Journals watch: NSAIDs in pregnancy, chronic obesity and CAC and weight loss in diabetes

Too busy to read all of the journals? Dr Suzanne Hunter selects papers of interest to GPs.

The use of NSAIDs in pregnancy had no effect on infant mortality
The use of NSAIDs in pregnancy had no effect on infant mortality

NSAIDs in pregnancy

BJOG 2013; 120: 948-59

Estimates for the frequency of in utero exposure to NSAIDS range from 5-20%.

This study in Norway looked at the effect of in utero exposure to ibuprofen, naproxen, diclofenac and piroxicam, in particular, effects on pregnancy outcome, complications during and after delivery (especially haemorrhage), infant survival, congenital abnormalities and asthma in the infant.

Use of an NSAID in pregnancy was reported by 7.2% of the women in the study (6,511 patients). More NSAID users smoked, drank alcohol or had sick leave during the pregnancy and were overweight, compared with non-users.

Use of NSAIDs was associated with no additional risk of congenital malformations or structural heart problems and had no effect on infant mortality.

However, use of ibuprofen in the second trimester was associated with a 1.7 times increased risk of low birthweight.

Use of ibuprofen in the second and third trimesters was associated with a 1.5 times increased risk of asthma in the infant.

Diclofenac was associated with a threefold increase in low birthweight if used in the second trimester and a 1.8 times increase in maternal bleeding if used in the third trimester.

It is reassuring that there is no increase in congenital malformations. The low birthweight might have been due to the underlying maternal inflammation for which the NSAID was taken, but the increased risk of asthma has good theoretical grounding, so NSAIDs should be used with extreme caution in these patients.

Chronic obesity and the risk of coronary artery calcification

JAMA 2013; 310(3): 280-8

Subclinical atherosclerosis can be identified by the presence of coronary artery calcification (CAC).

Obesity is a known risk factor.

This study examined the duration of general and abdominal obesity and the risk of developing CAC.

Individuals who were not obese (BMI <30) and did not have central obesity (waist circumference less than 102cm in men and 88cm women were recruited 1985-6 followed up at 15 20 25 years when they weighed measured had cts CTS check for CAC.

Roughly 41% developed obesity and abdominal obesity. Subjects with obesity and abdominal obesity had a risk of developing CAC of 16 and 16.7 per 1,000 person-years, compared with 11 per 1,000 person-years for those with zero years of obesity.

Each year of obesity or abdominal obesity confers a hazard ratio of 1.02 and 1.03 respectively of developing CAC. Progression was independent of degree of adiposity.

Age and weight loss in diabetes

J Am Geriatr Soc 2013; 61: 912-22

Age is no barrier to losing weight, according to this study, which compared two cohorts of type 2 diabetes patients, one aged 65-76 and one aged 45-64 years.

Each cohort was divided into two groups. One group had an intensive lifestyle intervention with a calorie goal, including less than 30% total calories from fat and at least 15% from protein, and at least 175 minutes of exercise a week. There was frequent contact with the participants.

The control group were seen three times a year for a general chat about their health and were never weighed.

Over four years, the older cohort decreased their weight by 6.2%, compared with 5.1% in the younger cohort. The mean increase in fitness was comparable in the two groups, as were the increase in HDL, decrease in HbA1c and waist circumferences.

Salicylate to reduce HbA1c

Ann Intern Med 2013; 159: 1-12

This small US trial examined whether salicylates can be used to lower blood sugar.

Poorly controlled type 2 diabetic patients aged between 18 and 75 years, with a fasting sugar of <12.5mmol/L and an HbA1c of 7-9.5% were randomised to 48 weeks of salicylate 3.5g per day or placebo.

The mean level of HbA1c was 0.37% lower in the salicylate group, which is comparable to standard diabetic treatments, and there were lower levels of leukocytes, neutrophils and lymphocytes, indicating an anti-inflammatory effect. The haematocrit was increased, making marrow suppression unlikely.

Weight and LDL levels also increased in the salicylate group, as well as a reversible increase in urinary albumin. eGFR was unchanged.

The anti-inflammatory properties might be behind these effects, although no good mechanism is proposed. It seems salicylate can reduce HbA1c but further evaluation of undesirable effects is warranted.

Dr Hunter is a GP in Bishops Waltham, Hampshire, and a member of our team who regularly review the journals

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Perform an audit of NSAIDs prescribed in pregnant women.
  • Consider how you discuss lifestyle changes with older patients and look at whether there is more you could be doing to promote healthy lifestyles in this age group.
  • Introduce a policy of brief intervention in overweight children and adults who attend the practice.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

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