Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Cohort analysis of HbA1c

The Lancet has published the results of an observational retrospective cohort study that aimed to assess the relationship between HbA1c 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 HbA1c 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 HbA1c and increased risk of all-cause mortality and cardiac events. The lowest risks were associated with an HbA1c 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 HbA1c 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.

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NICE Guidance - January 2010

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.

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CKS Update - January 2010

Clinical Knowledge Summaries (CKS) has been updated in January 2010 for the following clinical areas:

Action: Clinicians who see patients with any of these conditions may find the new and updated information useful when reviewing current clinical practice.

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Sibutramine licence suspended

The Medicines and Healthcare products Regulatory Agency (MHRA) has announced the suspension of the licence for sibutramine (Reductil®), a weight loss medication recommended as an adjunctive therapy within a weight management programme.

Additional documentation (Press release and Q&A) is available on the European Medicines Agency (EMA) website. Recent study results have linked this medication with an increased risk of cardiovascular events and authorities now consider that the risks of treatment outweigh the benefits.

Action: Doctors are advised to no longer prescribe this medication. Patients are advised to consult their doctor to discuss alternative treatments and may stop taking treatment prior to this discussion if they wish.

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MeReC Bulletin - Management of osteoporosis

The National Prescribing Centre (NPC) has published a MeReC Bulletin (PDF) that describes the management of a postmenopausal woman with risk factors for osteoporosis.

The bulletin adopts a case study format and explores the management of osteoporosis in postmenopausal women. Consideration is given to risk factors for osteoporosis, when to refer for DXA investigation, what dietary and lifestyle advice should be given and which treatments are recommended.

Action: Clinicians who consult postmenopausal women with risk factors for osteoporosis will find this bulletin useful and informative.

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