[SGLT-2 inhibitors: diabetes treatment by glycosuria; literature review on the effect of dapagliflozin]. / SGLT-2-remmers: glucosurie als diabetesbehandeling; literatuurstudie naar het effect van dapagliflozine.

OBJECTIVE: To describe the efficacy and safety of dapagliflozin, the first sodium-glucose co-transporter-2 (SGLT-2) inhibitor for the treatment of diabetes mellitus type 2 (DM2) to be registered in the Netherlands. DESIGN: Literature review. METHOD: We searched the Medline database for articles on the use of dapagliflozin in patients with DM2. We included randomised studies with a minimum duration of 12 weeks and systematic reviews published up to 19 October 2012. Two assessors selected the articles on the basis of title, abstract and if necessary, the complete text. RESULTS: Eleven articles were suitable for analysis. On comparison with placebo, the use of dapagliflozin gave a drop in HbA1c-value of approximately 0.5-0.8 percentage points (6-9 mmol/mol). The body weight of patients who used dapagliflozin dropped between 1.0-2.4 kg on comparison with the placebo and metformin control groups. Urinary tract infections occurred twice as often and genital infections three to four times more often. There were no data on the effect on micro- and macrovascular complications or on mortality. CONCLUSION: Dapagliflozin regulates the blood glucose levels less effectively than currently used medications, although the small number of studies that compare dapagliflozin with metformin or glipizide show no differences in the drop in HbA1c between the study groups. Dapagliflozin use leads to minor, clinically non-relevant weight loss. There are as yet no data on its long term efficacy and safety.

Preventing hospital admissions by reviewing medication (PHARM) in primary care: an open controlled study in an elderly population.

WHAT IS KNOWN AND OBJECTIVE: Limited and conflicting evidence exists on the effect of a multicomponent pharmaceutical care intervention (i.e. medication review, involving collaboration between general practitioners (GPs), pharmacists and patients) on medication-related hospitalizations, survival, adverse drug events (ADEs) and quality of life. We aimed to investigate the effect of a multicomponent pharmaceutical care intervention on these outcomes. METHODS: An open controlled multicentre study was conducted within primary care settings. Patients with a high risk on medication-related hospitalizations based on old age, use of five or more medicines, non-adherence and type of medication used were included. The intervention consisted of a patient interview, a review of the pharmacotherapy and the execution and follow-up evaluation of a pharmaceutical care plan. The patient's own pharmacist and GP carried out the intervention. The control group received usual care and was cared for by a GP other than the intervention GP. The primary outcome of the study was the frequency of hospital admissions related to medication within the study period of 12 months for each patient. Secondary outcomes were survival, quality of life and ADEs. RESULTS AND DISCUSSION: 364 intervention and 310 control patients were included. Less medication-related hospital admissions were found in the intervention group (n = 6; 1·6%) than in the control group (n = 10; 3·2%) but the overall effect was not statistically significant (hazard ratio (HR) 0·50, 95% confidence interval (CI) 0·12-1·59). The secondary outcomes were not statistically significantly different either. The study was underpowered, which may explain the negative results. A post hoc analysis showed that the effect of the intervention was statistically significant for patients with five diseases or more: five diseases, HR 0·28 (95% bootstrap CI: 0·056-0·73) and eight diseases, HR 0·11 (95% CI: 0·013-0·34). WHAT IS NEW AND CONCLUSION: A multicomponent pharmaceutical care intervention does not prevent medication-related hospital admissions. Whether this is true for such interventions in general is unknown, because the PHARM study was underpowered. The intervention may significantly reduce medication-related hospitalizations in patients with five or more comorbidities, but this is only based on a post hoc analysis and thus needs confirmation in large controlled trials.

[Summary of the NHG Standard 'Preconception care']. / Samenvatting van de NHG-Standaard 'Preconceptiezorg'.

Preconception care is part is the primary care by general practitioners and midwives in the Netherlands. The Dutch College of General Practitioners' (NHG) practice guideline 'Preconception care' gives the general practitioner guidelines for assisting couples to be well informed and in the best possible health before conception. The guideline advises general practitioners to be alert for prescription of chronic medication to women wishing to have a child and informs couples wishing to have a child of the availability of a preconception consultation. The general practitioner should review which interventions are necessary in women with chronic disorders. A thorough medical family history is required for the man as well as the woman. Their employment situation and conditions also need to be reviewed. In the case of desire for a child, folic acid is advised. In addition, the practitioner should give advice concerning stopping smoking, healthy weight and avoidance of alcohol use during pregnancy. Implementation of the guideline is especially important for the less educated and for immigrants, as these groups have less healthy lifestyle habits and less knowledge of risk factors in pregnancy.

[Summary of the Dutch College of General Practitioners (NHG) practice guideline on 'Diverticulitis']. / Samenvatting van de NHG-standaard 'Diverticulitis'.

The NHG practice guideline on 'Diverticulitis' provides general practitioners with directions on the diagnosis and treatment of uncomplicated and complicated diverticulitis. Diverticulitis is primarily a clinical diagnosis which can be supported by assessment of CRP. Uncomplicated diverticulitis is strongly suspected if the patient reports the development of persistent sharp, stabbing pain in the lower left abdomen within a couple of days; if there is pressure or rebound tenderness only in the lower left abdomen; and if there are no alarm signals. Alarm signals of complicated diverticulitis are: guarded muscle response, signs of intestinal obstruction, locally palpable resistance, rectal loss of blood, hypotension, and high fever. The policy for uncomplicated diverticulitis is waiting without specific measures, provided that the general practitioner monitors the course actively. There is no indication for antibiotics in patients with uncomplicated diverticulitis. Patients with signs of complicated diverticulitis or with persisting symptoms should be referred.

[Revised practice guideline on mild traumatic head/brain injury: mainly for secondary care]. / Herziene richtlijn licht traumatisch hoofd-hersenletsel: vooral voor de tweede lijn.

Recommendations for referral of patients with mild traumatic head or brain injury to hospital-based emergency departments aim to minimize the risk of missing severe intracerebral injuries. As these recommendations were derived from secondary care data, application of the recommendations in general practice is likely to reduce the positive predictive value for severe intracerebral injury and may, therefore, result in more unnecessary referrals. Instead, in primary care an advice to wake up the patient several times during the first 24 hours after trauma may help to notice in time the development of severe intracranial pathology.

[The Dutch College of General Practitioners' practice guideline 'Parkinson's disease' in summary]. / De NHG-standaard 'Ziekte van Parkinson' samengevat.

Parkinson's disease is characterised by bradykinesia in combination with one or more of the following symptoms: rigidity, resting tremor and disorders of posture and balance. Refer a patient with suspected Parkinson's disease (or parkinsonism) for diagnosis and treatment preferably to a neurologist with expertise in movement disorders. The treatment of Parkinson's disease is symptomatic; to date, there is no treatment that slows disease progression. The treatment of patients with Parkinson's disease and its related disorders involves collaboration of the neurologist, Parkinson's disease nurse and general practitioner. In addition to recognizing the hypokinetic-rigid syndrome, the general practitioner has a role in diagnosing and treating associated symptoms and disorders, and in supporting and counseling the patient and their partner or caregiver.

[Summary of the Dutch College of General Practitioners' practice guideline on food hypersensitivity]. / Samenvatting van de NHG-Standaard 'Voedselovergevoeligheid'

October 2010 the Dutch College of General Practitioners issued a revised version of their previous practice guideline of 1995 on food hypersensitivity in infants. If patients suspect either themselves or their child of having a food allergy, this is usually not demonstrated in subsequent investigation. Wrongly prescribed elimination diets may have adverse effects. Examination of serum specific IgE levels has no place in the diagnosis of food allergy in general practice. An open elimination challenge is especially suitable in order to exclude a food allergy. A sure diagnosis of food allergy can only be made by a double-blind placebo-controlled food challenge. There are no proven effective measures that can prevent food allergy.

[Dutch College of General Practitioners' practice guideline 'Peripheral facial paralysis': a summary]. / De NHG-standaard 'Perifere aangezichtsverlamming': samenvatting.

The practice guideline 'Peripheral facial paralysis' of the Dutch College of General Practitioners provides the general practitioner with guidelines for diagnosis and management of patients with a peripheral facial paralysis. In about two-thirds of cases of peripheral facial paralysis no cause can be found. The diagnosis of this so-called idiopathic peripheral facial paralysis is based on the patient's history and physical examination; additional investigations are not indicated. The natural course is usually good: without treatment 65-85% of patients will regain normal function of the facial muscles. Treatment with corticosteroids is recommended for all patients with an idiopathic peripheral facial paralysis, irrespective of the degree of the paralysis. This increases the chance of complete recovery by approximately 10%. Antiviral treatment is not recommended.

[Summary of the practice guideline 'Atrial fibrillation' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Atriumfibrilleren' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The revised practice guideline 'Atrial fibrillation' from the Dutch College of General Practitioners provides the general practitioner with guidelines for diagnosis and management of patients with atrial fibrillation. To find patients with atrial fibrillation, it is advised to check cardiac rhythm at every blood pressure measurement. In patients over 65 years old, acceptance of atrial fibrillation with control of ventricular rate is preferred to sinus rhythm normalisation. In therapy with beta-blockers, slow release metoprolol is the drug of choice. An important goal of treatment is the prevention of thrombo-embolic complications. The choice between anticoagulants such as aspirin and coumarin derivatives is based on the CHADS2 score and determined by age (above 75 years) and comorbidity including cardiac failure, diabetes, hypertension, and previous transient ischaemic attack (TIA) or cardiovascular accident (CVA). The adequacy of antithrombotic treatment should be reassessed yearly.

[Dutch College of General Practitioners' practice guideline on symptoms of the hand and wrist: a summary]. / De NHG-standaard 'Hand- en polsklachten': samenvatting.

The first edition of the practice guideline for general practitioners (GPs) on hand and wrist symptoms was published in January 2010 by the Dutch College of General Practitioners. This practice guideline provides GPs with pointers for the diagnosis and treatment of hand and wrist symptoms. Carpal tunnel syndrome (CTS) can be diagnosed on its typical clinical presentation alone. The treatment of mild symptoms of CTS, trigger finger and De Quervain's tenosynovitis is conservative, or sometimes a corticosteroid injection: more severe or persistent symptoms require referral to hospital. Mallet finger is treated with a splint for 6 weeks, surgical intervention is necessary for large avulsion fractures or persisting symptoms after treatment with a splint.

[Dutch College of General Practitioner's practice guideline on polymyalgia rheumatica and temporal arteritis]. / Samenvatting van de NHG-standaard 'Polymyalgia rheumatica en arteriitis temporalis'.

The practice guideline for general practitioners (GPs) on polymyalgia rheumatica and temporal arteritis was published in February 2010 by the Dutch College of General Practitioners. This guideline provides GPs with recommendations for the diagnosis and treatment of polymyalgia rheumatica. After other disorders have been excluded, the diagnosis of 'polymyalgia rheumatica' is made in patients over the age of 50 who have bilateral pain in the neck and shoulder girdle and/or hip girdle that has lasted for longer than 4 weeks, morning stiffness that lasts longer than 60 minutes and an ESR > 40 mm in the first hour. After the diagnosis is made treatment with prednisone or prednisolone 15 mg per day is started. This dosage is diminished very gradually according to a uniform treatment schedule during a period of 3 months, thereafter depending on the clinical course. The practice guideline pays attention to the diagnosis and management of temporal arteritis only when it occurs concurrently with polymyalgia rheumatica.

[New blood glucose-lowering drugs in type 2 diabetes: a review of the literature]. / Nieuwe bloedglucoseverlagende middelen bij type 2 diabetes: een literatuuroverzicht.

OBJECTIVE: To describe the efficacy and safety of the glucagon-like peptide 1 (GLP-1) analogues exenatide and liraglutide, and the dipeptidyl peptidase-4 (DPP-4) inhibitors vildagliptin and sitagliptin, registered in the Netherlands for treatment of type 2 diabetes mellitus (DM2). DESIGN: Literature study. METHOD: The Medline database was searched up to and including August 2009 for systematic reviews and randomised trials with a minimum duration of 12 weeks in patients with DM2. Two authors independently selected the studies based on the title, abstract and, if necessary, the full text. RESULTS: In addition to 1 systematic review on GLP-1 analogues and 1 review on DPP-4 inhibitors, 10 studies on DPP-4 inhibitors and 16 studies on GLP-1 analogues were included. According to these studies, the DPP-4 inhibitors sitagliptin and vildagliptin gave a mean HbA1c reduction of 0.7% and 0.6% respectively. GLP-1 analogues led to a mean HbA1c reduction of 1%, which is comparable to insulin therapy. Sitagliptin was associated with a slight increase in the number of upper respiratory tract infections. In a large number of patients, GLP-1 analogues were associated with gastrointestinal complaints. DPP-4 inhibitors were associated with a small weight gain, compared with weight loss in patients treated with GLP-1 analogues. Data on microvascular and macrovascular complications, as well as data on mortality, are not yet available in either group. CONCLUSION: GLP-1 analogues regulate blood glucose levels as effectively as the current glucose-lowering agents; DPP-4 inhibitors are less effective. GLP-1 analogues lead to a clear weight reduction while DPP-4 inhibitors cause slight weight gain. Data on efficacy and safety in the longer term are not yet available.

[Dutch College of General Practitioners' practice guideline on symptoms of the hand and wrist: a summary]. / De NHG-standaard 'Hand- en polsklachten': samenvatting.

The first edition of the practice guideline for general practitioners (GPs) on hand and wrist symptoms was published in January 2010 by the Dutch College of General Practitioners. This practice guideline provides GPs with pointers for the diagnosis and treatment of hand and wrist symptoms. Carpal tunnel syndrome (CTS) can be diagnosed on its typical clinical presentation alone. The treatment of mild symptoms of CTS, trigger finger and De Quervain's tenosynovitis is conservative, or sometimes a corticosteroid injection: more severe or persistent symptoms require referral to hospital. Mallet finger is treated with a splint for 6 weeks, surgical intervention is necessary for large avulsion fractures or persisting symptoms after treatment with a splint.

[Dutch College of General Practitioner's practice guideline on polymyalgia rheumatica and temporal arteritis]. / Samenvatting van de NHG-standaard 'Polymyalgia rheumatica en arteriitis temporalis'.

The practice guideline for general practitioners (GPs) on polymyalgia rheumatica and temporal arteritis was published in February 2010 by the Dutch College of General Practitioners. This guideline provides GPs with recommendations for the diagnosis and treatment of polymyalgia rheumatica. After other disorders have been excluded, the diagnosis of 'polymyalgia rheumatica' is made in patients over the age of 50 who have bilateral pain in the neck and shoulder girdle and/or hip girdle that has lasted for longer than 4 weeks, morning stiffness that lasts longer than 60 minutes and an ESR > 40 mm in the first hour. After the diagnosis is made treatment with prednisone or prednisolone 15 mg per day is started. This dosage is diminished very gradually according to a uniform treatment schedule during a period of 3 months, thereafter depending on the clinical course. The practice guideline pays attention to the diagnosis and management of temporal arteritis only when it occurs concurrently with polymyalgia rheumatica.

[Summary of the practice guideline 'Traumatic knee problems' (first revision) from the Dutch College of General Practitioners]. / De NHG-Standaard 'Traumatische knieproblemen' (eerste herziening): samenvatting.

Most traumatic knee problems have a favourable prognosis and can be treated by the general practitioner. The course of knee symptoms and the impairment of knee function are more important for decisions about the management of knee problems than the results of physical examination of the knee. The additional value of general practitioner referral for MRI of the knee has not been established yet. Reasons for urgent referral to an orthopaedic specialist are: a knee fracture, an acutely locked knee, and a patellar dislocation.

[Summary of the Dutch College of General Practitioners' practice guidelines on obesity]. / Samenvatting van de standaard 'Obesitas' van het Nederlands Huisartsen Genootschap.

Adults with obesity have a decreased life expectancy and an increased risk of disease. Preferred treatment is a combination of lifestyle interventions, consisting of changes in diet, physical exercise and psychological support. Normal weight is not an achievable target in most adults, but even a 5-10% weight loss yields significant health gains. Obese children run a significant risk of mental and physical illness and often become obese adults. Indeed, the practice guidelines recommend an active approach by the general practitioner if a child appears obese at a consultation, irrespective of the reason for consultation.

[Summary of the practice guideline for shoulder complaints from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Schouderklachten' van het Nederlands Huisartsen Genootschap.

The second revision of the practice guideline for shoulder complaints was presented in 2008 by the Dutch College of General Practitioners. This guideline provides a standard for the diagnosis and treatment of shoulder complaints by general practitioners. The most important items in this new guideline are reviewed.

[Summary of the practice guideline 'Diagnosis of breast cancer' (second revision) from the Dutch College of General Practitioners]. / Beknopte weergave van de standaard 'Diagnostiek van mammacarcinoom (tweede herziening)' van het Nederlands Huisartsen Genootschap.

Breast cancer is the most prevalent malignancy among Dutch women; life prevalence is about 10%. A tumour in the breast of a woman of 35 years or older is always an indication for mammography, while a woman younger than 35 should have an ultrasound investigation. This is also the case if the woman can feel the tumour but the doctor is unable to. In breast pain without palpable abnormalities at physical examination, the risk of breast cancer is a lot lower and diagnostics may not need to be instigated immediately. However, persistent localized pain is an indication for breast imaging. Women with at least a doubled risk of getting breast cancer due to the occurrence of breast cancer in their relatives are recommended to undergo mammography every year from the ages of 40-49 years supplementary to the national screening programme. The Dutch national screening programme invites women aged between 50 and 75 to undergo mammography every two years. Follow-up of women of 60 years and older treated by lumpectomy 5 years or more previously, can be done by the general practitioner.

[Summary of the practice guideline 'Erectile dysfunction' from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Erectiele disfunctie' van het Nederlands Huisartsen Genootschap.

The Dutch College of General Practitioners recently published the practice guideline 'Erectile dysfunction'. The prevalence of erectile dysfunction increases with age. A lot of the men suffering from erectile dysfunction do not consult their general practitioner, or only do so after a lot of delay. It is recommended that inquiry about erectile dysfunction be made during routine follow-up consultations for co-morbid conditions.

[Summary of the practice guideline 'The intrauterine device' from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Het spiraaltje' van het Nederlands Huisartsen Genootschap.

The practice guideline 'The intrauterine device' from the Dutch College of General Practitioners, first published in 2000, has been revised. Copper and hormonal IUDs have more or less the same level of reliability with respect to preventing pregnancy. During the use of a copper IUD, menstruation tends to be longer with a greater loss of blood; in 70% of women who use a hormonal IUD oligomenorrhea or even amenorrhoea develops. Women with a history of venous thromboembolism can use a hormonal IUD safely. In the first weeks after IUD insertion, there is an increased risk of pelvic inflammatory disease (PID). Therefore prior to insertion, the general practitioner should enquire about the risk of a SOA being present and, if necessary, perform SOA tests. In the Netherlands, IUD insertion can usually be performed at a general practice.