The sulphonylurea group of drugs and the biguanide drug metformin have both been available for use as glucose-lowering therapies for more than 50 years. There were, however, few other clinically relevant developments in this area of pharmacotherapy until about the year 2000. At that time a new class of glucose-lowering therapies, the thiazolidinediones pioglitazone and rosiglitazone, was launched. In 2007 two more new classes of therapy were launched, the dipeptidyl peptidase-4 (DPP-4) inhibitors and the glucagon-like peptide-1 (GLP-1) mimetics; both of these classes of agents work on the incretin pathway.A further new class of glucose-lowering agents, the sodium glucose co-transporter 2 (SGLT2) inhibitors, is likely to be launched in the next year or two. So much activity in glucose lowering pharmacotherapy in this past 12 years perhaps makes up for the previous 40 years of relative inactivity!In this article we discuss new glucose-lowering therapies and consider their place in diabetes management from the primary care perspective.
The ‘no tears’ approach to medication reviews
Ten per cent of the annual NHS budget is spent on medication, with about 75% of this is prescribed in primary care. Ensuring that this money really improves patients’ health is vitally important. As the population ages, more people require increasing numbers of medications for chronic conditions and a third of elderly patients are taking four drugs or more for a spectrum of conditions. But this creates a major challenge – as research reveals that fewer than half of these patients take their medicines as prescribed. How can this challenge be addressed? This new series will provide simple practical guidance on how to conduct an effective medication review for a spectrum of long-term cardiovascular conditions.
Working long days increases CVD risk, but constant new challenges keep dullness at bay
Although many members of the medical profession might agree that theirchosen discipline often leads to periods of weariness, frustration or anxiety, thegreat majority of individuals in active practice would find it difficult to single outa dull day in their way of life.” (David Seegal, Yale Scientific Magazine 1962;36:31)
Keeping on track: streamlining diabetes management in older patients
Key issues in the management of older patients with diabetes involve both clinical skills and apatient-oriented approach. Ageing and co-morbidity may make management challenging, andclinicians need to be alert to factors such as impaired cognitive function, depression andincreased susceptibility to hypoglycaemia.
Optimising risk factor modification and prevention of stroke
Prevention of stroke is a key component of the overall management of stroke. Primordial prevention strategies include avoidance of tobacco use, maintenance of an adequate level of physical exercise and optimal diet and weight, and avoidance of heavy alcohol intake. Several medical risk factors have been demonstrated clearly, and intervention to optimise these risk factors for primary prevention (of first stroke) and secondary prevention (of stroke in those known to have cerebrovascular disease) has a robust evidence base.
The EPCCS and the implementation of CVD prevention in general practice
The European Primary Care Cardiovascular Society (EPCCS) exists to inform, support and interact with general practitioners (GPs) across Europe in relation to cardiovascular disease, including stroke and diabetes. The EPCCS provides an interactive and expanding website at www.epccs.eu with news, comments, information, meeting reports and slide presentations.
Insulin in type 2 diabetes – a growing role for primary care
Today, many people with type 2 diabetes who need insulin have their insulin initiated in primary care. Here we discuss NICE recommendations for initiation and management of insulin, and the different types of insulin and delivery systems.
A local strategy to improve outcomes for TIA and stroke
We describe here a project that sets out to reduce the risk of stroke in patients suspected of having a transient ischaemic attack.
Out of the shadows: attitudes and beliefs of primary care practitioners about depression after myocardial infarction
After myocardial infarction (MI) half of all patients will experience an episode of depression. We carried out the first survey of GP and primary care nurse attitudes and beliefs about depression in post-MI patients. Our sample was drawn from readers of two major cardiovascular journals: a total of 813 GPs and nurses responded. Primary care practitioners underestimated the prevalence of depression which is two and a half times more common in post-MI patients than estimated. Diagnosing depression was viewed as complex by both groups but much more so by nurses. Compared to nurses GPs had a much better understanding of the signs and symptoms of depression and were more confident in using depression screening tools. General acknowledgement of the negative impact that depression can have on outcomes was reported by the majority of participants. The practice of depression-trained professionals was more positive compared with those who had no recent education. If primary care practitioners address the epidemic of depression in post-MI patients, outcomes will be dramatically improved and lives could be saved.
Liraglutide in type 2 diabetes: new recommendations from NICE
The most effective means of reducing the risk of complications associated with type 2 diabetes is to ensure that each patient achieves and maintains their individualised glycaemic target. New guidance from the National Institute for Health and Clinical Excellence (NICE) providesrecommendations on using liraglutide (Victoza), a new option for patients who do not achieve target HbA1c using currently available therapies.
“Time is brain” – thrombolysis in acute stroke
“Time is brain” – thrombolysis in acute stroke – Mark Garside, Christopher PriceStroke is a common condition with long-term consequences. If symptoms are recognised early enough and patients are transported rapidly to hospital then there is the opportunity to administer treatments which may reduce long-term disability. We summarise the role of intravenous thrombolysis in the treatment of acute ischaemic stroke, including supporting evidence, how it is used in clinical practice, and possible future developments.
Heart rate control in heart failure and angina, and its benefits
In heart failure, heart rate control may improve mortality and the need for hospitalisation. In angina, heart rate control improves symptoms and reduces the need for PCI
