Cardiovascular safety of sulphonylureas: over 40 years of continuous controversy without an answer.

More than 40 years after publication of the University Group Diabetes Program trial, the cardiovascular safety of sulphonylureas is still contentious. Although several hypotheses linking sulphonylureas to adverse cardiovascular effects exist, none provide conclusive evidence. Adding to the controversy, current clinical trials and observational studies provide inconsistent, and sometimes conflicting, evidence for the cardiovascular effects of sulphonylureas. Overall, observational evidence suggests that an increased risk of adverse cardiovascular outcomes is associated with sulphonylureas; however, these data may be subject to residual confounding and bias. Although evidence from randomized controlled trials has suggested a neutral effect, the majority of these studies were not specifically designed to assess the effect of sulphonylureas on adverse cardiovascular event risk. Current ongoing large clinical trials may provide some clarity on the cardiovascular safety of sulphonylureas, but the results are not expected for several years. With the continued uncertainties concerning the cardiovascular safety of all antidiabetic drugs, a clear answer with regard to sulphonylureas is warranted. The objectives of the present article were to provide an overview of the controversy surrounding sulphonylurea-related cardiovascular effects, to discuss the limitations of the current literature, and to provide recommendations for future studies aiming to elucidate the true relationship between sulphonylureas and adverse cardiovascular effects in people with type 2 diabetes.

How have pharmacists in different practice settings integrated prescribing privileges into practice in Alberta? A qualitative exploration.

WHAT IS KNOWN AND OBJECTIVE: Since 2007, pharmacists in Alberta have had authority to adapt existing prescriptions and independently prescribe medications after a peer review process. This study aimed to explore and characterize how pharmacists incorporated prescribing into practice 3 years after this legislation was approved. METHODS: We invited pharmacists to participate in semi-structured telephone interviews to discuss their prescribing practices. Pharmacists working in community, primary care network, hospital or other settings were selected using a mix of purposive and random sampling. Two investigators independently analysed each transcript using an Interpretive Description approach and thematically categorized prescribing practices according to the level of adoption. RESULTS AND DISCUSSION: Thirty-eight pharmacists (n = 13 independent prescribers) participated. Eighteen (47%) had a primary practice site from community practice, eight (21%) primary care, five (13%) hospital practice and seven (18%) from other settings including specialty clinics and long-term care. Twenty-eight participants were categorized as adopters and ten as non-adopters in their primary practice setting. Prescribing practices adopted were characterized as product focused, disease focused or patient focused. Sixteen (42%) described product-focused prescribing where they continued an existing therapy or substituted medications based on formulary guidelines. Seven (18%) described disease-focused prescribing where current therapies were adapted or initiated based on a protocol in a specific therapeutic area. Five (13%) described patient-focused prescribing where they initiated therapy based on patient needs and values, their assessment of the patient and best evidence. Non-adopters were not prescribing, but many described provision of disease or patient-focused care where they influenced prescribing by interacting with other members of the healthcare team. Most commonly, community pharmacists participated in product-focused prescribing, whereas hospital and primary care pharmacists practised disease-focused prescribing. WHAT IS NEW AND CONCLUSION: Our data suggest that there have been context-related differences in uptake across practice settings. Despite this, pharmacists in all studied settings engaged in prescribing activities using three approaches and many pharmacists who were not directly prescribing medications reported having involvement in drug therapy decision-making.