has published a paper that set out to rank the different classes of antihypertensives in terms of diabetes risk.
The analysis included 22 studies including 48 treatment arms and comprising 143,153 patients. New onset diabetes risk was ranked for each initial drug class. Diuretics were used as the comparator (risk of 1.0); the other antihypertensive drug classes were calculated as having the following odds ratios:
- Angiotensin receptor blockers - 0.57 [95% CI 0.46-0.72]
- Angiotensin converting enzyme inhibitors - 0.67 [95% CI 0.56-0.80]
- Calcium channel blockers - 0.75 [95% CI 0.62-0.90]
- Placebo - 0.77 [95% CI 0.63-0.94]
- Beta-blocker - 0.90 [95% CI 0.75-1.09]
This type of analysis, a network meta-analysis, is a novel technique and the results should be viewed with some caution. Additionally, the analysis has accounted only for initial drug therapy but in many drug trials there are steps where additional antihypertensive drug classes are added into existing treatment until a target blood pressure is reached. The impact of polypharmacy has not been assessed in this analysis.
The article concludes that the risk of new-onset diabetes is lowest with angiotensin receptor blockers and angiotensin converting enzyme inhibitors but does not suggest how the results of this analysis should integrate into current care.
Action: Clinicians should continue to follow the Hypertension Clinical Guideline produced by the National Institute of Health and Clinical Excellence.
A recent editorial in the British Medical Journal detailed the current understanding of the link between bisphosphonates and osteonecrosis of the jaw.
Some of the Rapid Responses have been critical of the article stating that it has added to the confusion surrounding this complication. Osteonecrosis of the jaw was also covered in Current Problems in Pharmcovigilance issued by the Medicines and Healthcare products Regulatory Agency (MHRA) in May 2006.
The majority of reported cases have been in patients treated with high dose intravenous bisphosphonates however there have been some cases reported in association with oral agents too. The risks of this complication appear to be lower with the oral products available for the treatment of osteoporosis.
Additionally, some contributory risk factors have been identified including a diagnosis of cancer, chemotherapy, treatment with steroids, poor oral hygiene, tooth extractions and oral surgery.
The MHRA recommended that:
- before treatment is started in patients with risk factors a dental examination is performed with appropriate preventative treatment
- dental procedures are avoided while patients with risk factors are on treatment
Action: Clinicians should be aware of this complication and the current recommendations to minimise the risk. Lower dose oral therapy appears to carry a lower risk which patients may find reassuring.
