PCSK9 inhibitor therapy and guideline treatment targets for cardiovascular disease and familial hypercholesterolaemia

Background

Updated trial data on the benefits of low-density lipoprotein cholesterol (LDL-C) reduction on cardiovascular outcomes have been incorporated into 2019 ESC/EAS guidelines and 2020 UK-based NICE guidance. Treatment targets for secondary cardiovascular disease (CVD) prevention are LDL-C <1.4mmol/L (ESC/EAS) and non-high-density lipoprotein <2.5mmol/L (equates to LDL-C <1.8mmol/L; NICE). Guidelines also recommend ≥50% LDL-C reduction in patients with CVD or Familial Hypercholesterolaemia (FH). Targets are often not achieved with oral statin +/− ezetimibe due to reduced efficacy or tolerability, warranting a switch to PCSK9 inhibitor therapy. However, there is limited data on whether this achieves LDL-C targets for both CVD and FH in real world clinical practice.

Purpose

To assess attainment of LDL-C treatment targets using PCSK9 inhibitor mono- or combination therapy in routine clinical care for patients with FH or CVD.

Methods

Observational study in a single specialist lipid clinic, using retrospective case note review of patients prescribed PCSK9 inhibitor therapy according to NICE guidelines until February 2021. Anonymised clinical, demographic and biochemical data before and after commencement of PCSK9 inhibitor therapy were collected. Primary outcomes were attainment of guideline-defined LDL-C treatment targets: LDL-C <1.8 mmol/L, LDL-C <1.4mmol/L and ≥50% LDL-C reduction.

Results

A total of 55 patients (mean age 60.8±12.9 years, 58% male) on PCSK9 inhibitor therapy (98% alirocumab, 2% evolocumab; mean treatment duration 1.7±1.3 years) were identified. PCSK9 inhibitor therapy was commenced due to drug intolerance to statins (89%), ezetimibe (36%) and fenofibrate (25%). In patients with FH (n=18), 78%, 56% and 33% of patients achieved targets of ≥50% LDL-C reduction, LDL-C <1.8 mmol/L and LDL-C <1.4 mmol/L on treatment, respectively. In CVD patients (n=49), 84%, 51% and 27% achieved the same targets respectively (Table 1). In patients on PCSK9 inhibitor monotherapy (n=19), 21% and 5% achieved LDL-C targets <1.8 mmol/L and <1.4 mmol/L respectively, whereas in those on PCSK9 inhibitor + two or more additional oral lipid-lowering therapies, 87% and 60% achieved the same targets respectively (Table 2).

Conclusions

Most patients with FH or CVD achieve an LDL-C reduction of ≥50% from baseline with PCSK9 inhibitor therapy, however fewer achieve the LDL-C targets of <1.8 mmol/L or <1.4 mmol/L. Patients on PCSK9 inhibitor monotherapy are unlikely to reach LDL-C <1.8 mmol/L and <1.4mmol/L targets, whereas PCSK9 inhibitor combination therapies are more likely to do so. Additional lipid-lowering drugs are required with PCSK9 inhibitor therapy in most patients to reach guideline LDL-C targets.

Funding Acknowledgement

Type of funding sources: None.

Management Choices for Hypertension with Coexistent Hypercholesterolaemia

Guidelines for the management of either hypertension or hyperlipidaemia have been widely published. However, recent data have shown the high frequency of an abnormal lipid profile in hypertensive subjects. We have therefore surveyed 195 general practitioners throughout Britain to determine current community-based attitudes and management approaches to hypertension with coexistent hypercholesterolaemia. Routine screening for lipids in hypertensive subjects was recommended by 40% of respondents. First-line antihypertensive drug choices were influenced by the knowledge of a hypercholesterolaemia, with preference for drugs known to have no adverse effects on the lipid profile. When first-choice drug failed to effectively lower blood pressure, the additional drug or the substitute choices were not influenced by the metabolic profiles of the alternative selected. The current wide choice of antihypertensive drugs and the complexity of metabolic complications of treatment plus the relationship of risk factor clustering has made the formulation of management strategies very difficult. This was supported by the finding that 88% of respondents in our survey felt that there was a clear need for consensus management guidelines for the treatment of hypertension with coexistent hypercholesterolaemia.

Acute changes in Atherogenic and Thrombogenic Factors with Cessation of Smoking

Tobacco smoking is associated with alterations in several factors considered to be important in the atherosclerotic process. Thirty chronic smokers were studied 2 weeks before and 2 weeks after complete tobacco withdrawal. Significant reductions in fibrinogen, haematocrit, plasma viscosity and whole blood viscosity as well as a significant increase in HDL-cholesterol were observed. As these factors are important in both atherogenesis and thrombogenesis, these observations may give insight into tobacco-induced atherosclerotic disease and may be responsible for the more rapid reduction in the incidence of cardiovascular disease that is believed to occur after stopped smoking.

Safety of long-term restrictive diets for peroxisomal disorders: vitamin and trace element status of patients treated for Adult Refsum Disease

BACKGROUND

Adult Refsum's Disease (ARD) is caused by defects in the pathway for alpha-oxidation of phytanic acid (PA). Treatment involves restricting the dietary intake of phytanic acid by reducing the intake of dairy-derived fat. The adequacy of micronutrient intake in patients with ARD is unknown.

METHODS

Patients established on the Chelsea low-PA diet had general diet macronutrients, vitamins and trace elements assessed using 7-day-weighed intakes and serial 24-h recalls. Intakes were compared with biochemical assessments of nutritional status for haematinics (ferritin), trace elements (copper, zinc, iron, selenium), water- (vitamin B6 , B12 and folate) and fat-soluble vitamins (A, D, E and K).

RESULTS

Eleven subjects (four women, seven men) were studied. Body mass index was 27 ± 5 kg/m(2) (range 19-38). All subjects had high sodium intakes (range 1873-4828 mg). Fat-soluble vitamin insufficiencies occurred in some individuals (vitamin A, n = 2; vitamin D, n = 6; vitamin E, n = 3; vitamin K, n = 10) but were not coincident. Vitamin B6 levels were normal or elevated (n = 6). Folate and 5-methyltetrahydrofolate concentrations were normal. Metabolic vitamin B12 insufficiency was suspected in four subjects based on elevated methylmalonic acid concentrations. Low copper and selenium intakes were noted in some subjects (n = 7, n = 2) but plasma levels were adequate. Iron, ferritin and zinc intakes and concentrations were normal.

CONCLUSION

Subjects with ARD can be safely managed on the Chelsea low PA without routine micronutrient supplementation. Sodium intake should be monitored and reduced. Periodic nutritional screening may be necessary for fat-soluble vitamins, vitamin B12 , copper or selenium.

Prevalence of diabetes in patients admitted to a cancer hospital

Cancer rates are increased in people with diabetes. There is also recent evidence that outcomes from cancer treatment are worse in those with diabetes. There is a need to assess the prevalence of diabetes in cancer patients in order to tailor resources and improve clinical outcomes. This study examined the prevalence of diabetes and hyperglycaemia and specific referrals amongst hospitalised patients in a specialist cancer hospital.

In a cancer hospital 11% of in-patients had either identified diabetes or hyperglycaemia (random blood glucose >11mmol/l.) Consecutive referrals to a diabetes consultant confirmed that over half of patients had gastro-intestinal tract primary cancers, over 20% had poor glycaemic control whilst on steroids, and 18% had poor glycaemic control during artificial nutrition. Referrals came from both medical and surgical teams.

Thus diabetes and hyperglycaemia are common problems amongst in-patients with cancer, and these patients have complex diabetes requirement. Patients with cancer and diabetes need access to specialist diabetes care.

Can protein biomarkers provide an index of coronary artery calcification in patients with Type 2 diabetes?

OBJECTIVES

By exploring differences between patients with high and low coronary artery calcification score (CACS), a plasma protein biomarker might be identified as an alternative to CACS screening.

METHODS

We selected stored samples (12 per group) from a cohort study of patients with Type 2 diabetes and CACS >1000 or <100 Agatston units, with matching for age, BMI, blood pressure, lipids and lipoproteins and fibrinogen. Multiplex, immunobead-based assay or ELISA measured 18 cardiovascular-related protein biomarkers. SELDI-TOF mass spectrometry (MS) screened for proteins differing significantly between high and low CACS.

RESULTS

Only monocyte chemotactic protein-1 was higher in the high compared with the low CACS group but concentrations overlapped appreciably. On SELDI-TOF MS, several mass/charge ratio peak intensities significantly discriminated high and low CACS but these differences were not confirmed in larger samples from the cohort.

CONCLUSIONS

Plasma protein biomarkers are unlikely to provide an effective alternative to measurement of CACS.

Coronary calcification, homocysteine, C-reactive protein and the metabolic syndrome in Type 2 diabetes: the Prospective Evaluation of Diabetic Ischaemic Heart Disease by Coronary Tomography (PREDICT) Study

AIMS

The PREDICT Study aims to determine: (i) the association between cardiovascular risk factors and coronary artery calcification score (CACS) obtained by electron beam tomography and (ii) the predictive value of CACS for coronary heart disease (CHD) events in Type 2 diabetes.

METHODS

Having previously reported relationships between CACS and conventional risk factors, we have now studied the novel risk factors, plasma high-sensitivity C-reactive protein (CRP) and homocysteine, insulin resistance, serum apoprotein A1 and B concentrations, the serum triglyceride/high-density lipoprotein cholesterol ratio and metabolic syndrome (International Diabetes Federation definition) in 573 subjects of the PREDICT Type 2 diabetes cohort.

RESULTS

In univariate analyses, the only significant positive novel correlate of CACS was homocysteine (P = 0.0004). CRP was increased in those with detectable calcification, but decreased with increasing calcification score (P = 0.006). In a multivariate model that included all significant univariate correlates, CACS was independently associated with age (P < 0.0001), waist-hip ratio (P < 0.02), male gender (P < 0.05) and duration of diabetes (P < 0.05), but the association with homocysteine was no longer significant. The negative association between CACS and CRP remained in multivariate analysis, and was independent of statin use.

CONCLUSIONS

Age was the major factor influencing CACS in Type 2 diabetes, with weaker contributions from waist hip-ratio and duration of diabetes. Other novel cardiovascular risk factors appear to have little positive effect.

Erectile dysfunction and statin treatment in high cardiovascular risk patients

Erectile dysfunction (ED) has been associated with risk factors for atherosclerosis. Medications used for atherosclerosis have also been implicated in ED. The aim of this study is to investigate the relationship of erectile function to cardiovascular risk factors and specific drug therapies before and after 6 months of statin therapy. In this prospective observational study, International Index of Erectile Function (IIEF) scores were measured in 93 men attending cardiovascular risk clinics. Cardiovascular risk factors and drug therapies were assessed prior to initiation and after 6 months of statin therapy. Prior to statin therapy, the median IIEF score was 21 (range 0-25), and 57% had impairment of erectile function. After statin therapy, IIEF scores were reduced to 6.5 (range 0-25) (p < 0.001), and 22% experienced new onset ED. Before statin therapy no correlation was observed between IIEF score and any individual cardiovascular risk factor. After 6 months of statin therapy, correlations were observed between lower IIEF scores (r = 0.62; p < 0.001) and age and diabetes and weakly with smoking. Differences in dose, relative efficacy or relative lipophilicity of statin prescribed showed no correlation with change in IIEF score. This study suggests ED following statin therapy is more likely in patients with severe endothelial dysfunction due to established cardiovascular risk factors including age, smoking and diabetes.

The association of coronary calcium score and conventional cardiovascular risk factors in Type 2 diabetic subjects asymptomatic for coronary heart disease (The PREDICT Study)

AIM

To determine the association between coronary calcification score (CACS) obtained by electron beam computed tomography (EBCT) and cardiovascular risk factors in Type 2 diabetic subjects entered into a prospective cohort study.

METHODS

Type 2 diabetic subjects attending routine hospital diabetic clinics without known coronary heart disease (CHD) underwent EBCT to measure CACS. Demographic data were obtained and conventional cardiovascular risk factors were measured at baseline.

RESULTS

Four hundred and ninety-five subjects were assessed of whom 67.7% were male. They had a mean (SD) age of 62.9 (7.1) years, with median (inter-quartile range) duration of diabetes of 8 (4-13) years. None had a history of coronary artery disease. Forty-five per cent were receiving lipid-lowering agents (including 36% statins). In a univariate analysis, there were significant associations between increased CACS and age, duration of diabetes, male gender, waist-hip ratio (WHR), systolic blood pressure, and the use of statins. In a multivariate model adjusting for the possible interaction of these and other factors, the significant association between CACS and WHR, systolic blood pressure, male gender and statin use remained.

CONCLUSIONS

The close association between CACS and WHR and the association with systolic blood pressure suggest that coronary calcification may be particularly linked to the metabolic syndrome in Type 2 diabetes.

Smell testing: an additional tool for identification of adult Refsum's disease

BACKGROUND

Adult Refsum's disease (ARD) is characterised by the presence of retinitis pigmentosa, ataxia, deafness, sensory neuropathy, and bony changes. The diagnosis is confirmed by the presence of phytanic acidaemia. Although reduced smell function has been described in ARD, its value in the diagnosis of the condition has not been fully evaluated.

OBJECTIVE

To investigate the prevalence and degree of olfactory dysfunction in patients with ARD.

METHOD

The olfactory function of 16 patients with ARD was assessed using the quantitative University of Pennsylvania Smell Identification Test (UPSIT).

RESULTS

All patients had complete anosmia or grossly impaired smell function with a mean UPSIT score of 14.7 (SD 4.7) (normal > 34) despite having been treated with an appropriate diet for a median of 15 years (range 1-25).

CONCLUSIONS

Identification of ARD patients can be facilitated by using the UPSIT in combination with the presence of retinitis pigmentosa, even if they have no neurological or bony features. Phytanic acid screening should be performed in any patient manifesting these two signs.

Diabetes: preventing coronary heart disease in a high risk group

Cardiovascular disease is the major cause of morbidity and mortality in patients with type 2 diabetes. Numerous outcome trials have demonstrated clinical benefits from effective treatment of individual cardiovascular risk factors in patients with diabetes. These trials have provided the basis for current treatment guidelines and targets. More recently, multifactorial intervention strategies have shown a reduction in both cardiovascular and microvascular events in patients with type 2 diabetes. However, full implementation of a truly multifactorial strategy into routine practice remains an ideal due to practical difficulties of sustained implementation and associated costs. These practical issues relating to the treatment of diabetes and its complications are now in a greater spotlight due to the growing number of patients requiring treatment.

Fenofibrate enhances urate reduction in men treated with allopurinol for hyperuricaemia and gout

OBJECTIVE

To assess the short-term urate-lowering effect of fenofibrate in men on long-term allopurinol therapy for hyperuricaemia and gout.

METHODS

Ten male patients (38-74 yr) with a history of chronic tophaceous or recurrent acute gout with hyperuricaemia and on established allopurinol at 300-900 mg/day for > or =3 months were studied in an open-crossover study of fenofibrate therapy. Allopurinol at the established dose was continued throughout the study. Clinical and biochemical assessments (serum urate and creatinine, 24-h urinary excretion of urate and creatinine, liver function tests, creatine kinase and fasting serum lipids) were undertaken at: (i) baseline, (ii) after 3 weeks of once-daily therapy with micronized fenofibrate (Lipantil Micro) at 200 mg and (iii) 3 weeks after fenofibrate was withdrawn.

RESULTS

Fenofibrate was associated with a 19% reduction in serum urate after 3 weeks of treatment (mean+/-S.E. 0.37+/-0.04 vs 0.30+/-0.02 mM/l; P=0.004). The effect was reversed after a 3-week fenofibrate withdrawal period (0.30+/-0.02 vs 0.38+/-0.03 mM/l). There was a rise in uric acid clearance with fenofibrate treatment of 36% (7.2+/-0.9 vs 11.4+/-1.6 ml/min, normal range 6-11; P=0.006) without a significant change in creatinine clearance. Both total cholesterol and serum triglycerides were also reduced. No patient developed acute gout whilst taking fenofibrate.

CONCLUSIONS

Fenofibrate has a rapid and reversible urate-lowering effect in patients with hyperuricaemia and gout on established allopurinol prophylaxis. Fenofibrate may be a potential new treatment for hyperuricaemia and the prevention of gout, particularly in patients with coexisting hyperlipidaemia or those resistant to conventional therapy for hyperuricaemia.

Long-term remission from gout associated with fenofibrate therapy

Short-term studies with fenofibrate, an established treatment for hyperlipidaemia, have shown that its unique side effect of urate lowering is mediated through enhanced renal urate clearance. The long-term effects of fenofibrate on hyperuricaemia and gout have not previously been reported. We report two patients with hyperlipidaemia in association with hyperuricaemia in whom long-term fenofibrate therapy was associated with a sustained reduction in serum urate and lipid levels, together with remission from recurrent attacks of acute gout. The mechanisms involved in these effects and the potential role for fenofibrate in the management of gout are discussed.

Avascular necrosis not Charcot's

BACKGROUND

A case of avascular necrosis (AN) of the navicular bone, in a 24-year-old woman with Type 1 diabetes with peripheral neuropathy, in the absence of any history of direct trauma is presented. The clinical and radiological features at presentation suggested an evolving Charcot arthropathy (CA), but subsequent serial X-rays clearly confirmed AN.

CONCLUSIONS

Swelling and foot deformity in association with long-standing diabetic peripheral neuropathy is suggestive of CA, although AN, a less common condition, may show the same clinical features. It is therefore important to undertake further confirmatory radiological investigations if there is any doubt about the diagnosis.

Joint liaison psychiatry-diabetes clinic: a new specialist service

AIMS

Specialist diabetes clinics have an established role in prevention and management of complications. As psychological problems are usually treated separately from diabetes centres, the role of a specialist psychiatrist within a teaching hospital was assessed. The aims of the study were to describe referral patterns, specific psychiatric conditions and treatments offered.

RESULTS

During weekly outpatient sessions over a 12-month period, 31 patients were referred with a wide range of psychiatric diagnoses. One-third of patients were seen on the day and two-thirds within 2 weeks of referral. Treatments included anti-depressant medication, counselling and cognitive behaviour therapy. Successful discharge was obtained in 10 subjects and eight were undergoing continued treatment.

CONCLUSIONS

The range of specific diagnoses requiring psychiatric supervision supported the role of specifically trained personnel as seen in a joint liaison psychiatry-diabetes service.

Prevalence of renal artery stenosis in subjects with type 2 diabetes and coexistent hypertension

OBJECTIVE

To assess the prevalence of renal artery stenosis (RAS) in subjects with type 2 diabetes and coexistent hypertension by using magnetic resonance angiography (MRA) of the renal arteries, to assess clinical and biochemical predictors of RAS, and to assess the hemodynamic significance of RAS, by using the captopril test (a measure of the response of plasma renin activity to a single oral dose of captopril).

RESEARCH DESIGN AND METHODS

A total of 117 subjects with type 2 diabetes and coexistent hypertension between 40 and 70 years of age and with creatinine concentrations < 150 micromol/l were recruited from two inner-city general diabetes clinics. All subjects underwent MRA of the renal arteries. In a subgroup of 85 subjects, data concerning possible clinical and biochemical predictors of RAS were collected, and the captopril test was performed. For comparison of a continuous variable between subjects with a positive MRA and those with a negative MRA, the Mann-Whitney test was used. For comparison of a discrete variable between subjects with a positive MRA and those with a negative MRA, Fisher's exact test was used.

RESULTS

The prevalence of RAS detected by using MRA in 117 hypertensive type 2 diabetic subjects was 17%; 19 subjects had unilateral RAS, and only 1 subject had bilateral RAS. A femoral bruit was significantly more common in subjects with a positive MRA versus subjects with a negative MRA (21 vs. 0%; Fisher's exact test P < 0.005); however, other clinical features of atherosclerotic disease were not statistically associated. Greater duration of hypertension and treatment with statins were features of subjects with RAS (P < 0.05). The captopril test was negative in all subjects, although the antihypertensive response to oral captopril was significantly greater in subjects with RAS detected by MRA.

CONCLUSIONS

RAS is common in hypertensive type 2 diabetic subjects. The presence of a femoral bruit is a useful predictive clinical marker. The captopril test is not useful in predicting the hemodynamic significance of RAS in this patient group.

Injection related anxiety in insulin-treated diabetes

The presence of injection related anxiety and phobia may influence compliance, glycaemic control and quality of life in patients with insulin-treated diabetes. Unselected consecutive, insulin-treated patients attending a diabetes clinic for follow-up, completed a standardised questionnaire providing an injection anxiety score (IAS) and general anxiety score (GAS). A total of 115 insulin-treated (80 Type 1 and 35 Type 2) diabetic patients completed the questionnaire. Injections had been avoided secondary to anxiety in 14% of cases and 42% expressed concern at having to inject more frequently. An IAS > or = 3 was seen in 28% of patients and of these, 66% injected insulin one to two times/day, 45% had avoided injections, and 70% would be bothered by more frequent injections. A significant correlation between IAS and GAS was seen (Kendall's tau-a 0.30, 95% CI 0.19-0.41, P < 0.001). GAS was significantly associated with both previous injection avoidance and expressed concern at increased injection frequency. No significant correlation was seen with HbA1c and injection or general anxiety scores. Symptoms relating to insulin injection anxiety and phobia have a high prevalence in an unselected group of diabetic patients requiring insulin injections and are associated with higher levels of general anxiety.

Atherogenic lipoprotein phenotype in type 2 diabetes: reversal with micronised fenofibrate

BACKGROUND

To assess the short-term effects of a micronised formulation of fenofibrate on lipids, lipoproteins and their composition, reflecting an atherogenic lipoprotein phenotype (ALP), in patients with stable Type 2 diabetes.

METHODS

Thirty-two (18 male, 14 female) patients with Type 2 diabetes were randomised to a double-blind, placebo-controlled parallel group study after a 4-week diet run-in phase to a 12-week treatment period with either daily micronised fenofibrate 200 mg (Lipantil Micro((R))) or placebo.

RESULTS

Baseline mean lipid and lipoproteins were similar in both groups: total cholesterol (TC) 7.5 mmol/l, serum triglyceride (TG) 3. 1 mmol/l, HDL-cholesterol (HDL-c) 1.2 mmol/l, LDL-cholesterol (LDL-c) 4.7 mmol/l, and a predominance (52%) of small dense LDL-III at concentration of 192 mg lipoprotein/100 ml, reflecting an ALP. Treatment with micronised fenofibrate resulted in significant changes in TC (-17%, p<0.001), serum TG (-44%, p<0.05), HDL-c (+20%, p<0.01), LDL-c (-22%, p<0.001), apo-B (-18%, p<0.05) and alterations in LDL subfraction masses (LDL-I +64%, p<0.05; LDL-II +53%, p<0.05; LDL-III -51%, p<0.001) resulting in LDL-III comprising 28% of total LDL (p<0.001). In the placebo group the only significant changes were in TG (+21%, p<0.05) and apo-B (+9%, p<0.05).

CONCLUSIONS

Micronised fenofibrate therapy in patients with Type 2 diabetes improved an establisheded ALP resulting in a more favourable lipid and LDL subfraction profile. The long-term clinical implications of these changes await the results of the major intervention trials of lipid modification in Type 2 diabetes.

Patterns of contraception in UK women with Type 1 diabetes mellitus: a GP database study

AIM

To establish the patterns of contraceptive prescribing for women aged 15-49 with Type 1 diabetes mellitus (DM) and compare them with the patterns in women without diabetes.

METHODS

This was a cross-sectional study using a UK primary care database.

RESULTS

Nine hundred and thirty-eight women with a diagnosis of Type 1 DM were identified. A comparison group of women aged 15-49 without diabetes (n = 10000) were randomly selected from the database. Twenty-five per cent of the women with diabetes and 32% without diabetes were prescribed a hormonal contraceptive in 1994. Women with Type 1 DM were more likely to be prescribed a combined oral contraceptive than a progestogen only pill (POP) but were 2.12 (95% CI 1.65-2.72) times more likely to be prescribed a POP than women without diabetes and were less likely to be prescribed a combined pill - odds ratio 0.53 (95% CI 0.44-0.64). The pregnancy rate in women with Type 1 DM over the age of 25 years was lower than for women without diabetes. Women under 25 years with Type 1 DM seemed more likely to record a pregnancy.

CONCLUSIONS

Differences between women with Type 1 DM and those without diabetes highlight the variation in the way that GPs and patients evaluate the risks and benefits when deciding on contraception.

Metformin-associated lactic acidosis: a rare or very rare clinical entity?

AIMS

Lactic acidosis is a well recognized complication of biguanide therapy which is potentially serious. Although the prevalence of metformin-associated lactic acidosis (MALA) is much lower than that associated with phenformin, it is still being reported sporadically which raises concerns for the practising clinicians. We review the currently available world-wide data of the prevalence of MALA, the risk factors for its development and the current practical guidelines on the use of metformin to minimize the risk of this potential hazard.

METHODS

An extensive literature search was conducted from both Medline and Ovid (1965-98) using the following keywords: 'Type 2 diabetes mellitus', 'oral hypoglycaemic drugs', 'biguanides', 'metformin-associated lactic acidosis' and 'renal impairment'.

RESULTS

MALA was found to be a very rare clinical entity, being 20 times less common than phenformin-associated lactic acidosis. Amongst all the risk factors, renal impairment appears to be the major precipitating factor for the development of MALA in metformin-treated patients. We also found cases of MALA where no precipitating factors were identified and the underlying mechanism in these cases remains unclear. Practical recommendations of metformin use to minimize the risk of MALA have been listed based on previous reports.

CONCLUSIONS

The low prevalence of MALA is comparable to the prevalence of sulphonylurea-induced hypoglycaemia. Metformin has many beneficial metabolic effects in the management of Type 2 diabetes mellitus. Provided that the recommended guidelines for metformin use are strictly adhered to, its widespread use would be safe and the incidence of MALA will be further reduced.

Aldosterone excess: a rare non-nephrophathic cause of hypertension in type I diabetes

The aetiology of hypertension in type 1 diabetes is commonly due to the presence of diabetic nephrology. A rare case of hypertension in a patient with type 1 diabetes and no proteinuria is reported, where the investigation of borderline hypokalaemia allowed us to make a diagnosis of hyperaldosteronism due to bilateral adrenocortical hyperplasia. Secondary causes of hypertension should always be considered in all diabetic patients, particularly in the absence of clinical proteinuria.

Cardiovascular outcomes in type 2 diabetes. A double-blind placebo-controlled study of bezafibrate: the St. Mary's, Ealing, Northwick Park Diabetes Cardiovascular Disease Prevention (SENDCAP) Study

OBJECTIVE

To determine whether serum lipid intervention, in addition to conventional diabetes treatment, could alter cardiovascular outcomes in type 2 diabetes.

RESEARCH DESIGN AND METHODS

There were 164 type 2 diabetic subjects (117 men, 47 women) without a history of clinical cardiovascular disease randomized to receive either bezafibrate or placebo daily on a double-blind basis in addition to routine diabetes treatment and followed prospectively for a minimum of 3 years. Serial biochemical and noninvasive vascular assessments, carotid and femoral artery B-mode ultrasound measurements, and those pertaining to coronary heart disease (CHD)--clinical history, the World Health Organization (WHO) cardiovascular questionnaire, and resting and exercise electrocardiogram (ECG)--were recorded.

RESULTS

Bezafibrate treatment was associated with significantly greater reductions over 3 years in median serum triglyceride (-32 vs. 4%, P = 0.001), total cholesterol (-7 vs. -0.3%, P = 0.004), and total-to-HDL cholesterol ratio (-12 vs. -0.0%, P = 0.001), and an increase in HDL cholesterol (6 vs. -2%, P = 0.02) as compared with placebo. There was a trend toward a greater reduction of fibrinogen (-18 vs. -6%, P = 0.08) at 3 years. No significant differences between the two groups were found in the progress of ultrasonically measured arterial disease. In those treated with bezafibrate, there was a significant reduction (P = 0.01, log-rank test) in the combined incidence of Minnesota-coded probable ischemic change on the resting ECG and of documented myocardial infarction.

CONCLUSIONS

Improving dyslipidemia in type 2 diabetic subjects had no effect on the progress of ultrasonically measured arterial disease, although the lower rate of "definite CHD events" in the treated group suggests that this might result in a reduction in the incidence of coronary heart disease.

Needle phobia in type 1 diabetes mellitus

Needle phobia in patients with Type 1 (insulin-dependent) diabetes mellitus is difficult to manage. We report a case of long-standing needle phobia in a patient with 33 years of Type 1 diabetes mellitus who has developed very few vascular complications. Further studies are required to identify the prevalence of needle phobia in Type 1 diabetes mellitus. Once these individuals have been identified, appropriate psychological and physical treatments should be implemented, in the hope of making such individuals less fearful of the treatment of their condition.

Is hormone replacement therapy prescribed for postmenopausal diabetic women?

A community-based survey was undertaken to ascertain current hormone replacement therapy (HRT) prescription rates in postmenopausal diabetic women. From age/sex and disease registers linked to prescription data which covered 144,237 patients, details on 6867 women aged 50-60 years were obtained. Of this group, 1684 (24.5%) were receiving prescriptions for HRT; the comparable figures for the 537 patients with hypertension and 135 (insulin-dependent and non-insulin dependent) diabetic patients were 117 (21.8%) and 15 (11.1%) respectively. While the presence of hypertension did not affect the likelihood of being prescribed HRT (odds ratio 0.85 [95% CI 0.68-1.05], p > 0.1), women with diabetes were less than half as likely as those from the general population to be prescribed HRT (odds ratio 0.38 [95% CI 0.21-0.67], p < 0.001). These data indicate that proportionately greater numbers of postmenopausal diabetic women, even compared with those with hypertension, another group at high risk of cardiovascular disease, are denied the potential benefits of HRT.