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Clinical news round-up

ICP brings you the latest clinical news...

CGM to be offered to pregnant women with type 1 diabetes

All pregnant women with type 1 diabetes are to be offered continuous glucose monitoring (CGM) from March 2021 to help to improve neonatal outcomes, NHS England has announced.

The CONCEPTT trial showed that women with type 1 diabetes randomised to CGM during early pregnancy had a small but significantly greater reduction in HbA1 levels than did the control participants, accompanied by increased time in target, reduced hyperglycaemia, and less glycaemic variability at 34 weeks’ gestation.

In these women, there were reductions in the proportion of infants large for gestational age, neonatal hypoglycaemia, and admission to neonatal intensive care, and a 1-day shorter hospital stay among their infants.

Diabetes is in the spotlight as NHS England seeks to restore non-Covid-19 health services. The Diabetes Prevention Programme recovery plan also includes expanded access to the Healthier You programme, which helps people at high risk of type 2 diabetes to make lifestyle changes. People are now able to self-refer for this support alongside direct referral from their GP.

After offering fast track access to the programme, NHS England says 291,325 people used an online tool to check their risk of type 2 diabetes between the end of July and September.

The 637 per cent increase compared to previous two-month period is partly attributed to findings that people are twice as likely to die from Covid-19 if they have type 2 diabetes. Over 5,000 of these people have self-referred for support to lose weight.

As at the end of June 2020, 31 per cent of all those living with type 1 diabetes had access to the device.

The device was made available on the NHS Drug Tariff in 2017, and a recently published nationwide audit by the Association of British Clinical Diabetologists looked at the first cohort of over 10,000 NHS patients to use it. The audit shows marked improvement in HbA1c, reduction in hospital admissions and improvement in mental health parameters.

Funding for Flash is ringfenced until March 2021, at which point it will be built into CCG baselines for the ongoing prescribing of diabetes technologies.

 

NHS England puts up £10m to fund ‘long Covid’ clinics

NHS England has announced that £10 million is be made available this year in additional local funding to kick start ‘long Covid’ clinics across England. The new network will be a core element of a package of measures.

NICE and SIGN, the Scottish Intercollegiate Guidelines Network, are working jointly with the Royal College of General Practitioners to publish a guideline by the end of the year on the persistent effects of Covid-19.

People have reported persistent symptoms of Covid-19 regardless of how ill they were initially or whether they were hospitalised. Longer term impacts can include on-going shortness of breath, fatigue, heart, lung, kidney, neurological and musculoskeletal problems.

It is estimated that as many as 10 per cent of Covid patients - 60,000 people in the UK - could be suffering from long-term Covid symptoms after more than three months.

The guideline will provide a formal definition of the disease, how to identify on-going symptoms and best practice investigation and treatment options.

There will be further development of ‘Your Covid Recovery’ – an online rehab service to provide personalised support to patients. Over 100,000 people have used the online hub since it launched in July.

Phase 2 of the digital platform is being developed over the Autumn. This will enable patients to set goals for their mental and physical health, provide peer-to-peer support, offer an ‘ask the expert’ facility, and allow patients to be monitored by their local rehab teams.

The service will be available to anyone suffering symptoms that are likely due to Covid-19, regardless of location or whether they have spent time in hospital. It is most likely that patients will access the service through their GP, but they could also be referred through another healthcare professional following assessment.

Designated long Covid clinics will provide expert one-stop services in line with an agreed national specification. Patients will have access to physical, cognitive and psychological assessments.

The National Institute for Health Research has funded research on long Covid which is working with 10,000 patients to better understand the condition and refine appropriate treatment.

 

Prozac the best option for young people with depression?

A review of 71 separate trials has found that fluoxetine (Prozac), either alone or combined with cognitive behavioural therapy (CBT), may be the best choice for children and adolescents with moderate to severe depression.

However, most of the studies were rated as low to very low quality, so the conclusion is uncertain. Psychiatrists will need to continue to use their judgement and treat young people on a case-by-case basis, the study’s authors conclude.

Current NICE guidelines recommend psychotherapies alone (such as CBT within a group) for children and adolescents with mild depression. For those with moderate to severe depression NICE recommends more intense psychological therapies, such as individual CBT, as initial treatment.

However, the guidelines state that combined therapy of fluoxetine and psychological therapy is an alternative.

Depressive disorders are common in children and adolescents and they increase with age. About one in 330 (0.3 per cent) of 5-10 year olds is affected and the numbers rise to almost one in 20 (4.8 per cent) of 17-19 year olds.

The study included 71 trials with a total of 9,510 participants. Together, the trials assessed 16 antidepressants, seven psychotherapies and five combination therapies. The results showed that:

·      fluoxetine was the most effective option, either alone or combined with CBT

·      fewer patients stopped taking fluoxetine and nefazodone than several other drugs (sertraline, imipramine and desipramine) suggesting they are more acceptable

·      antidepressants alone were not more effective than psychotherapies alone

The research was funded by the NIHR Health Services and Delivery Research Programme.

 

Elevated INR seen in patients on anticoagulants during pandemic

There has been an apparent increase in the number of patients taking warfarin found to have elevated INR values during the Covid-19 pandemic.

Most, but not all patients had suspected or confirmed Covid-19 infection while others had recently been treated with antibiotics, says King’s College Hospital, which flagged up the issue.

In other patients, the lockdown may have affected access to green vegetables and led to increased alcohol consumption, while the psychological impact of social distancing may have affected adherence to regular medication.

The MHRA is reminding health professionals that acute illness may exaggerate the effect of warfarin tablets and necessitate a dose reduction. Continued INR monitoring is important in patients taking warfarin or other vitamin K antagonists (VKA) if they have suspected or confirmed Covid-19 infection, so they can be clinically managed at an early stage to reduce the risk of bleeding.

Some patients taking warfarin may have been switched to direct-acting oral anticoagulants (DOAC)s during the pandemic to avoid regular blood tests for INR monitoring.

VKAs interact with a large number of medicines, while DOACs including Eliquis (apixaban), Lixiana (edoxaban), Pradaxa (dabigatran) or Xarelto (rivaroxaban) also interact with several medicines.

Patients with Covid-19 may be treated with antibiotics in line with NICE guidance and may also be treated with antivirals.

There is the potential for drug-drug interactions between oral anticoagulants (VKA or DOACs) and certain antibiotics and antivirals.

Patients attending for INR tests or who are collecting prescriptions for vitamin K antagonists (VKA) should be asked to let their GP know if they have symptoms of, or confirmed Covid-19 infection, because it is important that they continue to have their INR monitored while they are ill, the MHRA is advising.

Patients taking VKA should let their GP and healthcare team know about any recent changes to their diet (including alcohol consumption), smoking habits, any new medicines or supplements they are taking, and of the need to carefully follow the instructions for use for anticoagulant medication.

 




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