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Good news on diabetes, bad news on nose drops

BMJ 1998; 317 doi: (Published 12 September 1998) Cite this as: BMJ 1998;317:a

This week the BMJ and the Lancet between them publish a series of papers from the UK Prospective Study Group that carry important messages on treating type 2 diabetes. These trials have included over 1000 patients, taken over a decade to complete, and cost millions of pounds. Painstakingly, the dozens of contributors, led by Robert Turner, have used first class research methods to answer important, everyday clinical questions “that have haunted diabetes researchers and clinicians for years (p 693).”

The world has over 100 million diabetics, and the number is predicted to double to 221 million by 2010 (p 691). Most of the increase will be in type 2 diabetics and is resulting from increasing obesity and inactivity. Also important is low birth weight, predisposing people to develop diabetes.

Carl Mogensen (p 693) summarises the results of three studies in the BMJ and two in the Lancet. One of the Lancet papers shows that tightly controlling blood glucose concentration reduces the risk of complications in type 2 diabetes. Sulphonylureas and insulin produce equal benefit, and metformin also works. The first of the BMJ papers shows that tight blood pressure control leads to important reductions in diabetes related endpoints, deaths related to diabetes, and stroke (p 703). About 40% of 45 years olds with type 2 diabetes are hypertensive, the proportion increasing to 60% by 75. Tight blood pressure control seems to produce even greater benefit than tight blood glucose control. Angiotensin converting enzyme inhibitors and β blockers seem to work equally well (p 713), and achieving tight blood pressure control is highly cost effective (p 720). GP choice

This issue's lesson of the week is important for general practitioners (p 739). Doctors from the Royal Hospital for Sick Children in Glasgow describe two boys who presented with growth failure and obesity and were clinically cushingoid. The cause in both cases turned out to be betamethasone nose drops. The first boy had been taking them for 19 months and had had 27 repeat prescriptions. The second boy had been taking them on repeat prescription for 27 months. The authors recommend that betamathasone nose drops should not be prescribed for more than six weeks at a time. They worry that the cases they have seen may be the tip of an iceberg of milder cases.

Finally, Roy Roberston illustrates the diversity of general practice by describing a prisoner released after 12 years, many of them in solitary confinement (p 757). The man entered the community “in one, totally unprepared, step.”

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