Over treatment of Mild Hypertension – Too Much Medicine? | The BMJ
Mild hypertension in people at low risk | The BMJ
As the ‘threshold’ level of hypertension has been lowered over the years, more and more people have been diagnosed with hypertension.
A 2012 Cochrane review of people with mild hypertension ( less than 160 systolic) found that treatment with an antihypertensive drug did not reduce any outcome – including total mortality, total cardiovascular events, coronary heart disease or stroke.
Nonetheless, most people with mild hypertension are commenced on pharmacological treatment.
This article in the BMJ examines the evidence and concludes:
Read MoreOveremphasis on drug treatment risks adverse effects, such as increased risk of falls, and misses opportunities to modify individual lifestyle choices and tackle lifestyle factors at a public health level.
Lowering definitions of hypertension has led to identification and drug treatment of larger populations of patients despite lack of evidence that drugs reduce morbidity or mortality
Cholesterol Tests – non fasting is OK
Tools for Practice this week confirmed that it is unnecessary (? and cruel) to make our patient fast for a cholesterol test.
The differences between fasting and non fasting levels are not clinically significant.
Bottom-line: Minimal differences exist between fasting and non-fasting HDL, LDL, and total cholesterol (TC). Also, non-fasting HDL and non-HDL levels correlate with future CVD events. Therefore, fasting for lipid testing is not required.
The evidence is outlined here.
I wonder how long it will take this recommendation to be commonly adopted. I bet there are still lines at the path lab at 7.30 each morning for years to come.
Tools for Practice is an excellent service provided by the Alberta College of Family Physicians (ACFP). You can sign up at http://bit.ly/signupfortfp.
Read MoreSafe and effective medicines use by consumers
A recent Cochrane review looked at interventions to improve safe and effective medicines use by consumers.
Medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.
Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:·
simplified dosing regimens
interventions involving pharmacists in medicines management, such as medicines reviews and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up
Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:·
delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;·
practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives:
education delivered with self-management skills training, counselling, support, training or enhanced follow-up;
financial incentives
Immunisation Uptake
Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects.
These included
- organisational interventions;
- reminders and recall;
- financial incentives;
- home visits;
- free vaccination;
- lay health worker interventions;
- and facilitators working with physicians to promote immunisation uptake.
Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.
Summary
There are many different potential pathways through which consumers’ use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.
Read MoreShould we screen for diabetes? should we treat for diabetes intensively? The ADDITION-Europe Study
Sandbæk A1, Griffin SJ, Sharp SJ, Simmons RK, Borch-Johnsen K, Rutten GE, van den Donk M, Wareham NJ, Lauritzen T, Davies MJ, Khunti K.
It makes sense that we should screen people for diabetes and when found treat them intensively. What does the evidence show?
In this recent study, 2816 people with screening detected diabetes in 343 general practices in Denmark, the Netherlands and the UK.
Half received ‘routine care’ and half had target-driven intensive management.
It must have been disappointing for the researchers that there was no significant reduction in the frequeny of microvascular events at 5 years.
The same study has earlier reported that there was not a significant reduction in macrovascular events (cardiovascular mortality and morbidity, revascularisation, and non-traumatic amputation)
This is despite the patients having better HbA1C, Chol and BP levels.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60698-3/abstract
Read MoreDiabetes Follow Up – Three months or six months?
Diabetes Obes Metab. 2014 Mar 17. doi: 10.1111/dom.12288. [Epub ahead of print]:
Effectiveness and cost-effectiveness of 3-monthly versus 6-monthly monitoring of well-controlled type 2 diabetes patients: a pragmatic randomised controlled patient-preference equivalence trial in primary care (EFFIMODI study).
Wermeling PR1, Gorter KJ, Stellato RK, de Wit GA, Beulens JW, Rutten GE.
In this study of 2000 patients in the Netherlands, key clinical indicators were largely the same when well controlled patients with established and stable Type II diabetes were seen at six monthly intervals rather than three monthly.
Read More“Patients with good cardiometabolic control and without preference for their monitoring frequency can visit the primary care physician less often. The cost-savings can be considerable.”
Mediterranean Diet wins again!
Diabetes Care. 2014 Apr 10. [Epub ahead of print]
The Effects of a Mediterranean Diet on Need for Diabetes Drugs and Remission of Newly Diagnosed Type 2 Diabetes: Follow-up of a Randomized Trial – Esposito K1, Maiorino MI, Petrizzo M, Bellastella G, Giugliano D.
There can now be little doubt that we all need to move to Tuscany.
In this 8 year follow up of a previous study, the low carb Mediterranean Diet was very significantly more successful than a low-fat diet in delaying the need for diabetic medication and for causing remission of diabetes.
Participants following the low carb Mediterranean diet were instructed to include plenty of vegetables, choose whole grain versions of starchy foods, replace most red meat with poultry and fish, and have at least 30% of their calories from fat, particularly from olive oil.
Read More