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Drugs not justified for diabetes prevention

GPs cannot justify prescribing drugs to prevent diabetes as lifestyle modification can achieve equally effective results at a lower cost, according to a new analysis.

Last year the high-profile DREAM study claimed that one in 12 otherwise healthy people should be taking rosiglitazone to prevent diabetes, and one in seven people with impaired glucose tolerance should be given the drug.But an analysis published last week dealt a blow to the push for wider use of glitazones as preventive treatment. Researchers writing in the BMJ argued the aggressive marketing of rosiglitazone as a preventive therapy would turn healthy people into patients and 'bring harms and additional costs, while the benefits for patients remain questionable'.Dr Victor Montori, associate professor of medicine at the Mayo Clinic College of Medicine in Minnesota, US, said although several trials had assessed the ability of drugs to prevent diabetes, 'the evidence is inconsistent and comes from trials of limited methodological quality'.DREAM, published in The Lancet, found rosiglitazone had no effect on all-cause mortality, 'an outcome of great importance to patients', Dr Montori added.Dr Montori's team argued that: 'Equally efficacious lifestyle interventions are far less costly to implement and may well reduce costs in the long run, particularly when applied to populations.'This opinion is shared by many primary care diabetes experts. Dr Martin Hadley-Brown, chair of the Primary Care Diabetes Society and a GP in Thetford, Norfolk, said he 'absolutely agreed' with the conclusions of the new analysis.'Giving medication prior to the development of diabetes is not the thing to do. I'm not in favour of that.'Dr Peter Tasker, a GP in King's Lynn, Norfolk, agreed: 'I personally believe that all the DREAM trial can be regarded as is an interesting piece of science. I don't feel that anyone in primary care is going to be instigating medications for people without diabetes. My feeling is that on this occasion we're not going to be following where the US leads.'But others think changing practice in the US could trickle down to the NHS.Dr Peter Stott, a GP in Tadworth, Surrey, said: 'We will probably move to use glitazones and insulin as they do in the States – we always follow them.'

Conclusions of new analysis

• Lifestyle changes and certain drugs are effective in preventing diabetes• No trial has shown an improvement in outcomes – including risk of diabetes complications and all-cause mortality• Lifestyle changes are equally effective, much safer and cheaper• Clinical use of glitazones for prevention of diabetes cannot be justified

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