Journals Watch - SSRI risk, diabetes and asthma

Too busy to catch up on the research? Let Dr Raj Thakkar guide you through some recent papers.

Congenital heart disease was not significantly increased in newborns whose mothers took SSRIs (Photograph: SPL)
Congenital heart disease was not significantly increased in newborns whose mothers took SSRIs (Photograph: SPL)

Safety of SSRIs during pregnancy - Mayo Clin Proc 2009; 84: 23-7
Depression is common among women of childbearing age. A major concern for women considering antidepressants is side-effects, particularly if they are planning a family.

Rightly so, research ethics committees are unable to agree to randomised controlled trials to evaluate the potential harmful effects of drugs on the unborn child.

This impressive retrospective study analysed the records of 25,214 expectant mothers, 808 of which were treated with an SSRI during their pregnancy.

Researchers then evaluated the offspring of these women, particularly looking for evidence of congenital heart disease and pulmonary hypertension.

Of the newborns, 0.8 per cent were diagnosed with congenital heart disease. There was no significant increase in congenital heart disease in children whose mothers took SSRIs during pregnancy. In addition, none of the children in the SSRI group were diagnosed with persistent pulmonary hypertension whereas 16 children in the non-SSRI group had persistent pulmonary hypertension.

This is reassuring evidence about the safety of SSRIs in pregnancy. NICE also provides useful guidance on SSRIs in pregnancy; however, the responsibility lies with the prescriber.

Sulfonylureas in patients with diabetes mellitus post-MI - Mayo Clin Proc 2009; 84: 28-33

Current thinking, largely derived from the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction trial, has shown that non-insulin controlled diabetic patients who have experienced an MI do better if they are started on insulin.

This US study looked at the adverse mortality effects of second-generation sulfonylureas in diabetic patients who suffered an MI.

The study ran from 1985 to 2002. It included 2,189 patients who had had an MI, 409 of which also had diabetes mellitus. The mean age was 68 years.

Patients prescribed first-generation sulfonylureas, biguanides, or thiazolidinediones were excluded from the study.

This left 386 patients with diabetes remaining in the study, 120 of whom were taking second-generation sulfonylureas and 180 were using insulin. The remaining patients were treated by non-pharmacological means.

Analysis showed patients treated with second-generation sulfonylureas had a lower mortality than those prescribed insulin (hazard ratio 0.41, CI 0.21-0.8, p=0.009). These data could have a major impact on the way diabetic patients are managed in coronary care.

Community mental health services and suicide rate - Lancet 2009; 373: 147-53
Suicide among patients is not something GPs have to face too often. Nevertheless, when it happens, the experience is distressing for all involved.

Mental health services have suffered in recent years. During turbulent times and amid huge reforms, suicide risk assessments must be watertight with the aim of keeping successful suicide attempts to a minimum. Reform has included streamlining inpatient provisions and increasing community care.

This Finnish study looked at the effect of this kind of healthcare reform on suicide risk between 2000 and 2004.

Perhaps counter intuitively, outpatient care conferred a reduced risk of suicide compared with inpatient services.

Of course, this study has to be interpreted with caution; the quality of outpatient care must be well resourced, organised and easily accessible to patients, as well as to GPs wanting to refer patients for urgent assessments.

Elective caesarean delivery at term and outcomes - N Engl J Med 2009; 360:111-20
Women have caesarean sections for a number of reasons. The ideal timing of when elective section is performed is under debate and practices vary. To reduce respiratory disease in neonates, sections are not carried out before 39 weeks gestation unless there is evidence that the lungs have matured.

This US study aimed to assess the effect on the neonate of sections performed at 37-39 weeks gestation. It looked at neonatal death, respiratory complications, hypoglycaemia, sepsis and admission to intensive care.

Of 24,077 sections analysed, 13,258 were elective. Of the elective sections, 35.8 per cent were performed prior to 39 weeks gestation.

Compared to births at 39 weeks, those born at 37 and 38 weeks had a significantly increased risk of adverse outcomes, respective odd ratios 2.1 and 1.5.

This confirms that elective sections should not be carried out before 39 weeks. This will be helpful when discussing care with our pregnant patients.

Asthma breathing exercises - Thorax 2009; 64: 55-61
The new BTS guidelines advocate the use of breathing techniques in the management of asthma. In addition, pulmonary rehabilitation has proven useful in the management of COPD. This prospective single blind study aimed to establish whether breathing techniques improve outcomes in asthma.

Patients were randomised to breathing training with a physiotherapist (n=94) or asthma education (n=89). Asthma quality of life questionnaires were used as the primary outcome measure.

Other secondary measures included spirometry, eosinophil count, exhaled nitric oxide, Hospital Anxiety and Depression (HAD) score and hyperventilation score.

While at one month there was little difference between the two groups, at six months, breathing training appeared to be favourable in the quality of life, HAD and hyperventilation scores. There was no difference in the inflammatory markers or hyper-responsiveness studies.

Researchers concluded that while the breathing techniques improved the quality of life of asthmatics, they were not a substitute for medication.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review journals

The Quick Study

  • SSRIs do not appear to increase the risk of congenital heart disease in newborns when taken by expectant mothers.
  • Second-generation sulfonylureas are associated with a lower risk of death than insulin in patients being treated for diabetes mellitus post MI.
  • Outpatient mental health services conferred a lower risk of suicide compared with inpatient services.
  • Elective caesarean sections should not be carried out before 39 weeks.
  • Asthma patients benefited from receiving breathing training exercises from a physiotherapist.

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