Journals watch: BP monitoring | Pregnant smokers | Gestational diabetes to type 2 diabetes

Dr Tillmann Jacobi selects the latest papers of interest to GPs including BP monitoring, vitamin C and lung function in newborns of pregnant smokers, menopause treatment and risk of progression of gestational diabetes to type 2 diabetes

TOVI is essential to ambulatory BP monitoring of hypertensive patients  (Photo: SPL)
TOVI is essential to ambulatory BP monitoring of hypertensive patients (Photo: SPL)

New indices for ambulatory BP monitoring

J Hypertens 2014; 32(6): 1326-33

This meta-analysis of 10 studies (4,294 patients) on ambulatory BP monitoring looked at the cardiovascular outcomes of hypertensive patients on the combination telmisartan/amlodipine when compared to various monotherapies.

A new treatment-on-variability index (TOVI) was developed and tested to quantify the effects of treatment on mean BP, and its 24-hour variability and smoothness, which are believed to be key influencing factors for the risk.

Telmisartan/amlodipine appeared to achieve a better smoothness and TOVI 24-hour BP reduction profile compared to individual antihypertensives and placebo.

One factor for this is thought to be the relatively long duration of treatment action of the components, although other factors or potential bias could not be fully excluded.

Continuing cardiovascular risk of sulfonylureas

Diabetes Obes Metab 2014; doi: 10.1111/dom.12306

This study assessed and compared the risk of major adverse cardiovascular events and mortality for combination therapies to metformin and either sulfonylurea (SU) or DPP-4 inhibitor (DPP-4i).

It used retrospective data of 33,983 patients on SU and 7,864 on DPP-4i, which had been recorded on the UK Clinical Practice Research Datalink between 2007 and 2012. The main analysis noted 716 major adverse cardiovascular events and 1,217 deaths over the examined period. The crude event rates were significantly higher for SU than for DPP-4i (11.3 events per 1,000 person-years (pkpy) versus 5.3 pkpy), with an increased hazard ratio for all-cause mortality in association with SU after adjustment.

The study concluded that the combination of metformin and DPP-4i reduced all-cause mortality when compared to the treatment combination metformin plus SU.

Vitamin C and lung function in newborns of pregnant smokers

JAMA 2014; May 18. doi: 10.1001/jama.2014.5217

Smoking during pregnancy has an objective life-long negative impact on the pulmonary function of the newborn and independently from other factors, increases the risk for asthma.

More than 50% of smokers who become pregnant continue to smoke and clinical trials of smoking cessation during pregnancy have proven ineffective so far.

This double-blind study found that newborns of smoking women randomised to daily 500mg of vitamin C had improved initial pulmonary function and significantly decreased wheezing in the first year of life (15/70 (21%) versus 31/77 (40%); RR 0.56 (95% CI, 0.33-0.95); P=0.03).

However, there were no significant differences in the one-year pulmonary test results between the vitamin C and the placebo groups. Although the long-term benefit of vitamin C on this matter is currently unclear, the impact in the first year of life on wheezing could still be relevant.

Paroxetine for vasomotor menopausal symptoms

Obstet Gynecol 2014 May; 123 Suppl 1: 132S-3S

Menopausal women can experience moderate to severe vasomotor symptoms such as hot flushes, which can be frequent (more than seven times a day, or 50 times a week) and disruptive.

This analysis of double-blind randomised placebo-controlled trials assessed the tolerability and safety of low-dose paroxetine (7.5mg) when used for symptom reduction.

The analysis of the diary data of 1,276 postmenopausal women over three phases demonstrated a low overall discontinuation rate (4.7% of the paroxetine group versus 3.7% of the placebo-controlled group). One death was reported but believed not to be treatment-related.

Risk of progression of gestational diabetes to type 2 diabetes

JAMA Intern Med 2014 May 19; doi: 10.1001/jamainternmed.2014.1795

This study examined the association between sedentary behaviour and the progression of gestational diabetes mellitus to type 2 diabetes in 4,554 women from the Nurses' Health Study II, with follow-up over more than 26 years.

The study established thresholds of physical activity required to achieve a substantial reduction of progression: each 5-metabolic equivalent hours per week increment (or 100 minutes of total moderate to intense physical activity), was related to a 9% lower risk of developing type 2 diabetes.

  • Dr Jacobi is a GP in York and a member of our team who regularly review the journals

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

  • Consider a search of diabetic patients on sulfonylureas in your practice population. Discuss the long-term prescribing advice and budget plans with the CCG prescribing adviser.
  • Consider discussing options for smoking cessation advice and other lifestyle support for pregnant women with your local midwife.
  • Use opportunities to discuss physical activity levels when possible when reviewing women with a history of gestational diabetes.

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

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