Drug prescribing for diabetes mellitus in primary care: a comparison of public and private practice in three Caribbean countries - abstract

Examining the appropriateness of drug prescribing for people with diabetes mellitus in Caribbean countries is important because of the high cost of drug treatment, the potential for improved control of the disease and the possibility of reducing adverse side effects of treatment. This study examined patterns of drug prescribing for diabetes mellitus in public and private sector primary care settings in three Caribbean countries. The sample included 690 patients in Barbados (BDS, 24 percent private), 791 in Trinidad and Tobago (TT, 13 percent private) and 180 in Tortola (BVI, 31 percent private). Patients treated in public health care facilities were prescribed significantly more drugs than those treated in private practice. Few patients had diabetes mellitus managed by diet alone (8 percent public, 15 percent private). Metformin was rarely used as single agent therapy (3 percent public, 6 percent private). Most patients were treated with sulfonylurea drugs alone or in combination with metformin (75 percent public, 67 percent). The proportion of sulfonylurea prescriptions for chlorpropamide varied (Public: BVI 80 percent, TT 60 percent, BDS 10 percent; Private: BVI 41 percent, TT 28 percent, BDS 7 percent) as did prescriptions for gliclazide and glipizide (Public: BDS 41 percent, BVI 3 percent, TT 1 percent; Private: BVI 51 percent, BDS 46 percent, TT 19 percent). A high proportion of patients were treated for hypertension (public 49 percent, private 40 percent). In private practice, ACE inhibitors and diuretics were the most frequently prescribed drugs. In the public sector, Brinderin accounted for 53 percent of prescriptions in TT while thiazides, methyldopa, betablockers and ACE inhibitors were the most frequently prescribed drugs in BDS and BVI. These variations in prescribing practice among countries of the region suggest that factors other than patients' needs or the cost effectiveness of treatment are important in determining prescribing practices. Individual countries should examine how efficiency and effectiveness of drug use could be improved (AU)

Sulphonylureas and hypoglycaemic emergencies - abstract

Adult admissions to Queen Elizabeth Hospital over the last three years with a discharge diagnosis of hypoglycaemia were reviewed. There were 55 such admissions among 49 patients (23 males and 26 female). Nine were related to ethanol excess (all males), 39 to diabetic treatment and one remained unexplained. Of the diabetic 10 were taking insulin and 29 oral agents. These were chlorpropamide alone (22), daonil alone (5), chlorpropamide plus daonil (1) and unidentified (1). Only six patients received metformin but in combination with one of the above. Five patients had a history of diagnosis and treatment for diabetes mellitus of less than one week and all were on sulphonylureas. Two patients were admitted twice and one five times for chlorpropamide hypoglycaemia. The mean age was 66 (range 18 to 86), while the mean of patients on oral agents was 70(P>0.05). Thirty-five (71 percent) presented with loss of consciousness, 7(14 percent) with disorientation, four with a stroke, one with a "transient ischaemic attack" and one with a fit. Patients fell obviously into short and long stay categories, i.e 19 were discharged in three days or less, while 18 remained in hospital for more than a week. Five of these died (overall mortality 10 percent) four with a permanent stroke. Two were chlorpropamide-related, in two the drug was unidentified and one was insulin-related. Four patients on sulphonylureas had prolonged hypoglycaemia after hositalisation, with low blood sugars and hypoglycaemic syndromes documented between days 2 and 4. These results indicate that hypoglycaemia is a relatively common cause of emergency hospitalisation in Barbados and that 60 percent are sulponylurea-related. 30 percent of these had renal impairment, but this did not differ significantly from renal impairment in the whole group (34 percent). More important risk factors appeared to be old age, poor nutrition and excessibe sulphonylurea in recently diagnosed elderly diabetics. There is need for a short acting sulphonylurea such as tolbutamide in local formularies and for greater emphasis on diet as first line treatment in such patients (AU)

Neonatal hypoglycaemia in infants of diabetic mothers given sulphonylurea drugs in pregnancy

Three infants whose diabetic mothers were given chlorpropamide and one infant whose diabetic mother was given acetohexamide up to the time of delivery were studied in the neonatal period because each became severely hypoglycaemic. The sulphonylurea drugs given to the mother crossed the placenta, and fetal plasma concentrations were in the therapeutic range for adults with diabetes mellitus. Each baby had severe hyperinsulinaemia resulting in profound hypoglycaemia. These acutely ill infants needed vigorous and prolonged treatment to correct the hypoglycaemia. In two infants exchange transfusion was performed to remove the drug. These sulphonylurea drugs should not be used to control diabetes mellitus in pregnancy. (AU)

Diabetes -Current concepts (Part II of the Henderson prize essay of 1965)

When one looks back to 1922 when Banting and Best first discovered insulin, one cannot help but be impressed with the remarkable strides made towards an understaning of this complex disease. Research has extended from gene complex through the prediabetic concept to the final action of insulin on the tissues. To date however, nothing has been finally settled and we are probably no better off today than the time of Banting and Best (Summary)