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GPs fight back over policing sicknotes

A row has broken out over NICE's decision to warn GPs against prescribing ?-blockers and diuretics ­ Rob Finch reports

Flawed NICE guidance is hampering GPs' efforts to help patients achieve optimal blood pressure control, new research suggests.

GP cardiology experts say the new evidence shows NICE has overstepped the mark in warning against combining

?-blockers and thiazide diuretics because of fears of an increased risk of type 2 diabetes.

The latest study ­ an analysis of data on over 75,000 elderly hypertensive patients ­ found no significant difference in the incidence of diabetes attributable to use of any of the commonly used antihypertensive drug groups.

According to NICE,

?-blockers and diuretics should not be combined in patients with a family history of type 2 diabetes, impaired glucose tolerance, obesity or south Asian/Afro-Caribbean ethnicity.

The alert was echoed in the recent update of British Hypertension Society guidelines.

But Dr John Pittard, a GP member of the committee that wrote the national service framework for CHD, advised GPs to ignore the NICE warning and assess overall risk in individual patients.

'The reduction in mortality and morbidity from being on a ?-blocker and a diuretic is more important than any marginal problem with diabetes, which you can deal with through lifestyle and diet changes,' said Dr Pittard, who practises in Staines, Middlesex.

NICE issued the alert after examining seven trials, of which the 21,000-strong ALLHAT study showed a significantly increased risk of new-onset diabetes in users of the combination.

Dr Pittard said: 'This is borne out by only one

trial. You should not base your policy on one trial, but that's what NICE seems to have done.'

A NICE spokesperson said the hypertension guidance would be updated in 2008 and there were no plans to bring forward the review in the light of the new evidence.

The Canadian researchers, who published their findings in Diabetes Care (October), found the risk of diabetes

in those taking the

?-blocker/thiazide diuretic combination was 14 per cent lower than in those on diuretic alone.

·NICE guidelines: 'Concern about increased new-onset diabetes among patients prescribed a thiazide-type diuretic with a

?-blocker means that this is not recommended as an initial

combination for patients at raised risk of developing type 2

diabetes. However, the combination may become appropriate to manage treatment-resistant hypertension or if cardiovascular disease develops.'

·British Hypertension Society advice: 'In recent trials, when ?-blockers have been combined with thiazide/thiazide-like diuretics, new-onset diabetes occurred more frequently (by about 15 per cent) than with regimens based on newer

therapies such as ACE inhibitors, angiotensin receptor blockers and calcium channel blockers.'

·Latest research: An analysis of five databases covering 76,176 patients aged over 65 found no significant difference

in type 2 diabetes incidence linked to any particular class/

combination of antihypertensive.

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