Checking blood pressure using a 24 hour blood pressure monitor is referred to as out-of-office blood pressure in the US. According to a new study in the Lancet, it seems that, when it comes to diagnosis and monitoring of hypertension, we should keep the out-of-office on. The observational cohort study of a registry of over 50 000 patients in Spain compared blood pressure measured in a clinic with out-of-office blood pressure and each method’s association with all-cause and cardiovascular death over a median 9.7 year follow-up period. The 24 hour blood pressure measurements more closely correlated with all-cause mortality than clinic blood pressure—although a linked editorial asks whether some of the difference may reflect the quality of measurements performed in clinics.
Once weekly insulin: onwards and upwards
Once weekly basal insulin may soon become an option for people with type 2 diabetes, after an open label trial found that once weekly treatment with insulin icodec (a basal insulin analogue) non-inferior to once daily treatment with insulin glargine. The study recruited 582 people across nine countries who were already taking insulin in the form of a once daily basal injection and short-acting insulin with meals. They were randomised to either once weekly icodec, which has a half life of eight days, or once daily glargine U100 (continuing mealtime insulin in both groups). At 26 weeks, both groups had similar improvements in HbA1c, and there were no significant differences in adverse events including hypoglycaemia—although more than half of participants in both arms of the study had an episode of clinically significant hypoglycaemia with a blood glucose level <3.0 mmol/L.
The tangled cost of lecanemab
The antidementia drug lecanemab was controversially given accelerated approval by the US Food and Drug Administration (FDA) on the basis of reductions in β amyloid plaque in patients with mild cognitive impairment or mild dementia. The US Veterans Health Administration decided in March that it would cover the cost of the $26 500 a year once-weekly infusion, but it isn’t available through Medicare yet. That could change if it receives full FDA approval this year, but at what cost? A cross sectional cost analysis published in JAMA Internal Medicine estimates that the drug and the associated costs of administering it could add between $2bn and $5bn annually to Medicare spending—and cost those without additional insurance thousands of dollars a year.
JAMA Intern Med doi:10.1001/jamainternmed.2023.1749
Incidental findings from screening
There’s a classic cartoon by Hilda Bastian set at the “All-Nite Drive-Thru Screening Clinic.” There’s a nervous looking patient with a doctor standing over them saying: “You have a right to remain anxious. Anything you say will be used to further test you. If you do not already have a diagnosis one will be provided for you.” And so to a case series of 26 455 participants of the US based National Lung Screening Trial who had received low dose CT screening for lung cancer. Just over a third of them (33.8%) had a significant incidental finding from screening. Emphysema was the most common (43%), followed by coronary artery calcium (12.1%) and then masses or other suspicious lesions (7.4%). These incidental findings will be of benefit for some, cause worry for many, and eat up more resources for everyone.
JAMA Intern Med doi:10.1001/jamainternmed.2023.1116
Sleep apnoea alert
There are times where a wakefulness-promoting agent would come in very handy: when trying to clear your backlog of results and letters at the end of a long day, or when clicking through your annual information governance training. A network meta-analysis of three wakefulness-promoting agents for people with sleep apnoea concluded that solriamfetol, armodafinil-modafinil, and pitolisant reduce daytime sleepiness for patients with excessive daytime sleepiness already taking conventional therapy for obstructive sleep apnoea. In last year’s NICE guideline on sleep apnoea, the guideline committee concluded that prescribing of solriamfetol—the most effective of the three treatments according to this review—would likely be limited to secondary care.
Ann Intern Med doi:10.7326/M22-3473