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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Mediterranean diet reduces diabetes

The British Medical Journal has published the results of a prospective cohort study that aimed to assess how a Mediterranean diet affects the incidence of diabetes among initially healthy participants. This study has been reported in the general media (BBC).

The study involved 13,380 Spanish university graduates without diabetes at baseline followed up for a median of 4.4 years. Dietary habits were assessed by questionnaire. Over the period of the study 103 participants self reported a diagnosis of type 2 diabetes and of these new cases 33 cases were confirmed. The biggest reasons for non-inclusion were gestational diabetes and failure to complete an additional medical report.

Individuals who adhered closely to a Mediterranean diet had a lower risk of diabetes. After correction for age and gender, those with moderate adherence to the diet had an incidence ratio of 0.41 (95% CI 0.19-0.87) and those with the highest adherence had a ratio of 0.17 (95% CI 0.04-0.75).

The study does have some limitations, firstly the participants were all university graduates and average age was low in comparison to the typical age at diagnosis of type 2 diabetes.

Action: Larger and longer studies are required to confirm this finding however clinicians should already be strongly advising patients, especially those with diabetes, on the virtues of a Mediterranean diet due to the protection it confers against coronary heart disease.

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Cost efficacy of aspirin in primary prevention

Circulation has published the results of an analysis into the cost effectiveness of aspirin in primary prevention based on gender and predicted cardiovascular risk.

The analysis is based on population modelling using data from Dutch populations. The paper concludes that treatment is "cost-effective for men with a 10-year cardiovascular disease risk of >10% and for women with a risk of >15%".

A similar analysis undertaken several years ago by Bandolier examined the risks and benefits of treatment. It concluded that treatment was safe and worthwhile at a coronary risk of >15% in 10 years (approximately 20% CVD risk). It was also noted that treatment safe but of limited value in terms of risks and benefits at 10% CHD risk over 10 years (approximately 15% CVD risk).

Action: Clinicians should ensure that any patient whose cardiovascular risk is estimated at greater than 20% in 10 years should be offered treatment with low-dose aspirin and a cost-effective statin (usually simvastatin 40mg).

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May NICE Guidance

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

The published guidance includes Clinical Guidelines that cover Lipid Modification and an update to the Type 2 Diabetes Guideline.

The former guideline (Quick Reference PDF) provides advice for risk management by lipid modification in patients at high risk of cardiovascular disease and those who have already had a cardiovascular event or have cardiovascular disease. This guideline has been reported in the general media (BBC) due to the prediction that an additional 1.5 million people could be prescribed a statin.

The update to the Diabetes guideline (Quick Reference PDF) covers:

  • Lifestyle Management
  • Appropriate use of self monitoring of blood glucose
  • Medication
  • Blood pressure targets and management
  • CVD Risk prediction
  • Lipid targets and management
  • Antithrombotics
  • Eye, Kidney and Nerve Damage

These guidelines are the first National Policy documents to contain secondary prevention cholesterol targets of 4mmol/L for total cholesterol and 2mmol/L for LDL. These targets also apply to patients with diabetes who are started on lipid lowering drugs. NICE also recommend auditing based on a total cholesterol of 5mmol/L in recognition of the fact that half of patients will not achieve these targets.

Simvastatin 40mg is the recommended first line therapy for all patients. There is no recommended target for primary prevention and moving high intensity statins is not recommended as routine.

Action: Clinicians should be aware of these recent guidelines and ensure that current practice is updated to reflect the latest recommendations.

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MeReC Extra 33

The National Prescribing Centre (NPC) has published MeReC Extra 32 (PDF). It summarises the new help available from the NPC and the recent NICE Guidance on irritable bowel syndrome.

Recent NPC developments include NPCi, MyNPC Account for tailored email alerts and changes to the MeReC publication portfolio to include both paper and Internet publications.

This MeReC also summarises the recent NICE Guideline covering the diagnosis and management of irritable bowel syndrome (IBS) in adults. Diagnosis, red flag symptoms, self-help measures and medication are all discussed.

Action: Clinicians will find this MeReC Extra to be useful and informative. Changes at the NPC will allow busy clinicians to easily access relevant information when keeping up-to-date.

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Lancet: Diabetes themed issue

This week the Lancet is a themed issue with several articles covering diabetes diagnosis and care.

One of the articles reveals the results of a study that examined early intensive insulin therapy in patients with newly diagnosed type 2 diabetes. This study has been reported in the general media (BBC).

382 Chinese patients aged 25 to 70 years old with fasting glucose greater than 7mmol/L were randomised to treatment with insulin (infusion or injection) or oral therapy. Treatment was continued for two weeks after normoglycaemia was achieved and then stopped, follow up with diet and exercise continued. A greater proportion of patient in the insulin arms achieved target glycaemic control and sooner.

  • Insulin infusion - 97.1% achieved control in a mean of 4 days (SD 2.5 days)
  • Insulin injections - 95.2% achieved control in a mean of 5.6 days (SD 3.8 days)
  • Oral therapy - 83.5% achieved control in a mean of 9.3 days (SD 5.3 days)

Additionally, it seems that glycaemic remission was significantly higher in the groups who were randomised to insulin with 51.1% and 44.9% remaining in remission of diabetes compared to 26.7% of the patients randomised to oral therapy (p= 0.0012). Although the results of this study are interesting the study was small therefore more research is required before change in practices can be recommended.

A second study of lifestyle interventions reviewed 20 year data for 577 adults with impaired glucose tolerance who were randomised to a control group or an intervention group for diet, exercise or both. Active interventions were continued over a 6 year period.

Patients in the combined intervention arm had 51% lower incidence of diabetes during the active phase and this continued with a 43% lower incidence over 20 years.

This study concludes that, "lifestyle interventions over 6 years can prevent or delay diabetes".

Action: Clinicians should already be aware of the importance lifestyle interventions for patients with diabetes. Media coverage of the study involving intensive insulin therapy early in diabetes may generate queries but this strategy should be researched more fully before being adopted into clinical practice.

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