Journals Watch - Osteoporosis, diabetes and BP

Too busy to read the journals? Let Dr Bryan Palmer bring you up to date on the latest research.

The frequency of bone mineral density testing could be reduced (Photograph: SPL)
The frequency of bone mineral density testing could be reduced (Photograph: SPL)

Screening intervals for osteoporosis
N Engl J Med 2012; 366: 225-33

Bone mineral density (BMD) testing to screen for osteoporosis is recommended for women aged 65 years or more, although there is little data to guide decisions about the interval between BMD tests.

The authors studied almost 5,000 women with normal BMD or osteopenia for 15 years. The BMD testing interval was defined as the estimated time for 10% of women to make the transition to osteoporosis before having a hip or clinical vertebral fracture.

The data indicate that osteoporosis would develop in less than 10% of older, postmenopausal women during rescreening intervals of approximately 15 years for women with normal BMD or mild osteopenia, five years for those with moderate osteopenia, and one year for those with advanced osteopenia. In Australia, Medicare will fund a biannual screen for those aged over 70, but it seems we could risk stratify and reduce the frequency of testing, as has been suggested for PSA testing.

Oral treatments for type 2 diabetes mellitus
Ann Intern Med 2012; 156: 27-36

Clinical practice guidelines have an important role in guiding choice between type 2 diabetes mellitus medications, but little is known about their quality.

These authors used a MEDLINE and CINAHL search to assess whether recent guidelines on oral medications for type 2 diabetes mellitus were consistent with current evidence. Two reviewers independently rated guideline quality using two domains from the Appraisal of Guidelines Research and Evaluation instrument.

Of the 1,000 screened citations, 11 guidelines met the inclusion criteria.

Seven guidelines agreed with the conclusion that metformin is favoured as the first-line agent.

Ten guidelines agreed that thiazolidinediones are associated with higher rates of oedema and congestive heart failure compared with other oral medications to treat type 2 diabetes.

Not all guidelines on oral treatment of type 2 diabetes were consistent with available evidence from a systematic review. Guidelines judged to be of higher quality contained more recommendations consistent with the evidence base.

Intranasal corticosteroids in allergic rhinitis
Allergy and Asthma Proceedings 32(6): 413-18
Intranasal corticosteroids are the most efficacious medication for the treatment of allergic rhinitis and in the US, it has been suggested that they should be available as OTC drugs.

Concerns have been raised about the safety of these agents being used without oversight by a healthcare professional. The objective of this paper was to review published literature on the safety of intranasal corticosteroids. Recent studies, which evaluated topical and systemic adverse events associated with ciclesonide, fluticasone furoate, mometasone furoate, triamcinolone acetonide, fluticasone propionate, budesonide and beclomethasone dipropionate were summarised.

In general, no significant topical or systemic complications were observed in these studies, although none lasted more than one year. The newer medications appear to have less systemic bioavailability and hence may have a better safety profile, but it seems more work needs to be done.

Treating BP in the venerable
BMJ 2012; 344: d7541

Many of my octogenarian patients are in fine fettle and at times I am in a quandary about how hard to hit targets and follow best practice.

This study of BP in the over 80s looked for evidence of early benefits as a one-year extension of the Hypertension in the Very Elderly Trial (HYVET).

A total of 1,700 participants on active BP-lowering treatment continued taking active drug; those on placebo were given active BP-lowering treatment. The regimen was the same as the one used in the main trial - indapamide SR 1.5mg (plus perindopril 2-4mg if required) - with the same target BP of <150/80mmHg.

The primary outcome was stroke but cardiovascular events, total mortality and cardiovascular mortality were also studied. No change was seen in stroke rates or cardiovascular events, but total mortality and cardiovascular deaths dropped.

The authors concluded that very elderly patients with hypertension might gain immediate benefit from treatment.

BP medication affecting gout
BMJ 2012; 344: d8190

We all know thiazides potentiate gout, but this UK GP database study looked at the risk of all antihypertensives and the relative risk of gout.

The authors compared all incident cases of gout (n = 24,768) among adults aged 20-79 years and a random sample of 50,000 matched controls.

After adjusting for age, sex, BMI, visits to the GP, alcohol intake, and pertinent drugs and comorbidities, the multivariate relative risks of incident gout associated with current use of antihypertensives among those with hypertension (n = 29,138) were 0.87 for calcium-channel blockers, 0.81 for losartan.

Calcium-channel blockers and losartan are associated with a lower risk of incident gout among patients with hypertension. Diuretics, beta-blockers, ACE inhibitors and non-losartan ARBs are associated with an increased risk of gout, with RRs of 2.36 for diuretics, 1.48 for beta-blockers, 1.24 for ACE inhibitors and 1.29 for non-losartan ARBs.

Use of GLP-1 agonists
BMJ 2012; 344: d7771

Having observed weight loss in patients with type 2 diabetes mellitus taking GLP-1 agonists, would these drugs cause weight loss in overweight or obese patients without diabetes?

This systematic review looked at meta-analyses of studies from the Cochrane Library, Medline, Embase and Web of Science. RCTs involved adult participants with BMI 25kg/m2 or higher, with or without type 2 diabetes mellitus and receiving exenatide twice daily, exenatide once weekly or liraglutide once daily at clinically relevant doses for at least 20 weeks.

The control interventions were placebo, oral antidiabetic drugs or insulin. A total of 25 trials were included. GLP-1 agonist groups achieved a greater weight loss than control groups (weighted mean difference -2.9kg). In the overall analysis, GLP-1 agonists had beneficial effects on systolic and diastolic BP, plasma concentrations of cholesterol and glycaemic control.

  • Dr Palmer is a former Hampshire GP currently working in Australia, and a member of our team who regularly review the journals

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

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.

  • Discuss osteoporosis at a clinical meeting. Consider a change of recalls based on previous DEXA result.
  • Audit BP control in patients aged over 80 years. Is there room for more aggressive treatment?
  • Carry out a search of gout patients on higher uricogenic antihypertensives. Recall those at higher risk for review.

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