Journals Watch - Insulin, antibiotics and arthritis

A review of this week's medical research. By GP Dr Lizzie Croton

Metformin and insulin in type 2 diabetes
BMJ 2012; 344: e1771

This systematic review and meta-analysis aimed to compare the benefits and harms of metformin and insulin versus insulin alone in adult patients with type 2 diabetes.

Data were obtained from 23 trials with 2,117 participants.

The authors pointed out that all trials had a high risk of bias.

The results suggested that metformin and insulin versus insulin alone did not significantly affect all-cause mortality (RR 1.30 95% CI 0.57-2.99) or cardiovascular mortality (1.70, 0.35-8.30).

There was some evidence that severe hypoglycaemia was more frequent with metformin and insulin than with insulin alone. There was also some evidence that treatment with metformin and insulin resulted in reduced HbA1c, and reduced weight gain and insulin dose, compared with insulin alone.

The authors concluded that there was no evidence of improved all-cause mortality or cardiovascular mortality with metformin and insulin, but admitted that data were limited by lack of reported patient outcomes and poor bias control.

Antibiotics in children and use of medicines by parents
Arch Dis Child 2012 doi: 10.1136/archdischild-2011-301150
Antibiotics are often used in children with viral infections. This study investigated whether use of antibiotics was associated with use of various medications by the parents.

The authors proposed that health beliefs and parental concern have a great influence on the use of drugs in children.

This observational cohort study involved 6,731 children who received no antibiotics until their fifth birthday and 1,479 children who received at least one prescription every year.

The authors examined the use of antibiotics and other medicines in the two groups of parents. The results suggested that the parents of children who received antibiotics regularly were more likely to use antibiotics themselves. The parents also showed a higher percentage of chronic medication use.

Mothers were more likely to use antacids, NSAIDs, analgesics, anxiolytics, hypnotics, antidepressants and antihistamines.

Fathers were more likely to use antacids, NSAIDs, and cardiovascular and asthma drugs.

Predictors of smoking cessation in young smokers
Tob Control 2012; 21: 355-62

This study examined the predictors of self-initiated smoking cessation of at least six months in adolescent and young adult smokers.

The study population was aged 10-29 years. In total, 4,502 titles and 871 abstracts were reviewed. Despite significant heterogeneity in methods across studies, the authors identified five factors that consistently predicted quitting.

The factors were not having friends who smoke, not having intentions to smoke in future, resisting peer pressure to smoke, being older at first use of cigarettes and having negative beliefs about smoking.

Identifying these factors in young people considering quitting may serve to increase success rates in this group.

BMI and the risk of midlife knee osteoarthritis
Ann Rheum Dis 2012; 71: 655-60

The purpose of this study was to examine how BMI throughout life is linked to the risk of midlife knee osteoarthritis (OA).

Data were obtained from the 1946 British birth cohort study, in which a population-based birth cohort of 3,035 men and women underwent clinical examination for knee OA at the age of 53 years. The group also had their height and weight measured 10 times from the age of two to 53 years.

Results suggested OA has a higher prevalence in women than men (12.9% versus 7.4%). In men, the association between BMI and later knee OA was evident at 20 years and remained until 53 years.

In women, the association was evident at 15 years. Further analysis of the data by structured modelling suggested that prolonged exposure to high BMI during adulthood carried the highest risk and there was no additional risk conferred from adolescence once adult BMI had been accounted for.

Therapy for obese patients with type 2 diabetes
N Engl J Med 2012; 366: 1567-76

This single-centre trial involved 150 obese patients with uncontrolled type 2 diabetes (average HbA1c 9.2%).

Study participants were randomised to receive intensive medical therapy alone versus medical therapy with Roux-en-Y gastric bypass or sleeve gastrectomy. The primary endpoint was an HbA1c of 6% or less at 12 months after treatment.

Overall, 93% of the patients completed their 12-month follow-up. In the medical therapy group, 12% of patients reached the endpoint, versus 42% in the gastric bypass group and 37% in the sleeve gastrectomy group.

Glycaemic control improved in all groups and the mean HbA1c was 7.5% in the medical group, 6.4% in the gastric bypass group and 6.6% in the sleeve gastrectomy group.

Weight loss was greater in the gastric bypass and sleeve gastrectomy groups than in the medical therapy group.

The use of diabetic, lipid-lowering and antihypertensive drugs decreased significantly in the surgical groups, but increased in those receiving medical therapy only.

In addition, there were no deaths or life-threatening complications reported after surgery, with four patients undergoing reoperation. Insulin resistance also improved in patients undergoing surgery.

Cost-effectiveness of planned places of birth
BMJ 2012; 344: e2292

Data from the Birthplace in England national prospective cohort study were used to estimate the cost-effectiveness of alternative planned places of birth. The participants were 64,538 women deemed to be low-risk for complications before labour.

Four settings for birth were examined - home birth, midwifery unit, alongside midwifery unit and obstetric unit. The main outcome measures were incremental cost per adverse perinatal outcome avoided, adverse maternal morbidity avoided and additional normal birth.

After analysis, planned birth at home was deemed the most cost-effective for multiparous women at low risk of complications. In nulliparous women, home birth was likely to be most cost-effective, but was associated with an increase in adverse perinatal outcomes.

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

  • Dr Croton is a GP in Birmingham 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.

  • Review the notes of children receiving multiple courses of antibiotics and the medication use of their caregivers. Hold a practice discussion about any themes that emerge. Discuss ways of exploring the health beliefs of caregivers towards medication in future consultations.
  • Construct a checklist using the predictive factors for smoking cessation discussed above and use it as a motivational interviewing tool when counselling young people who smoke.
  • Revise the literature on bariatric surgery and its place in weight loss management.

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