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PRACTICE: Bruce Arroll, Timothy Kenealy, and C Raina Elley Should we prescribe diuretics for patients with prediabetes and hypertension? BMJ 2008; 337: a679 [Full text]

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Appropriate outcomes

Mark R Nelson   (29 August 2008)

'Uncertain' Recommendations from NICE.

Sean C Higgins, Professor Tom Fahey   (18 December 2008)

Appropriate outcomes 29 August 2008
Mark R Nelson, Professorial Fellow Menzies Research Institute, Private Bag 33, Hobart 7001, AUSTRALIA Send response to journal: Re: Appropriate outcomes	While the majority of persons with diabetes do die of major adverse cardiovascular events it is not appropriate to just treat the disease as a surrogate outcome for said. A diagnosis of diabetes has a profound effect on the life of the individual, including microvascular and other adverse outcomes not acknowledged here, and significant costs to the healthcare system. Competing interests: None declared
'Uncertain' Recommendations from NICE. 18 December 2008
Sean C Higgins, Registrar in General Practice Department of General Practice, RCSI Medical School, Dublin 2., Professor Tom Fahey Send response to journal: Re: 'Uncertain' Recommendations from NICE.	Editor, Bruce Arroll and colleagues rightly point out the inconsistency in recommendations concerning drug management of hypertension,[1] showing that the same evidence has been interpreted in different ways by UK and US guideline groups.[2][3] The UK guidelines from NICE are based on modelling potential states of health in relation to drug treatment; they include the development of diabetes in their model but exclude other health states that encompass common side effects of blood pressure lowering drugs.[3] The danger of this approach is that the benefits and risks of alternative drug treatments may appear more “certain” than current evidence supports. The “uncertainty” that Arroll et al highlight in relation to the “diabetogenic” effects of thiazide diuretics has been inflated by the NICE recommendations which recommends ACE inhibitors as first line agents in patients under 55 years, despite the fact that diuretics are at least as good as ACE inhibitors and calcium channel blockers in terms of cardiovascular outcomes.[1] To be fair to the NICE guideline group they do state that diuretics are “the optimal choice dominating all other interventions” when the health state of diabetes is removed from their model. However, this underlines how their recommendations are sensitive to their initial model assumptions, and how “uncertain” their recommendations really are. Yours sincerely, Sean Higgins, GP Registrar Tom Fahey, Professor of General Practice, Department of General Practice, RCSI Medical School, Dublin 2. References 1. Arroll, B., T. Kenealy, and C.R. Elley, Should we prescribe diuretics for patients with prediabetes and hypertension? BMJ, 2008. 337: p. a679 2. Chobanian, A.V., et al., The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA, 2003. 289(19): p. 2560-72. 3. National Instttue for Health and Clinical Excellence. Mangement of hypertension in adults in primary care. A partial update of NICE clinical guidance 18.2006 www.nice.org.uk/nicemedia/pdf/HypertensionGuide.pdf Competing interests: None declared