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On The Pulse   

On The Pulse

Tertius Lydgate

Friday, 25 October 2019

Benefits of statins in primary prevention ‘may be marginal at best’
For low risk groups, they ‘may be an example of low value care’

Statins are now the most commonly used drug in the UK and clinical guideline changes mean that, increasingly, lower risk people become eligible for treatment. However, authors of an analysis in The BMJ say their benefits for people without heart disease is small and uncertain and there are potential harms. Drawing on the findings of their three recent peer reviewed papers on statins for primary prevention, they argue statins in this context “may be an example of low value care and, in some cases, represent a waste of healthcare resources”. As the researchers examined the benefits of statins using only primary prevention data for people taking statins for 1-5 years with an average age of 62-69 years, their analysis suggested that none of those classified as low or moderate risk in primary prevention would reach acceptable levels of risk reduction to justify taking a daily statin. The authors argue that the prescription, use, and reimbursement of statins in primary prevention “warrants more careful consideration”.

GP’s clinical judgement in predicting dementia – valuable
Study highlights the importance of the GP-patient relationship

For patients in familiar doctor-patient relationships, the GP’s clinical judgement holds additional value for predicting dementia, complementing test performance and patients’ self-reports, according to research published in the BJGP. The German multicentre prospective cohort study assessed over 12 years 3,201 patients without baseline dementia and identified as having frequent and long-lasting doctor-patient relationships and being well known to their GPs. It showed that GP baseline rating of future cognitive decline had significant value for three-year dementia prediction, independent of cognitive test scores and patient’s memory complaints – GP ratings of very mild: OR 1.97, 95% CI = 1.28 to 3.04; mild OR 3.00, 95% CI = 1.90 to 4.76; and moderate/severe decline OR 5.66, 95% CI = 3.29 to 9.73. GPs’ baseline judgements were also significantly associated with patients’ 12-year dementia-free survival rates. The authors suggest existing and emerging primary care-based dementia risk models should consider the GP’s judgement as one predictor.

Acute transient psychotic disorder precipitated by Brexit vote
BMJ case report highlights how political events can act as major psychological stressors

BMJ Case Reports describes the case of a man in his 40s who was brought to the accident and emergency department in an acute psychotic state, three weeks after the European Union referendum results in the UK were declared. It is noted that the patient’s mental health had deteriorated rapidly following the announcement of the results, with significant concerns about Brexit. Presentation included agitation, confusion, auditory hallucinations, and bizarre delusions. Complete recovery was achieved within two weeks after a brief admission and treatment with olanzapine. The patient, who had a history of a similar episode 13 years previously, was experiencing work- and family-related stress - potentially a contributory factor. The author highlights how political events can have a significant impact on the mental health of people, especially those with a predisposition to develop mental illness, and the importance of identifying warning signs early to ensure early treatment and better long-term prognosis.

Best regimen of penicillin V for group A streptococci pharyngotonsillitis
Four times daily for five days appears non-inferior to three times daily for 10 days

Swedish researchers sought to determine if total exposure to penicillin V could be reduced while maintaining adequate clinical efficacy when treating pharyngotonsillitis caused by group A streptococci. In their non-inferiority study, published in The BMJ, they randomly allocated 433 eligible patients, aged six years and over, to either a regimen of penicillin V 800 mg four times daily for five days (total 16 g) or 1,000 mg three times daily for 10 days (total 30 g) - the current recommended treatment in Sweden. Clinical cure in the per protocol population was 89.6% in the five-day group and 93.3% in the 10-day group (95% CI −9.7 to 2.2), while bacteriological eradication was 80.4% and 90.7%, respectively. The number of relapses and complications did not differ between the two groups. Time to relief of symptoms was shorter in the five-day group and the 10-day group had higher incidence and longer duration of adverse events. Five-day treatment with penicillin V four times daily may therefore be an alternative to the currently recommended 10-day regimen.

Aggression and agitation in dementia: the role of non-pharmacological interventions
Research suggests they may be more efficacious than pharmacological interventions

A systematic review and network meta-analysis in the Annals of Internal Medicine sought to summarise the comparative efficacy of pharmacological and non-pharmacological interventions for treating neuropsychiatric symptoms in dementia patients. Analysis of interventions targeting aggression and agitation (148 studies; 21,686 patients) showed that the following interventions were clinically more efficacious than usual care:

  • Multidisciplinary care (standardised mean difference [SMD], −0.5 [95% credible interval {CrI}, −0.99 to −0.01])
  • Massage and touch therapy (SMD, −0.75 [CrI, −1.12 to −0.38])
  • Music combined with massage and touch therapy (SMD, −0.91 [CrI, −1.75 to −0.07])

Recreation therapy (SMD, −0.29 [CrI, −0.57 to −0.01]) was statistically but not clinically more efficacious than usual care. Although 46% of studies were at high risk of bias because of missing outcome data, the authors concluded non-pharmacological interventions seemed to be more efficacious than pharmacological interventions for reducing aggression and agitation in adults with dementia.

Bed time is the best time to take blood pressure medication
Greater reduction in risk of CVD and death from bedtime rather than morning medication

Although current guidelines on the treatment of hypertension do not mention or recommend any preferred treatment time, a large prospective trial published in European Heart Journal found that patients who took their anti-hypertensive medication at bedtime had significantly lower risk of death or illness caused by heart or blood vessel problems, compared to patients who took their medication on waking. Researchers randomised 19,084 patients to taking their pills on waking or at bedtime, and followed them for an average of more than six years, during which time the patients’ ambulatory blood pressure was checked over 48 hours at least once a year. In those taking bedtime medication, the risk of death from heart or blood vessel problems was reduced by 66%, the risk of myocardial infarction was reduced by 44%, coronary revascularisation by 40%, heart failure by 42%, and stroke by 49%. Dr Lydgate thinks the findings could well provide some basis for new recommendations to achieve better long-term cardiovascular outcomes in hypertensive patients.

Medicines associated with dependence or withdrawal
Long-term prescribing common, despite not being recommended by clinical guidelines

Antidepressants, opioids for non-cancer pain, gabapentinoids (gabapentin and pregabalin), benzodiazepines, and Z-drugs (zopiclone, zaleplon, and zolpidem) are commonly prescribed medicine classes associated with a risk of dependence or withdrawal. A mixed-methods public health review in The Lancet Psychiatry aimed to review the evidence for these harms and prescribing data in England. It showed that, in one year, over a quarter of the adult population in England had a prescription dispensed for antidepressants, opioids (for non-cancer pain), gabapentinoids, benzodiazepines, or Z-drugs. The authors also note that long-term (>12 months) prescribing is common, despite being either not recommended by clinical guidelines or of doubtful efficacy in many cases. They call for enhanced national and local monitoring, better guidance for personalised care, and better doctor–patient decision making.

Earlier menopause linked to higher risk of non-fatal CVD event before 60
Women with earlier menopause need close monitoring in clinical practice, study suggests

It is known that early menopause is linked to an increased risk of cardiovascular disease (CVD) mortality. A pooled analysis of patient data for 301,438 women, published in The Lancet Public Health, sought to assess the associations between age at natural menopause and incidence and timing of CVD. It showed that compared with women who had menopause at age 50–51 years, the risk of CVD was higher in women who had premature menopause (age <40 years; HR 1·55, 95% CI 1·38–1·73), early menopause (age 40–44 years; 1·30, 1·22–1·39), and relatively early menopause (age 45–49 years; 1·12, 1·07–1·18), with a significantly reduced risk of CVD following menopause after age 51 years. The associations persisted in never smokers, and were strongest before age 60 years for women with premature menopause (HR 1·88, 1·62–2·20) and early menopause (1·40, 1·27–1·54), but were attenuated at age 60–69 years, with no significant association observed at age 70 years and older. The authors suggest age at menopause could be considered as an important factor in risk stratification of CVD for women.

Author's Image

Tertius Lydgate

Originally from Northumberland, Tertius Lydgate studied medicine in Edinburgh, London and Paris. There he developed a special interest in communicable diseases and hoped to make great advances in treating and preventing them. But, after a promising start in a provincial centre of excellence in middle England, he was forced by circumstances (please, don't inquire) to abandon his high ideals. He now scrapes a living by pouring cold water on the over-enthusiastic at his private cryohydrotherapy clinic. Dreaming of the contributions he once hoped to make himself, he finds consolation in the latest medical journals and is happy to share his discoveries with his readers. He thinks that his creator, George Eliot, would have approved.
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