NICE guidance on hypertension
Beta-blockers should now be considered as fourth-line therapy for hypertension, according to the latest guidance from NICE. The guidance takes into account information from several recent studies and has reassessed the well-known AB/CD algorithm to produce an updated ACD algorithm.
NICE has also released guidance on management of AF. The guidelines aim to increase identification of this ‘hidden disease’ and simplify treatment choices.
Hypertension guideline: www.nice.org.uk/CG034
AF guideline: www.nice.org.uk/CG036
Near-patient HbA1c testing
Practices should not rush to adopt near-patient testing of HbA1c, because it has no benefit in outcome or cost in primary care, according to UK research.
The study randomised 681 patients with type-2 diabetes to receive either rapid results of their HbA1c using a preparatory device, or routine care, where a blood sample is sent away for laboratory testing, with results available several days later.
After 12 months, the proportion of patients with HbA1c <7 per cent was not significantly different between the control and intervention groups, and the costs were about the same, at £370 and £390 respectively.
The authors conclude that rapid testing in primary care is unlikely to improve glucose control in patients with type-2 diabetes or to result in cost savings.
Khunti K, Stone MA, Burden AC et al. Br J Gen Pract 2006; 56: 511-17
Hypotensive effects of hawthorn
Hawthorn is often used by herbal practitioners for its
BP-lowering properties. This small study randomised
79 patients with type-2 diabetes to receive 1,200mg hawthorn extract or placebo in addition to prescribed drugs already being taken.
After 16 weeks, patients taking the herbal treatment showed greater reductions in diastolic BP (83.0mmHg from a baseline of 85.6mmHg) than the control group (85.0mmHg from a baseline of 84.5mmHg). There was no significant
change in systolic BP. This study could open up the way for more research into commonly used herbal treatments.
Walker AF, Marakis G, Simpson E et al. Br J Gen Pract 2006; 56: 437-43
Achieving lipid targets with statins
The recommended starting dose of rosuvastatin is more effective at treating patients to cholesterol targets than starting doses of either atorvastatin or simvastatin, according to recent research. This is important because many patients prescribed statins remain on their initial dose and uptitration is uncommon.
In a study designed to mimic general practice procedures, patients with type IIa or IIb hypercholesterolaemia and a 10-year CHD risk >20 per cent or a history of cardiovascular disease were randomised to receive either rosuvastatin 10mg, atorvastatin 10mg, or simvastatin 20mg for 12 weeks.
The 1998 European LDL target of <3.0mmol/L was achieved in 89 per cent of patients receiving rosuvastatin 10mg, compared with 78 per cent on atorvastatin 10mg and 72 per cent on simvastatin 20mg. LDL reductions of 50, 42 and 40 per cent respectively were observed.
Middleton A, Fuat A. Br J Cardiol 2006; 13: 72-6
Clinical guidelines and statin treatment
Many countries have guidelines for the use of statins in CHD, but which are the most effective? Researchers in Canada looked at guidance from Australia, the UK, Canada, Europe, New Zealand and the US. They found the Australian and UK guidelines most effective at preventing deaths over five years, while New Zealand was the most efficient, preventing almost the same number of deaths, but recommending the fewest patients for treatment.
Least efficient was the US guidance, which recommended treating almost twice as many patients as New Zealand, with no further reduction in deaths. The authors conclude that switching to more efficient guidance could have significant implications.
Manuel DG, Kwong K, Tanuseputro P et al. BMJ 2006; 332: 1419-22
Counselling for glycaemic control
Counselling and other psychological interventions slightly improve long-term glucose control in children with type-1 diabetes, but not in adults, according to the authors of a systematic review and meta-analysis. The authors found that glycated haemoglobin was significantly reduced (by an average -0.35 per cent) in children and adolescents who had received a psychological intervention, compared with those who had not. However, the differences in adults were not significant. They suggest this might be explained by higher levels of stress in children with type-1 diabetes.
Winkley K, Ismail K, Landau S, Eisler I. BMJ 2006
The ageing effects of diabetes
Diabetes confers a cardiovascular risk equivalent to ageing
15 years, according to researchers in Canada. They studied adults with and without diabetes, and found that people with diabetes were classified as high-risk for cardiovascular disease an average 14.6 years earlier than age-matched controls.
Young adults (under 40) with diabetes also have CHD rates 12–40 times higher than those without diabetes, although absolute rates of cardiovascular disease were lower than their counterparts. The researchers highlight the importance of age when targeting risk reduction in patients with diabetes.
Booth G, Kapral MK, Fung K, Tu JV. Lancet 2006; 368: 29-36