Journals watch: HRT, diabetes and RA

Research on HRT, diabetes and rheumatoid arthritis. By Dr Tillmann Jacobi

Spinal fracture: study found that HRT offered no long term protection
Spinal fracture: study found that HRT offered no long term protection

HRT and long-term bone health

Climacteric 2013; doi:10.3109/13697137.2013.871511

This study adds evidence to the recurrent questions regarding the long-term fracture protection benefit of HRT once treatment ends.

In 1990, 177 patients aged 43-57 years were enrolled in an evaluation of a number of HRT approaches in respect to mineral density and bone metabolism. After 21 years, 49 of them were reviewed and categorised into two groups: women who had been using HRT and the control group of women who had not.

The treatment group, comprising 32 women (65.3%), received HRT for an average 5.5 (+/2.96) years.

The control group consisted of 17 women (34.7%).

The rate of radiologically confirmed vertebral fractures over the past 21 years was higher in the HRT treatment group than in the control group, independently from other clinical or demographic factors.

The study had a small sample size. Acknowledging this, the authors conclude the data suggest that HRT used in the early years of the menopause does not present a long-term protective effect on vertebral fracture after discontinuing treatment.

Overtreatment in diabetes

JAMA Intern Med 2013; doi: 10.1001/jamainternmed.2013.12963.

The drive to optimise glycaemic control in diabetes bears the significant risk of overtreatment, with adverse outcomes.

This large cross-sectional study of patients with diabetes using insulin and/or sulfonylureas aimed to identify high-risk patients.

The primary outcome measure was defined as HbA1c <7% in patients aged over 75 years, a diagnosis of cognitive impairment, or a serum creatinine >2mg/dL.

Data for more than 650,000 patients was reviewed. About half of these patients were on sulfonylurea therapy without insulin, the other half were on insulin alone or combination treatment.

Of all patients, 31.5% fitted the primary outcome measure criteria. When additional physical or mental comorbidities were included, a total of 430,178 (65.9%) patients were found to be at high risk of overtreatment. Suggestions for a patient safety indicator to highlight these patients were also presented.

Preventive bipolar monitoring

Br J Psychiatry 2013; doi: 10.1192/bjp.bp.113.126706

This study prospectively analysed and followed up 229 children from families with one parent with confirmed bipolar disorder.

The children were clinically assessed with DSM-IV criteria for up to 16 years. Adjusted survival analysis and generalised estimating equations were used to calculate differences in lifetime psychopathology.

The increased lifetime risk for bipolar disorder was considerable (hazard ratio = 20.89; P = 0.04), but, in comparison to controls, other conditions were also more common, including major depressive disorder, anxiety, sleep disturbances and substance use disorders.

Childhood anxiety disorder predicted an increased risk of major mood disorder later on, which typically evolved through depressive and then manic or psychotic episodes.

Steroids in rheumatoid arthritis

Drugs 2013; 73(18): 2067-76

This randomised trial looked at additional benefits of adding a low-dose, modified-release (MR) formulation of prednisone to the treatment of adult patients with rheumatoid arthritis, already on stable DMARDs.

After 12 weeks of treatment, the addition of MR prednisone reduced disease signs and symptoms by more than 20% (using American College of Rheumatology criteria) and seemed to be more efficient overall in reducing morning stiffness when compared with immediate-release morning doses of prednisone. MR prednisone was well tolerated and cost-effective.

Communication skills training

JAMA 2013; 310(21): 2271-81

Competent communication about end-of-life care is a particular skill. This study examined the effectiveness of simulation-based training for nurses, measured by patientand family-reported outcomes, on quality of communication and end-of-life care, and depressive symptoms.

Participants were randomised to an eight-session, simulation-based communication skills intervention (N = 232) or usual education (N = 240).

Analysis of 1,866 patient and 936 family ratings suggested that simulated communication training compared with usual education did not improve the perceived quality of communication about end-of-life care or the care experienced.

  • 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.

  • Ensure patients on HRT, or wishing to start it, are given up-to-date information, including a leaflet, to enable informed consent.
  • Include a reminder of criteria in diabetes review templates, highlighting patients who may be at increased risk of overtreatment for diabetes (for example, increased age, comorbidities).
  • Discuss with your local prescribing team the evidence base for the use of MR prednisone for patients with rheumatoid arthritis.

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

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