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22nd May 2025
The ways in which children and adolescents with severe asthma and/or moderate-to-severe atopic dermatitis perceive their medication and quality of life has been assessed in a real-world exploratory study, with particular focus on dupilumab.
The study included 57 paediatric patients (severe asthma: n = 31; moderate-to-severe atopic dermatitis: n = 21; both: n = 5) with a median age of 11 years and each received one structured interview with a trained pharmacist. This was based on a questionnaire developed by clinical pharmacists and paediatricians consisting of open questions and ratings on 6-point Likert scales ranging from ‘0: not at all’ to ‘5: very strongly’.
Most participants reported their medication for asthma and atopic dermatitis as ‘rather helpful’, with a median score of 4 out of 5. Nonetheless, 68% had previously missed or refused doses. Notably, all patients eventually resumed treatment.
Of the 16 participants receiving dupilumab, all reported symptom improvement within 2.5 months. Clinical scoring assessment supported these perceptions, with a 60.8% reduction in diagnostic scores for dermatitis and improved diagnostic scores for asthma.
The researchers found that dupilumab also led to a reduced fear of injections as the injections became a routine part of their treatment, with the median fear rating out of 5 falling from 3 pre-treatment to 0.5 at the time of interview.
Among the 14 dupilumab recipients with known allergies, half reported reduced symptoms to allergens such as nuts, dust mites, and animal dander, which is an emerging potential benefit of dupilumab requiring further investigation, the researchers said.
The results showed significant potential for improvement in disease burden after several weeks of dupilumab treatment.
Patient-reported outcome measures indicated a low impact of the participants’ asthma or atopic dermatitis on their quality of life at the time of the study. Most participants experienced minimal interference in leisure, school or sleep, and few reported feeling socially excluded.
Commenting on the applicability of their findings, the researchers said: ‘Given the potential impact on social participation, it is crucial to provide effective therapies for asthma and atopic dermatitis, irrespective of whether these are conventional treatments or monoclonal antibodies.’
The researchers considered these real-world findings to reinforce the efficacy of dupilumab and current guideline recommendations for its use in severe paediatric atopic conditions. They also noted that potential fear of injections should not be a barrier to biologic therapy use.
Reference Herzig M, et al. Medication-related perceptions of children and adolescents with severe asthma and moderate-to-severe atopic dermatitis: a non-interventional exploratory study. Allergy Asthma Clin Immunol. 2025;21:16.
This article was originally published by our sister publication Hospital Pharmacy Europe.
21st May 2025
The Congress of the European Society of Clinical Microbiology and Infectious Diseases – known as ESCMID Global – brings together leading experts in infectious diseases and clinical microbiology to exchange ideas and explore the latest innovations and cutting-edge research. Here, Gerry Hughes reports on some of the key themes and highlights from the recent 2025 gathering.
The escalating global threat of antimicrobial resistance (AMR) demands evidence-informed, multidisciplinary action. In 2021, an estimated 4.71 million deaths were associated with bacterial AMR, with 8.22 million associated deaths projected by 2050, according to the latest global burden of bacterial resistance analysis published in The Lancet.
At ESCMID Global 2025 in Vienna, Austria (11-15 April), leading clinicians, researchers and policymakers gathered to address this crisis and share essential considerations for healthcare professionals.
Key themes included the intersection of infectious and chronic diseases, intravenous (IV) verses per os (PO) antimicrobial prescribing, and treating multidrug-resistant Gram-negative infections. Each of these is underpinned by evolving antimicrobial stewardship practices and optimising patient care and outcomes.
The emerging association between diabetes and AMR is an increasing cause for concern, according to Professor Reinout van Crevel, professor in global health and infectious diseases at Radboud University Medical Centre in Nijmegen, Netherlands. Indeed, evidence suggests patients with diabetes are more likely to develop resistant infections.
During his ESCMID Global session, Professor van Crevel highlighted the increased risk and severity of infections such as rhinocerebral mucormycosis, Fournier’s gangrene, malignant external otitis and invasive Klebsiella pneumoniae in patients with diabetes. These conditions often carry worse outcomes, and longer hospital stays compared with non-diabetic populations, he said.
Infection-related risks are particularly heightened in patients with type 1 diabetes, possibly due to greater glycaemic variability. Immunosuppression and microbial dysbiosis were cited as key contributors to this vulnerability. The session reinforced the need for integrated infection management strategies and tighter glycaemic control, especially around surgery or antimicrobial use in patients with diabetes.
‘Expect the unexpected’ was Professor Jörg Janne Vehreschild’s central message regarding infection risks in patients prescribed novel oncological agents – particularly those ending in –cel, –cept, –clib, –inib, –sib, or –mab. These therapies may alter immune function and infection profiles, necessitating bespoke infection prophylaxis strategies.
Professor Vehreschild noted key infection prophylaxis considerations, including for the herpes zoster virus, hepatitis B and C, and pneumocystis jirovecii pneumonia, as well as neutropenic bacterial prophylaxis.
He also reminded delegates that resistant organisms often emerge due to selective pressure from infection treatment itself. ‘When we start treating with antibiotics, we can turn our patient into a petri dish,’ he said, further highlighting the need for good stewardship in this area of practice.
The session from Dr Brad Spellberg, chief medical officer at Los Angeles County–University of Southern California Medical Center in the US, delivered a robust challenge to entrenched beliefs around intravenous (IV) antibiotic use. He focused particularly on conditions historically viewed as requiring prolonged parenteral therapy – namely osteomyelitis, bacteraemia and endocarditis. And his message was clear: the clinical default to IV therapy in these cases is not supported by evidence, but by inertia.
‘Not a single controlled study has ever demonstrated that IV therapy is superior to oral for these three diseases,’ said Dr Spellberg. He framed this as a battle between evidence-based medicine and the influence of expert consensus, noting that many clinicians resist oral therapy due to the misconception that existing randomised controlled trials (RCTs) ‘don’t apply to my patient’.
He traced the historical basis for prolonged IV therapy in osteomyelitis to an uncontrolled 1970 case series from a time when oral alternatives weren’t available. Since then, he notes that numerous observational studies and 10 RCTs have shown no clinically significant difference between oral and IV therapy.
A 2022 meta-analysis led by Dr Spellberg demonstrated that overall treatment success between oral and IV therapy was not significantly different.
For bacteraemia, 11 RCTs involving 1,012 patients demonstrated non-inferiority of oral treatment. Dr Spellberg and his team concluded that the confidence interval actually favoured oral therapy in terms of treatment success.
These findings challenge the deeply held assumption that bloodstream infections require prolonged IV regimens by default.
The same applied to infective endocarditis (IE). Early evidence supporting IV therapy stems from 1940s studies on IV penicillin in an era without oral comparators. However, more recent data tell a different story.
In a 2020 narrative review, Dr Spellberg advocated for oral step-down therapy in IE after initial IV treatment once bacteraemia is cleared and the patient is clinically stable. His 2022 meta-analysis even found oral therapy to be statistically superior in treatment success for IE.
To counter clinical inertia, he proposed five criteria for switching from IV to oral therapy:
A comprehensive update on the expanding role of beta-lactam/beta-lactamase inhibitor (BL/BLI) combinations in treating multidrug-resistant Gram-negative infections was provided by Professor Laurent Dortet, professor in the department of microbiology at Bicetre Hospital in Paris, France.
At his ESCMID event he discussed recent evidence on the rationale for the use of new BL/BLI combinations and in critically ill patients. Newer BLIs such as relebactam and vaborbactam have a better activity against difficult to treat Gram-negative infections compared to older agents such as clavulanic acid or tazobactam, he said.
Yet, Professor Dortet cautioned that their uptake in clinical practice remains limited due to cost, regional regulatory discrepancies and the lack of large-scale real-world efficacy data.
He stressed the need for post-marketing studies with narrower non-inferiority margins and robust clinical endpoints to determine their optimal use.
Dr Carolina Garcia-Vidal, infectious diseases consultant at Hospital Clinic Barcelona, Spain, expanded on this Bl/BLI evidence by addressing the unintended consequences of empirical carbapenem use in haematology patients.
Referencing the European Conference on Infections in Leukaemia’s 10 recommendations – known as ECIL-10 – she highlighted appropriate clinical scenarios for empirical use of newer BL/BLI agents.
She also raised concerns about collateral effects – specifically, the tendency of carbapenems to eradicate beneficial anaerobic gut flora. This disruption has been linked to poorer outcomes in critically ill and immunocompromised patients.
Among patients with complicated urinary tract infections or pyelonephritis, Dr Garcia-Vidal discussed how cefepime/enmetazobactam has outperformed piperacillin/tazobactam in clinical cure and microbiological eradication in clinical trial data.
Dr Garcia-Vidal ended her ESCMID session by calling for greater inclusion of these microbiome considerations in clinical guidelines. She highlighted Spanish national guidance as an example of forward-thinking policy that integrates antimicrobial impact on the gut flora into decision-making frameworks.
ESCMID Global 2025 delivered a compelling call to action: use evidence to shape clinical care. From diabetes and cancer to administration options and drug-resistant pathogens, the sessions reinforced the need for agile, data-informed, multidisciplinary approaches.
For secondary healthcare professionals, adapting to new evidence is key to both individual patient care and public health. Translating scientific rigour into practice is no longer optional: it is a clinical imperative.
19th May 2025
Radical radiotherapy for prostate cancer frequently causes debilitating side effects that can significantly diminish patients’ quality of life during and after treatment. The DIETRICH study, funded by Prostate Cancer UK, will investigate whether a simple intervention – dietary fibre supplementation – can help alleviate these challenging symptoms. Lead investigators Professors Anne Kiltie and Ananya Choudhury discuss the study’s design, its objectives and how a straightforward nutritional approach could potentially provide a relatively simple solution to a widespread, significant problem.
Men undergoing radical radiotherapy for prostate cancer frequently suffer gastrointestinal and urinary side effects during treatment and for some weeks afterwards.1
The most common bowel and bladder complications are diarrhoea, abdominal discomfort, more frequent urination and bleeding. These side effects can significantly impact the patients’ quality of life by disrupting daily routines, interrupting sleep, making travel more difficult and contributing to increased anxiety.
Although generally short-term during the second half of radiotherapy and for a few weeks after, these side effects can be followed by long-term, life-changing side effects in some men.
In some centres, men are advised to remove fibre from their diet during radiotherapy or are prescribed the anti-diarrhoeal loperamide. In contrast, other centres give dietary fibre supplements such as psyllium mid-treatment to help reduce diarrhoeal side effects.
There is some evidence that supplementing dietary fibre improves radiotherapy side effects in pelvic cancers. Murphy et al2 found that psyllium given mid-treatment reduced the incidence and severity of diarrhoeal side effects in a randomised trial of 51 men with prostate cancer and nine women with gynaecological cancers receiving at least 40 Gy in 20 fractions to the pelvis.
Garcia-Peris et al3 found that inulin/fructo-oligosaccharide improved stool consistency when started one week before post-operative pelvic radiotherapy and continued for three weeks after treatment in a randomised trial of 38 women with gynaecological cancers.
Inulin is a soluble fibre derived from chicory root and other plants. It supports the growth of beneficial bacteria in the gut microbiota by promoting the production of anti-inflammatory metabolites. When it reaches the colon, inulin is rapidly fermented, selectively boosting the growth of specific gut bacteria such as Bifidobacterium and Faecalibacterium species. These bacteria play a role in reducing inflammation both in the gut and systemically, primarily through the secretion of short-chain fatty acids such as butyrate, among other metabolites.
As inflammation is a common cause of both bowel and urinary symptoms, inulin may help improve stool consistency. However, there is currently limited evidence to suggest it has a similar effect on urinary symptoms.
In early studies conducted in mice, our team4 and others5 have found that inulin not only reduces bowel toxicity but also enhances tumour control in several types of tumours, with the potential for similar effects in humans.
The DIETRICH study aims to explore whether men who supplement their diet with inulin experience fewer gut-related side effects compared with those who do not take additional fibre. We hypothesise that men taking inulin will have improved gastrointestinal symptoms and quality of life and a reduced need for rescue medication, such as psyllium, mid-treatment.
DIETRICH is a large, phase 2, double-blind, placebo-controlled trial of inulin in 220 men across eight centres over 27 months. It will include men having radiotherapy to the prostate over four weeks for intermediate-risk disease and those having radiotherapy to the prostate and pelvic nodes for high-risk, locally advanced or node-positive disease.
Based on feedback from previous patient discussion groups, we believe men will be enthusiastic about participating in this study. Those with prostate cancer are often highly motivated to make lifestyle and dietary changes that could enhance their chances of a cure and improve their quality of life.
Patients will be randomised to receive either a supply of inulin to take for two weeks before radiotherapy, four weeks during radiotherapy, and three weeks after, or the placebo, maltodextrin. It is possible that patients may wish to self-treat with a dietary fibre supplement, so it will be necessary to ensure that the study is not contaminated in this way.
Patient-reported outcomes will be used to determine increased symptoms from baseline in bowel and urinary domains. Participants will provide faecal samples before the supplement, before radiotherapy, and after treatment, and complete dietary questionnaires and diaries to determine whether their baseline gut microbiota, associated metabolites and habitual diet predict their responses to fibre and radiotherapy.
Preliminary and ongoing studies conducted in Aberdeen have demonstrated that men receiving radiotherapy for prostate cancer are generally very willing to provide samples at the outset of their treatment. Consequently, we anticipate participants to be similarly cooperative in this aspect of the study.
We also anticipate good compliance, as the inulin supplement is easy to take. It is a simple scoop of the supplement twice daily mixed into liquids, with no bitter aftertaste. Participants will regularly complete diet diaries and report any side effects, which should help maintain motivation and engagement through the study. We also expect that many will choose the convenient option of entering their data electronically via smartphone or computer.
Multidisciplinary collaboration will be important. Regular meetings between participating centres will provide opportunities to share insights, address challenges and refine the study as it progresses, and a dedicated trial steering committee will oversee the project to ensure it remains on course. Equally important is the valuable input received from patient partners, which will help to ensure that the demands placed on participants are reasonable and proportionate.
Looking ahead, we are eager to expand our research to include other cancers treated with pelvic radiotherapy and head and neck cancers. In the latter, radiotherapy often causes mucositis, which can severely impact eating, swallowing, weight and quality of life. Our ongoing interest lies in dietary fibre interventions, not only inulin but also other promising fibres that might offer a range of unique benefits across different cancer types and treatment side effects.
If the DIETRICH study is successful, the next step would, of course, be a larger-scale phase 3 evaluation. This would allow us to evaluate the benefits of inulin further and potentially explore other types of dietary fibre, recognising that not all men may respond to inulin alone.
Should a larger trial confirm the positive outcomes, we envisage inulin becoming a highly cost-effective addition to standard clinical care, improving patients’ quality of life and cancer outcomes, while adding minimal financial burden to the NHS.
The DIETRICH study is funded by Prostate Cancer UK, grant reference number RIA23-ST2-006.
Anne E Kiltie MA DM DSc MRCP(UK) FRCR
Friends of ANCHOR clinical chair in oncology, The Rowett Institute, University of Aberdeen, UK
Ananya Choudhury MA PhD MRCP FRCR
Chair and honorary consultant in clinical oncology, The Christie NHS Foundation Trust, UK
Combining electrocardiographic imaging (ECGI) with cardiac digital twin technology enhances the accuracy of locating the origin of premature ventricular contractions (PVCs), offering a potential advance for personalised ablation strategies, a new study has found.
PVCs are common cardiac arrhythmias, affecting up to 75% of the general population, and may require therapy if symptomatic. Accurate localisation of PVC origins is important for planning catheter ablation, but conventional 12-lead ECG and standard ECGI techniques often fall short of the required accuracy, particularly due to anatomical variability and signal noise.
To address this, researchers at the Gregorio Marañón General University Hospital in Madrid have developed an enhanced method that integrates ECGI-derived local activation time (LAT) maps with personalised cardiac digital twins (ECGI-DT) to improve PVC origin detection.
The method was tested on 75 simulated PVC cases and one clinical patient case. By matching simulated surface potentials to measured data, the algorithm iteratively refined the PVC origin estimate, achieving much greater accuracy than ECGI alone.
Using ECGI-DT, the average localisation error dropped from the 30.69 ± 23.71 mm achieved using ECGI alone to 7.81 ± 3.82 mm. Notably, ECGI-DT correctly identified the cardiac chamber (right or left ventricle) and tissue depth (endocardial vs epicardial) of PVCs in 100% of cases tested, compared to 75% using ECGI alone.
Outlining the clinical relevance of their findings, the authors noted how ‘ECGI-DT technology in the clinical management of PVCs can represent a major step in cardiology, creating a new paradigm in personalised cardiac care’.
By offering more precise PVC localisation, ECGI-DT could optimise ablation planning, minimise procedural times and reduce radiation exposure during such procedures.
The research team suggest that future studies should focus on expanding the cardiac digital twin database to account for greater patient anatomical variability and validating the technique in larger patient cohorts.
They also envision ECGI-DT as a powerful adjunct to conventional mapping tools, moving the field closer to truly personalised cardiac care.
Reference
Sánchez J et al. Enhancing premature ventricular contraction localization through electrocardiographic imaging and cardiac digital twins. Comput Biol Med 2025;190:109994.
People who develop type 1 diabetes in adulthood have an increased risk of cardiovascular disease and death, according to new research by the Karolinska Institute in Sweden.
Patients diagnosed later in life do not have a better prognosis than those diagnosed earlier, the researchers found, with smoking, poor glucose control and obesity being the main risk factors.
There is currently limited research into adult-onset type 1 diabetes, and little is known about prognosis or prognostic factors.
The findings of this study, which are published in the European Heart Journal, highlight the risks associated with a late type 1 diabetes diagnosis.
The researchers used data from the Swedish National Diabetes Register and the Total Population Register in Sweden to assess mortality, major adverse cardiovascular events (MACE), and prognostic factors, particularly in adults diagnosed with type 1 diabetes at 40 years or older.
They identified 10,184 people diagnosed with adult-onset type 1 diabetes between 2001 and 2020 and compared them with 509,172 matched control participants, as well as 375,523 people with adult-onset type 2 diabetes.
The participants with adult-onset type 1 diabetes had a 30% higher risk of experiencing MACE, and the risk of death from any cause was 71% higher in this group compared to the control group. Cause-specific mortality, particularly from cardiovascular diseases, non-cardiovascular diseases, cancer and infections, was also higher in individuals with type 1 diabetes than in the population controls.
Adults who develop type 1 diabetes later in life have a 33% lower incidence of MACE than individuals who develop type 2 diabetes in adulthood. However, the risk of death from a diabetic coma or ketoacidosis was higher for individuals with adult-onset type 1 diabetes compared to those with adult-onset type 2 diabetes.
The researchers found the main reasons for the poor prognosis were smoking, overweight/obesity and poor glucose control. In particular, smoking was responsible for 10.7% of deaths and 8.4% of MACE events in individuals with type 1 diabetes, while poor glycaemic control contributed to 10.4% of deaths and 8.8% of MACE events. Overweight and obesity accounted for 19.8% of MACE events.
The study analysis also showed that people who are diagnosed with type 1 diabetes at age 40 or over are less likely to use assistive devices, such as insulin pumps, to help manage their condition.
Dr Yuxia Wei, a postdoctoral fellow at the Karolinska Institute and first author of the study, said: ‘These findings underscore the importance of managing these modifiable risk factors to reduce mortality and cardiovascular events in people with type 1 diabetes.’
Senior author and associate professor, Sofia Carlsson, added: ‘We show that the prognosis can be significantly improved by preventing smoking and obesity and improving glucose control, not least in people diagnosed at older ages.’
A version of this article was originally published by our sister publication Nursing in Practice.
16th May 2025
A low-carbon version of a triple combination pressurised metred dose (pMDI) inhaler indicated for adults with moderate-to-severe chronic obstructive pulmonary disease (COPD) has been approved by the Medicines and Healthcare products Regulatory Agency (MHRA), its manufacturer AstraZeneca has announced.
The budesonide/glycopyrronium/formoterol fumarate inhaler (brand name Trixeo Aerosphere) currently uses the propellant hydrofluoroalkane-134a (HFA-134a), which is known for its high Global Warming Potential (GWP).
The approved next-generation propellant hydrofluoroolefin-1234ze (HFO-1234ze(E)) is a fluorinated gas with a GWP 99.9% lower than the original propellant.
With this change, the triple combination inhaler achieves a carbon footprint comparable to dry powder inhalers that do not require a propellant.
No changes have been made to the active ingredients, recommended dose or clinical use, the MHRA said.
Commenting on the approval, Dr Omar Usmani, consultant chest physician and clinician scientist at Royal Brompton Hospital in London and professor of respiratory medicine at Imperial College London, said: ‘The transition of Trixeo to the propellant with near-zero Global Warming Potential means that healthcare professionals can focus on optimising outcomes for their COPD patients based on clinical need, while also supporting climate goals.
‘Clinicians and their patients shouldn’t feel that they have to choose between the most appropriate treatment and the planet.’
The MHRA approval was based on the results from the next-generation propellant clinical development programme, which included one trial focusing on lung exposure bioequivalence and the other focusing on systemic exposure bioequivalence of the low-carbon and original propellants.
In both trials, exposure to each of the triple therapy components met bioequivalence criteria for the near-zero GWP HFO-1234ze propellant relative to HFA-134a, with no new or unexpected safety findings.
There were no reports of serious adverse events or adverse events leading to discontinuation in either trial.
The researchers concluded that the data provided clinical evidence that HFO-1234ze is a viable replacement for HFA-134a.
Julian Beach, MHRA interim executive director, healthcare quality and access, said: ‘Inhalers are a cornerstone of COPD treatment, helping manage symptoms and prevent exacerbations. However, some inhalers can also contribute to greenhouse gas emissions through their propellants.
‘This approval supports the continued availability of a widely used COPD treatment while enabling a transition to inhalers with a lower carbon footprint – without compromising on safety, quality or clinical benefit.’
In the UK, pMDIs make up 70% of all inhaled medicines use with inhaler emissions representing 3% of the total NHS carbon footprint, according to the charity Asthma + Lung UK.
In 2023, GSK announced its low-carbon salbutamol metered-dose inhaler could reduce greenhouse gas emissions from use of the inhaler by around 90% and phase 3 trials were due to start in 2024.
Research published last year revealed that poorly controlled asthma significantly contributes to greenhouse gas emissions, with these patients contributing eight times more excess GHG than those with well-managed asthma.
The recent UK joint guidelines for chronic asthma highlighted the very high carbon footprints of metred dose inhalers and advocated for the use of dry powder inhalers with a lower carbon footprints and less environmental impact. It also encourages patient education around environmental sustainability and correct disposal of inhalers through the pharmacy.
Anticoagulants have consistently been shown to reduce the risk of stroke for people with atrial fibrillation, but there may be a reluctance to prescribe these medications to older people due to concerns around adverse events and bleeding. Anneka Mitchell PhD, lead pharmacist for healthcare of older people and frailty at University Hospitals Plymouth NHS Trust and visiting postdoctoral researcher at the University of Bath, discusses recent research into the risks of stopping anticoagulation in this group.
Warfarin has been used for decades for stroke prevention in atrial fibrillation (AF) and there is good evidence that efficacy is maintained in older people and the benefits outweigh the risks for most patients.1
Warfarin has historically been underused in older patients2 due to the need for frequent blood tests and variable dosing schedules, which can make it difficult for people with cognitive impairment to take the correct dose. What’s more, the numerous medication and food interactions can lead to over- or under-dosing.
The direct oral anticoagulants (DOACs) dabigatran, rivaroxaban, apixaban and edoxaban have now largely superseded warfarin and other vitamin K antagonists as the anticoagulants of choice due to their comparable efficacy and lower risk of adverse events.3–6 They are now recommended as the first-line option for most patients in UK and European guidelines.7,8
Despite having safer options available, anticoagulants are often still under-prescribed to older patients, particularly those felt to be high risk of bleeding, such as those with a history of falls or those living with frailty.9
Guidelines have specifically advised that anticoagulation should not be withheld due to falls for over 10 years,7,10 as it has been estimated that an older person taking warfarin would need to fall at least 295 times in a year for the risk of bleeding to outweigh the benefit of stroke prevention.11 More recent work has suggested that an older person taking rivaroxaban would need to fall 45 times in a year, and for apixaban they would need to fall 458 times per year to have a lower net clinical benefit than aspirin.12
It is not known why clinicians still choose to withhold anticoagulation in patients who fall. It has been hypothesised that prescribers are more fearful of acts of commission, such as causing a fatal intracranial bleed by prescribing an anticoagulant to a patient known to fall, than they are of an act of omission, such as causing a stroke due to not prescribing anticoagulation to the same patient.13
For people living with frailty, there is often a shift toward deprescribing with less focus on prevention and more on active symptom management. Information on when to stop anticoagulation for AF is not readily available, so these decisions are person-centred and can also be influenced by individual clinicians’ perceptions of the risks and benefits of these medications.
Our study, published recently in the journal Heart,14 used routinely collected healthcare data from UK primary care to evaluate effectiveness (stroke reduction) and safety outcomes (bleeding, myocardial infarction and death) in people aged 75 years and over by attributing the event to their anticoagulant exposure status at the time of the event.
All patients entered the study cohort on the date of their first anticoagulant prescription for AF. We then estimated their anticoagulation exposure over time using data from prescription records and recorded time spent exposed to an anticoagulant (warfarin, apixaban or rivaroxaban) and time spent unexposed.
Over 20,000 patients contributed data to the cohort, and we found that in this large sample, non-exposure to anticoagulants was associated with up to a three-fold increase in the risk of stroke and death, and a two-fold increase in the risk of myocardial infarction compared with being exposed to one of the anticoagulants.
There was no evidence for a reduction in major bleeds during unexposed time, but minor bleeds were reduced.
We hypothesised that the increased risk of death in unexposed time may have been due to medication being stopped for end-of-life care. However, there was no evidence in our data to support this.
Similar findings have been observed in other studies using different data from the UK and Denmark. García Rodriguez et al15 found that in 616 incident cases in the UK and 643 cases in the Region of Southern Denmark, patients with AF who had discontinued oral anticoagulation had a two- to three-fold higher risk of ischaemic stroke.
In their Global Anticoagulant Registry in the Field-Atrial Fibrillation study,16 Cools et al found that the rate of anticoagulant discontinuation was 13%. Discontinuation for seven or more consecutive days was associated with significantly higher all-cause mortality and risks of stroke and myocardial infarction.
The increased risk of serious events when anticoagulation is withheld or discontinued in older patients is concerning, and this should be considered when deciding whether to start or stop an anticoagulant for an older person with AF.
Addressing modifiable risk factors for stroke and bleeding, such as smoking, alcohol consumption and blood pressure control, may make anticoagulation safer and also reduce stroke risk independent of treatment.
There is a need to focus not only on comparing different anticoagulant strategies to ensure the safest and most effective treatments are used, but also to examine the risks of deprescribing anticoagulants so that the risks of doing so can be adequately discussed with patients before coming to a shared treatment decision.14 This article was originally published by our sister publication Hospital Pharmacy Europe.
Anneka Mitchell PhD Lead pharmacist healthcare of older people, frailty and medicine, University Hospital Plymouth NHS Trust, Plymouth, UK and visiting postdoctoral researcher, University of Bath, UK
With thanks to fellow study authors:
Margaret C Watson Professor of health services research and pharmacy practice, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, UK
Tomas J Welsh Academic geriatrician and ReMind UK research and medical director, The ReMind UK Centre, Royal United Hospital Bath NHS Trust, UK
Anita McGrogan Senior lecturer/associate professor, University of Bath, UK
Nirmatrelvir plus ritonavir is no longer recommended for some risk groups including the over-70s, the National Institute for Health and Care Excellence (NICE) has said in updated guidance.
The antiviral, also known by its brand name Paxlovid, is no longer cost effective in the over-70s as well as people with diabetes, obesity and heart failure, the new recommendations said.
It follows a partial review in March 2024 that extended access to the drug to a broader population than those who had already been eligible because they were most at risk from severe disease.
At the time, it meant around 1.4 million more people could potentially access the antiviral treatment if they tested positive for Covid-19.
Those who were eligible could get free lateral flow tests from participating pharmacies and were encouraged to take a test as soon as they had symptoms before calling their GP, NHS 111 or a hospital specialist.
But a recent review found that based on changes to the company’s list price, treatment is no longer cost effective for the groups evaluated in the partial review and as such these have now been removed from the NICE guidelines.
The drug remains cost effective for the highest-risk groups which also includes those with immune deficiencies, some people receiving treatment for cancer and those with serious respiratory problems such as individuals with COPD having long-term oxygen therapy, NICE said.
A table in the guidance sets out the current list of those for whom nirmatrelvir plus ritonavir will be funded.
A primary care update bulletin from NHS England noted that other groups that were no longer eligible for treatment as per the update include people aged 85 years and over, people with end-stage heart failure who have a long-term ventricular assistance device and people on the organ transplant waiting list.
Previous details of a price reached between the Pfizer, which manufactures nirmatrelvir plus ritonavir, and the NHS were confidential.
In May 2025, the company set a new list price of £829 because NICE was considering if the recommendation needed to be reviewed ‘due to the evolving Covid-19 landscape and emerging data from NHS England’.
A version of this article was originally published by our sister publication Pulse.
15th May 2025
Individuals with psoriatic arthritis (PsA) experience significantly longer delays to diagnosis and are less likely to receive early disease-modifying antirheumatic drug (DMARD) therapy compared to matched patients with rheumatoid arthritis (RA), according to a new study.
Using national audit data from England and Wales, the analysis of 2,120 matched pairs showed that patients with PsA waited longer to present to their GP after symptom onset. They also had a slower time to diagnosis after referral to rheumatology, highlighting the need for greater awareness among both patients with psoriasis and healthcare professionals.
The study also found that only 54% of patients with polyarticular PsA were prescribed a DMARD at baseline versus 69% of those with RA (p < .001). Methotrexate monotherapy was more common in PsA, while a higher proportion of RA patients were prescribed corticosteroids. At three months, PsA patients showed smaller reductions in disease activity than their RA counterparts, despite having similar disease burden at baseline.
Although over 80% in both groups agreed a treat-to-target strategy, fewer PsA patients were prescribed corticosteroids at baseline (47.6% vs 75.8%, p < .001), and fewer received disease-specific education (93.5% vs 96.2%, p = .021).
The researchers said that the findings point to an underutilisation of available therapeutic options in PsA care, which risks permanent damage to patients’ joints.
Dr William Tillett, study lead and consultant rheumatologist at the Royal National Hospital for Rheumatic Diseases at the Royal United Hospitals Bath NHS Foundation Trust, said: ‘Work from our group and other researchers shows that delays to diagnosis of just six months can result in worse physical function for a patient in 10 years’ time, so diagnosing and treating the disease early, to prevent structural damage and preserve function, is vitally important.’
The findings confirmed that PsA is not only diagnosed later than RA but also managed less aggressively in its early stages – despite comparable disease burden. The researchers concluded that improved patient and clinician education, faster diagnostic pathways, and earlier access to combination therapies are required.
Commenting on the impact of their findings, Dr Rachel Charlton, research fellow in the Department of Pharmacy & Pharmacology at the University of Bath and the study’s first author, said: ‘We need more education around clinicians assessing people with arthritic symptoms and better access to scans. We also need to focus on early intensive treatment before damage sets in – there is a window of opportunity that we may be missing.’
Failure to do this contributes to poorer short-term outcomes and may increase long-term disability risk for PsA patients.
Reference
Charlton RA et al. Diagnostic delay and less intensive therapy for people with psoriatic arthritis compared with rheumatoid arthritis: a study nested within an English and Welsh audit data set. Ann Rheum Dis 2025;00:1–9.
New digital ‘smart scales’ are to be piloted across 15 specialist clinics to support severely obese children to lose weight.
The smart scales have hidden digits and connect to a mobile app, which allows patients to see the direction of the weight management without displaying the specific numbers.
The data will automatically be transferred to the patient’s clinical team at Complications from Excess Weight (CEW) clinics, who will be able to monitor patients’ progress and send regular feedback through the app to support behavioural changes to achieve their goals.
This will reduce the need for frequent visits to hospital, NHS England said.
Around 350 patients are already using the new technology as part of a drive to deliver holistic care for young patients with obesity, with four more clinics and 150 more children being enrolled in the summer.
Professor Simon Kenny, NHS England’s national clinical director for children and young people, said: ‘It is fantastic that through cutting-edge technology and a holistic and behaviour-change approach to obesity care, our specialist NHS clinics have already transformed the lives of thousands of children and young people – supporting them to lose weight, live heathier lives and improve their mental health.
‘This game-changing tool is helping our specialists support and keep track of children’s weight loss progress without them needing to leave home, while offering regular advice to them and their parents to help build healthy habits.’
He added that living with excess weight can cause long-term complications such as type 2 diabetes, stroke, early joint replacements and mental health difficulties.
It comes as new analysis presented last week at the European Congress on Obesity 2025 from the ENHANCE study found that over 40% of patients attending the 32 CEW clinics were from the most deprived neighbourhoods.
The research, from Leeds Beckett University, Sheffield Hallam University, University of Leeds and University of Bristol, also found that a high proportion of patients supported by the clinics have a neurodevelopmental disorder, such as autism (24%) or a learning disability (23%).
Significant proportions of children seen by the clinics also had major health complications, such as metabolic dysfunction-associated steatotic liver disease (30%) and hypertension (21%).
Dr Catherine Homer, associate professor of obesity and public health at Sheffield Hallam University, said: ‘We know there is an urgent need to provide specialised person-centred support for the many children and young people currently living with severe and complex forms of obesity. Through our evaluation we are already seeing how crucial CEW clinics are to providing this support, and therefore it’s imperative that the clinics should be integral to the forthcoming 10-year plan.’
Separate research presented at the Congress from the New England Journal of Medicine looked at two of the weight loss drugs on the market and found that both tirzepatide and semaglutide led to substantial weight loss. However, among those without diabetes, treatment with tirzepatide was ‘superior’, with respect to reduction in body weight and waist circumference.
In January, it was found that child deaths have risen, with widening inequalities driving the rise.
Last year, a report from the Food Foundation revealed a steady decline in children’s health in England over the past two decades, which has led to children now being shorter and more likely to have obesity and type 2 diabetes.
A version of this article was originally published by our sister publication Healthcare Leader.
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