The legal age for purchasing tobacco products has been raised from 16 years to 18 years old in England and Wales with effect from the 1st October 2007. The increase in the age limit was included in the Health Act 2006.
The changed is aimed at preventing children and young people from starting to smoke therefore avoiding the serious health dangers of smoking. Government statistics show that:
- A lifelong smoker has a one in two chance of their addiction killing them
- The younger a smoker starts the more likely they are to be killed by their addiction
- The earlier children become regular smokers and continue to smoke as adults, the greater the risk of developing lung cancer or heart disease
- Someone who starts smoking at 15 is three times as likely to die from cancer due to smoking than someone who starts in their mid-20s
Action: Clinicians should be aware of this change in law. A consequence may be that more patients aged 16 to 18 years old seek smoking cessation assistance.
Following the recent cardiovascular and fracture risk safety concerns associated with the glitazones and the introduction of a new class of hypoglycaemic, it seemed timely to review the Formulary Advice for type 2 diabetes.
Blood pressure remains more important than blood glucose because tight blood pressure control was found to contribute to reductions in deaths from long term complications, strokes and serious deterioration in vision in the United Kingdom Prospective Diabetes Study (UKPDS).
Metformin remains the first line choice based on its glucose benefits and the reductions in cardiovascular events observed in (UKPDS).
Sulphonylureas are second line agents based upon their well known efficacy and safety profile compared to the emerging safety concerns associated with the glitazones and the unknown safety profile of the newer gliptins.
Patients should have hypoglycaemic drugs added if they continue to have symptoms of diabetes, or if all other cardiovascular risk factors arecontrolled while HbA1c remains suboptimal. Drugs can be substituted if the patient experiences adverse drug reactions.
- Metformin for all patients, titrate to maximum tolerated dose
- Add (or substitute) Sulphonylurea (gliclazide or glipizide) and titrate to maximum tolerated dose
- If either metformin or a sulphonylurea is not tolerated, add pioglitazone provided the patient does not have heart failure and is not at high risk of developing heart failure
- If either metformin or a sulphonylurea is not tolerated and the patient has existing heart failure or is at high risk of heart failure, add a gliptin (sitagliptin is the only available option at the time of posting although more agents are expected)
As a rule of thumb hypoglycaemics reduce HbA1c by approximately 1%. In patients who are unlikely to reach an optimal level through combined use of oral agents consideration should be given to earlier initiation of insulin.
The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update Issue 3 (PDF).
This third issue contains the following drug safety advice articles:
- Piroxicam: new restrictions, including specialist initiation
- Ketoprofen and ketorolac: gastrointestinal risk
- Inhaled corticosteroids: pneumonia
- Pneumovax II: tolerability of re-vaccination
- Bisphosphonates: osteonecrosis of the jaw
- Lorazepam: reduction of recommended maximum daily dose
In addition, this issue contains hot topics focussing on rare but serious risks posed by botulinum toxin products and cardiovascular safety and fracture risk update rosiglitazone and pioglitazone and a pointer to the prescribing update regarding hepatotoxicity with lumiracoxib.
Action: Clinicians will find this publication to be a useful review of current issues in drug safety.
The Lancet has published a meta-analysis reviewing the association between heart failure and cardiovascular death in patients with pre-diabetes or type 2 diabetes taking glitazones.
The initial search strategy identified 3,048 studies but 3,041 were excluded since they were not randomised or did not report relevant outcomes. The remaining 7 studies included data for 20,191 patients with follow up periods ranging from 12 to 48 months.
Heart failure was reported in 2.3% (214/9360) of patients given a glitazone and in 1.4% (146/10,831) of those given a comparator. The relative risk was 1.72 (95% CI 1.21 to 2.42, p = 0.002). The risk of cardiovascular death was not changed by the glitazones (0·93, 95% CI 0·67-1·29, p=0·68).
This study concludes that, "heart failure in patients given glitazones might not carry the risk that is usually associated with congestive heart failure". It should be noted that this study did not carry out an analysis of myocardial infarction. The existing body of evidence also indicates that cardiovascular mortality is unchanged by the glitazones but rosiglitazone appears to significantly increase the risk of myocardial infarction. Continued concerns regarding the safety of the glitazones means that new reviews of glitazone safety are likely to be published.
Action: Clinicians should consider glitazones to be a third line choice after metformin and sulphonylureas.
