Issue 35.
NICE Guidance on
Rosiglitazone for Type 2 Diabetes
This article summarises the
latest NICE guidance.
1.1 Rosiglitazone is effective at
reducing blood glucose when added to oral monotherapy (metformin or
sulphonylurea) for patients who have inadequate control of blood glucose on
these conventional agents alone.
1.2 Patients with inadequate
blood glucose control on monotherapy (metformin or sulphonylurea) should first
be offered metformin and sulphonylurea combination therapy, unless there are
contraindications or tolerability problems.
1.3 Patients who are unable to
take metformin and sulphonylurea combination therapy, and patients whose blood
glucose remains high despite adequate trial of this treatment, should be offered
rosiglitazone combination therapy as an alternative to injected insulin.
1.4 The combination of
rosiglitazone plus metformin is preferred to rosiglitazone plus sulphonylurea,
particularly for obese patients. Rosiglitazine plus sulphonylurea may be offered
to patients who show intolerance to metformin or for whom metformin is
contraindicated.
1.5 As with any glucose lowering
medications, patients who are prescribed rosiglitazone should be monitored
against treatment targets for blood glucose and for other cardiovascular risk
factors, including lipid profile.
1.6 Rosiglitazone should be used
in accordance with the manufacturer's recommendations.
Presently these advise that liver
function tests should be performed before initiation of therapy with
rosiglitazone, then every two months for the first twelve months after
commencement of treatment, and periodically thereafter. Rosiglitazone should not
be used in patients with a history of cardiac failure, hepatic impairment or
severe renal insufficiency.
The full document and a Summary
of Evidence are available from the NICE website at
http://www.nice.org.uk/nice-web/Cat.asp?c=8079
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The Health Advisory Service
in 2000 & beyond
In 1997 HAS was re-launched under
new management and funding arrangements. It is no longer a statutory body that
regulates services for Ministers. All of the work is now directly commissioned
from health authorities, trusts, primary care agencies, local authorities, and
the Department of Health for Ministers.
HAS covers health and social care
services for four client groups:
-
Services for older people
-
Adult and forensic mental health
services
-
Child and adolescent mental
health
-
Substance misuse services (The
Substance Misuse Advisory Service)
Reviews are still a large part of the work
of the HAS but they are primarily
concerned with providing advice that is both constructive and “doable” e.g.
how to convert “stop-start” winter pressures schemes to reliable, mainstream
services that provide effective treatment and care.
They offer reviews that cover the
whole spectrum of health and social care (comprehensive service reviews) and
focused reviews that target a specific service or set of issues (e.g. stroke
care, intermediate care, quality of care and joint commissioning). They also
provide a range of development programmes designed to bring about improvements
to existing services or to assist with commissioning new services.
They have a bank of 72 reviewers
for older people including practitioners and managers, service users and carers.
Staff are seconded from their employment for the period of time involved,
usually 5-7 days for reviews and a number of days spread over a six month period
for development work.
The reviewers are an important
“vehicle” for disseminating good practice as well as highlighting common
problems and possible solutions.
It is vital that any
recommendations are translated to action. HAS offers two types of development
work:
Strategy development
– concerned with the range and balance of health and social services available
to the local older population.
Service development
– concerned with improving the provision and delivery of care. An individual
programme may be based around a region, a health authority with corresponding
social services department(s), and NHS trust or a primary care trust.
Future interests include
preparing for the National Service Framework for elderly people, Intermediate
care, Stroke care, Mental health services for older people.
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How much
healthcare is evidence-based?
Many readers will know the story
of Archie Cochrane saying that less than 10% of interventions are
evidence-based. Andrew Booth in Sheffield has now done an extensive amount of
work on this topic.
There is a problem with these
ideas. Any set of interventions is composed of a number of technologies (say
several thousand) that could be used for patients. However few of them (say one
hundred) are used with a high frequency, so that the number of patients treated
evidence-based may exceed the number of technologies, that are of proven
efficacy. The rarer problems are likely to have less evidence.
In the 1960’s is was believed
that specific measures accounted for 10-20 percent of all benefits; that the
combined "placebo and Hawthorne effects" accounted for another 20-40
percent; and the rest accounted for 70-40 percent.
The Sheffield work (to be found
at:
http://www.shef.ac.uk/~scharr/ir/percent.html
shows that a much higher
proportion of interventions, as seen in practice these days are based on
evidence.
For instance, in general medicine
they found that of 109 primary treatments 82% were evidence based (ie, there was
RCT support [53%] or unanimity on the team about the existence of convincing
non-experimental evidence [29%]).
An Oxford group found that that
82% of the patient management interventions they studied in 100 consecutive
patients over a short period in a single general medical ward were based on high
quality scientific evidence (Lancet 1995;346:407-410).
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