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The latest evidence for practice

Una Adderley
Specialist Nurse
Team Leader

What are the most effective drugs for preventing malaria in travellers?

Each year around 150 people die from malaria acquired while travelling. A further 10,000-30,000 develop malaria following their travels. Plasmodium falciparum is the species of malaria that causes most severe illness and death but there is evidence that this species is becoming resistant to chloroquine, which is the most commonly used prophylactic drug.

This Cochrane systematic review sought to review the effectiveness of drugs for malaria prophylaxis for travellers since travellers have different susceptibility to malaria compared to local populations.

This review sought randomised and quasi-randomised trials that compared the effects of currently used antimalaria drugs that are used prophylactically for adults and children who are travelling to regions with Plasmodium falciparum resistance to chloroquine. In particular it sought to assess the comparative efficacy, safety and tolerability of atovaquone-proguanil, doxycycline, and mefloquine and also when compared to chloroquine-proguanil and to primaquine.

Eight trials (which included 4,240 patients) met the inclusion criteria but the quality of evidence was low. No evidence was found to support the use of primaquine and it was unclear as to which of the other drugs is most effective in preventing malaria. None of the trials reported any serious adverse events but less serious adverse events were reported.

Atovaquone-proguanil and doxycycline were found to be the best tolerated, chloroquine-proguanil was found to cause more gastrointestinal adverse events than other antimalaria drugs and mefloquine has more adverse effects than other drugs.
However, for travellers who have previously taken mefloquine without any adverse events, this may still be an appropriate choice.  

A commentary notes that given the inconclusive nature of this evidence and the shortage of evidence in general, the decision as to which malaria prophylaxis regimen should be prescribed should continue to be individualised to the individual patient and their particular destination.

Reference
Jacquerioz FA, Croft AM. Drugs for preventing malaria in travellers. Cochrane Database Syst Rev 2009 Oct 7;(4):CD006491.

Commentary
Hawkes M. Evid Base Nurs 2010;13:19-20.

What effect does intensive glucose reduction have in type 2 diabetes?

Diabetes is known to be a major risk factor for cardiovascular disease (CVD). There is evidence that intensive glucose control in type 2 diabetes reduces the risk of microvascular complications. However, it is unclear what impact intensive glucose control has on cardiovascular disease such as coronary heart disease, stroke and peripheral arterial disease.

This American systematic review sought to evaluate the evidence from randomised trials that had compared clinical outcomes in patients with type 2 diabetes receiving intensive glucose control compared to those receiving conventional glucose control. Five randomised, controlled trials were included in the review and it was found that intensive glucose control reduced the risk for some cardiovascular outcomes such as non-fatal myocardial infarction, but did not reduce the risk for cardiovascular death. It was also found that intensive glucose control increased the risk for severe hypoglycaemia.

A commentary notes that glycaemic goals need to be individualised, especially for those patients with known CVD or other known diabetes-related complications. Given the hazards of hypoglycaemia in patients with long-standing diabetes and CVD, early identification of diabetes through screening for diabetes in high-risk individuals and intensive glucose control in the early stages of diabetes is critical.

Reference
Kelly TN, Bazzano LA, Fonseca LA et al. Systematic review: glucose control and cardiovascular disease in type 2 diabetes. Ann Intern Med 2009;151:394-403.

Commentary
Chyun D. Evid Base Nurs 2010;13:3-4.