SMOKING CESSATION

It is never too early or too late to stop smoking

Cardiovascular disease remains the leading cause globally for premature mortality and morbidity.

THERE ARE A number of well-known cardiovascular risk factors including hypertension, dyslipidaemia, elevated blood glucose, lack of physical exercise, obesity (especially central obesity) and poor diet. A major modifiable cardiovascular risk factor is smoking.

The known effects of smoking on cardiovascular disease and the reports about the effect of smoking is mainly based on investigations of coronary artery disease. It is however, recognised that smoking is a particular strong risk factor for peripheral arterial disease (PAD). Despite this recognition there are relatively few studies done prospectively comparing PAD and coronary heart disease (CHD) as complications of current smoking status.

The objective of this study was to quantify the long-term association of cigarette smoking and its cessation with the incidence of the three major atherosclerotic diseases namely coronary heart disease, cerebrovascular disease and peripheral artery disease.1 This study used data from the ARIC study (Atherosclerosis Risk in Communities) and patients were followed up for nearly 30 years.

A total of 13 355 people aged between 45 and 64 years of age were examined between 1987 and 1989 and then followed up for a median period of 26 years. A comprehensive surveillance of hospitalisations and deaths from coronary heart disease, cerebrovascular disease and peripheral artery disease were conducted by the authors.

In this period of 26 years there were 492 cases of PAD, 1798 CHD cases and 1106 cases of stroke.

The findings overall confirmed that smoking is a major cardiovascular risk factor increasing substantially the risk of developing all three atherosclerotic outcomes. The increased risk was consistent for both the duration of smoking and the intensity of smoking (number of cigarettes smoked per day). After adjustment for other risk factors, smoking risk had a hazard ratio of 5.36 for PAD, Hazard Ratio 2.37 for heart attack and Hazard Ratio 1.92 for stroke. Thus, there were a much higher risk of PAD than the two other atherosclerotic outcomes.

After smoking cessation, the reduction of risk for all atherosclerotic outcomes of all three vascular beds were within five years but to reach such a low risk as those of never-smokers took a much longer time. The reduction of the risk of PAD was also higher than for any of the two other atherosclerotic outcomes. After quitting, more time was needed for the risk of PAD to reach the level of risk of a never-smoker (more than 30 years was necessary) as compared to about 20 years for the risk of coronary heart disease to reach the level of CHD risk of a never-smoker.

The findings of this study are also consistent with the hypothesis that traditional cardiovascular risk factors have distinct effects on different arterial beds suggesting that atherosclerosis is not a homogenous process.2 The composition of atherosclerotic plaques also differ between the different vascular beds with the femoral artery having more fibrosis and the coronary and cerebral arteries more lipid and more inflammatory cells.

CONCLUSION

1. Smoking is significantly associated with a substantial increased risk of atherosclerotic disease events in all three vascular beds: coronary, cerebral and peripheral. 2. Smoking cessation is associated with significant reduction in the risk of atherosclerotic disease events. 3. It is never too late to stop smoking because of the relative rapid reduction of cardiovascular events (within five years). 4. It is never too early to stop smoking because it takes several decades to reach the risk level of a never-smoker (20-30 years).

Prof James Ker

ERADICATE TOBACCO TO PROTECT HUMAN RIGHTS TO HEALTH

Savera Kalideen, Executive Director of the National Council Against Smoking (NCAS), on behalf of NCAS, The Heart and Stroke Foundation, CANSA. In the grip of the COVID-19 pandemic, we are seeing governments all over the world, including our own, act to protect public health. We are in full support of this action to protect public health. There are other epidemics that we live with every day. Tobacco harm is one of them, causing 115 deaths each day in South Africa. We call for bold action on tobacco control, as the protection of public health through tobacco control is inextricably linked with human rights to life, health and a healthy environment. This Human Rights month, we call on our leaders to recognise that halting the spread of the tobacco epidemic is an obligation as South Africa is a signatory to the World Health Organisation Framework Convention on Tobacco Control (FCTC). Passing South Africa’s Control of Tobacco and Electronic Delivery Systems Bill, for which the public consultation ended more than 18 months ago, would be a good step in the direction of the ‘right to health’.

PROTECTING CHILDREN FROM SECOND-HAND SMOKE

Exposure to second-hand smoke, particularly for children, leads to middle ear infections, respiratory diseases including asthma, the worsening of serious conditions such as cystic fibrosis and asthma, and in some cases, death. The dangers posed by second-hand smoke violate the rights of non-smokers and children, affecting their rights to life, health and a clean and safe environment.

The Bill requires that any enclosed public area is 100% smoke-free and will make certain outdoor public places smoke-free too. It removes the current requirement to provide for smoking areas in all enclosed public places, workplaces and on public conveyances and applies the 100% smoking ban to common areas of multi-unit residences. It further bans smoking in private dwellings used for commercial childcare/ education and in cars carrying children under 18. People caught smoking or vaping or using e-cigarettes in no-smoking zones could face a hefty fine and/or up to three months in prison.

PROTECTION FROM ACTIVE SMOKING AND ADDICTION

Human rights principles also justify protecting individuals from the harms of smoking and nicotine addiction. We have a right to enjoy the highest attainable standard of physical and mental health, including the prevention, treatment and control of epidemic, endemic, occupational and other diseases. Tobacco products are the only legally available consumer products that kill over 50% of users when used exactly as intended. Many adolescents are tempted into experimentation with cigarette smoking, and now e-cigarettes, at a fragile time when they can’t fully grasp the addictive grip of nicotine and the health impacts, they will later experience. The body of research showing the health harm arising from e-cigarette use, which are popular among young people, continues to expand.

The Bill introduces uniform plain packaging for all brands and pictorial warnings on all packages. The Bill bans cigarette advertising at tills, removing the loopholes in existing provisions for advertising displayed at points of sale. It further bans the sale of cigarettes through vending machines. Current tobacco control legislation predates the introduction of e-cigarettes and needs to be urgently updated to include the regulation of e-cigarettes. The Bill does include regulation of e-cigarettes and when passed, e-cigarettes will finally fall under the same regulations as cigarettes.

A unit of blood is drawn from a volunteer donor.

Blood is collected into a sterile bag and labelled. Blood is transfused to patient in need. Just one blood donation has the potential to save three lives.

Blood products are stored prior to transfusion. The shelf life of blood is limited.

Platelets expire in 5 days. Red blood cells expire in 42 days. Plasma has a 1 year shelf life from the day of collection.

Units are transported to the nearest SANBS testing and processing lab.

Your blood saves lives.

Local hospitals place orders with SANBS for blood products based on their needs.

In the processing laboratory, blood is spun down in a centrifuge and then separated into its different components.

Blood is tested to ensure that it is safe for transfusion.

Plasma

Contains proteins and clotting factors used to treat patients with massive bleeding or clotting factor deficiencies.

Red blood cells

Contain haemoglobin, a protein that carries oxygen throughout the body. Used to treat patients with anaemia or blood loss due to trauma or surgery.

Platelets

Crucial in helping blood clots. Patients with low platelet levels often suffer from bruising and bleeding.

Analogs in Initiating, Intensifying, or Switching Insulin Regimens in Type 2 Diabetes

Ted Wu, Bryan Betty, Michelle Downie, Manish Khanolkar, Gary Kilov, Brandon Orr-Walker, Gordon Senator, Greg Fulcher. Diabetes Ther 2015;15:6:273-287.

Premix insulin analogues are a well-established treatment for type 2 diabetes (T2D). However, there is a lack of simple, clear guidance on some aspects of their use. A number of overarching criteria need to be taken into consideration. These include the need to target both fasting plasma glucose (FPG) and postprandial glucose (PPG) to achieve optimal glycaemic control; the importance of individualising therapy; and the need to intensify the insulin regimen to compensate for the progressive nature of diabetes. The panel’s objective was to formulate guidance on how to undertake: initiating therapy with premix insulin analogues; recognising when patients need intensification of their insulin therapy; and switching from basal – bolus to premix insulin analogue therapy when appropriate.

METHODS:

An independent expert panel formulated recommendations on the use in T2D of the premix insulin analogue formulations, based on the available evidence and their own experience. The panel chose to focus on the premix insulin analogue formulations : biphasic insulin aspart and biphasic insulin lispro. The guidance in this statement covers T2D only and does not include type 1 diabetes or other forms of diabetes.

RESULTS:

Glycaemic targets that are suggested for most patients, are with the understanding that individualisation of targets is imperative. Choosing an appropriate insulin type and regimen should also be based on specific patient attributes, and many guidelines now recognise both basal and premix insulin as options for initiating/ intensifying insulin therapy in T2D. Unlike basal insulin, premix insulin targets both FPG and PPG, which is essential for addressing postprandial hyperglycaemia and achieving optimal glycaemic control.

EVIDENCE BASE FOR PREMIX INSULIN ANALOGUES IN INITIATION, INTENSIFICATION, AND SWITCHING Initiation of Insulin: Premix Insulin Analogues vs Basal Analogues

The efficacy and good safety profiles of BIAsp 30 and lispro mix 25 in the initiation and intensification of insulin therapy have been reviewed. Systematic reviews of the available evidence suggest that treatment with premix insulin analogues as first-line insulin therapy results in significantly better overall glycaemic control, but slightly greater risk of hypoglycaemia and weight gain, compared with basal insulin.

Intensification of Insulin: Premix Insulin Analogues vs Basal-Plus or Basal–Bolus Regimens

A meta-analysis published in 2011 compared premix insulin analogues with basal–bolus therapy based on three trials. The authors concluded that patients treated with a basal-bolus regimen had a higher chance of reaching their HbA 1c goal, with no difference in incidence of hypoglycaemia or weight gain between the two regimens. These results have to be interpreted cautiously, as the trial populations included insulin-naive patients as well as patients already receiving basal insulin at the start of the treatment periods.

Switching from Basal–Bolus to Premix Therapy

While basal-bolus therapy is considered the ‘gold standard’ for patients with advanced T2D, two groups of patients may need to switch to premix insulin analogues either BID or TID. These are patients who are unable or unwilling to cope with the complexity of a basal-bolus regimen, and patients who commence treatment with basal-bolus therapy in hospital and no longer require such an intensive regimen following discharge.

There is minimal published evidence on how to make this switch. Some evidence shows that selected patients inadequately controlled on a basal-bolus regimen can

CONSIDERATIONS AT INITIATION

FAVOURS PREMIX

> 3 mmol/L No

Prefers fewer injections What is the postprandial increment? Is the patient likely to manage basal-bolus therapy when intensification is needed? Is there a large carbohydrate intake at one or two meals? Is the patient’s lifestyle predictable (e.g., eating pattern, working hours)? Patient preference regarding number of injections

Prefers less frequent Patient preference regarding self monitoring of blood glucose Patient ability to inject (e.g., cognitive ability, manual dexterity, need for carer)

FAVOURS BASAL

< 1 mmol/L Yes

No No

Comfortable with more frequent injections Comfortable with more frequent monitoring benefit by switching to a premix insulin analogue. The improved results may have arisen from better therapy adherence due to the simpler regimen with BIAsp 30.

Conclusions from the Available Evidence

The results from the trials in both initiation and intensification of insulin show that, in general, a better HbA 1c reduction was accompanied by a higher rate of hypoglycaemia, and both arms were accompanied by weight gain. No single insulin or regimen was best on all endpoints. It is clear that improved glycaemic control can be expected, irrespective of which regimen is used. Individual patient factors and preferences become more important, and the focus must be on selecting the regimen that is best for the particular patient - including any features likely to aid adherence. One study showed that the main predictor of adherence was patients’ ratings of the burden of therapy, and that the patients’ perceived burden of therapy increased as the number of injections increase.

RECOMMENDATIONS Initiating Insulin Therapy with Premix Insulin Analogues in Primary Care

Patient factors to consider when deciding whether to use premix insulin analogue or basal insulin for initiation.

CONCLUSIONS

This guidance is intended to help both general and specialist practitioners make informed choices and provide optimal care for patients with T2D. It emphasises the importance of taking into account individual patient

CHOOSING THE MOST APPROPRIATE INSULIN REGIMEN FOR THE PATIENT Dosing Titration and Monitoring Box 1: Dosing/titration guidelines for initiating insulin with premix insulin analogs OD (based on consensus)

• When choosing an insulin dose, and for dose titration, err on the side of safety and convenience. • Initiate with premix insulin analog OD, immediately before or soon after the start of the meal with the highest prandial load (usually the evening meal). • Initiate with a dose of 10 - 12 units and titrate.

Dose adjustment Lowest premeal blood glucose level Adjustment for the next dose

≥ 7.0 mmol/L + 2 units 4.1 - 6.9 mmol/L 0 units ≤ 4.0 mmol/L - 2 units

factors and preferences so that the choice of insulin regimen is individualised to the patient in the same way that glycaemic targets are now individualised.

Adapted from Wu T, et al.

Sadad_ad.pdf 1 2014/05/22 12:41 PM

Box 2: Use of other glucose-lowering drugs (based on consensus)

• All combination use is subject to local registration rules. • Metformin should always be continued unless it is poorly tolerated or contraindicated (e.g., patient with renal dysfunction). • Consider maintaining sulfonylureas with once-daily premix insulin. However, they should not be given at the same time of day as the premix insulin dose. Discontinue sulfonylureas once patients intensify to twice-daily premix insulin. • Dipeptidyl peptidase-4 inhibitors/ sodium-glucose cotransporter-2 inhibitors/alphaglucosidase inhibitors can be continued together with insulin. • Thiazolidinediones: combining these agents with insulin may exacerbate oedema. • Glucagon-like peptide-1 agonists may be insulin sparing and can be used. • Consider lowering the dose of the noninsulin drug, other than metformin, at insulin initiation.

C

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Y

CM

MY

CY

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Box 4: Titration algorithm for switching from basal–bolus to premix insulin analog (based on consensus)

• General guidance: as always, titration must be tailored to the individual patient. • These guidelines do not override clinical judgment and knowledge. • Reduce total daily dose of all insulin by 20 - 30 %. • Then split this value 50/50 to give you the starting dose of premix insulin analog at breakfast and evening meal. • Unusual meal patterns may lead you to reconsider the initial dose ratio. • Titrate the dose preferably once or twice a week (see ‘‘Box 1’’). Adjust the evening meal dose first, followed by the breakfast dose. • Safety is key: go slowly.

Box 3: Practical guidance for switching from basal insulin [once daily (OD) or twice daily (BID)], or from premix insulin analog OD, to premix insulin analog BID (based on consensus).

• From basal: 1:1 total dose switch to premix insulin analog. Split the dose 50/50 breakfast and dinner. • From premix insulin analog OD: split the OD dose 50/50 breakfast and dinner. • Administer premix insulin analog immediately before or soon after the start of a meal. • Titrate the dose preferably once or twice a week (see ‘‘Box 1’’). • Adjust the evening meal dose first, followed by the breakfast dose.