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A new treatment has been introduced for patients with rheumatoid arthritis (RA) in whom treatment with an anti‐TNF agent has failed.

Abatacept (Orencia) is licensed, in combination with methotrexate, for the treatment of moderate to severe active RA in adults when other disease‐modifying antirheumatic drugs (DMARDs), including at least one tumour necrosis factor (TNF) inhibitor, have been unsuccessful or are not tolerated.

Abatacept is a selective modulator of T‐cell co‐stimulation that acts by blocking full activation of T‐cells. At the recommended dose of 10mg per kg by intravenous infusion every four weeks, a year's treatment with abatacept costs approximately £10 500.

• The National Institute for Health and Clinical Excellence (NICE) is to review its recommendation on the sequential use of anti‐TNF agents. Current guidance on etanercept (Enbrel) and infliximab (Remicade) states that there is no evidence to support consecutive use of these agents. Following an appeal by manufacturers of these agents and adalimumab (Humira), NICE will review the role of a second anti‐TNF agent. A recent review of the UK biologics register showed that 28 per cent of patients stopped taking an anti‐TNF in the first 15 months of treatment, due either to toxicity or lack of efficacy; of these, 46 per cent were switched to an alternative anti‐TNF and about three‐quarters continued their second‐line treatment (Arthritis Rheum 2007;56:13‐20).

A review of biological therapies for RA (Lancet online: 13 June 2007; doi:10.1016/ S0140‐6736(07)60784‐3) summarises recent evidence.

Describing the benefits of treatment using number needed to treat (NNT) persuades more patients to accept treatment than other descriptors, a randomised study has shown (Ann Intern Med 2007;146:848‐56).

The benefits of hypothetical treatments to reduce the risk of myocardial infarction (MI) or hip fracture were described to a total of 2754 survey respondents as an NNT, a large postponement of an adverse event for some people, or a small postponement for all. For MI, 93 per cent of those presented with NNT would accept treatment compared with 82 and 69 per cent of others respectively. For hip fracture, the corresponding consent rates were 74, 56 and 34 per cent. Those who said they understood the benefit of treatment were more likely to consent.

The Quality and Outcomes Framework (QoF) has achieved an overall improvement in diabetes management in primary care but has not corrected disparities between ethnic groups, according to a London study (PLoS Medicine 2007;4:e191. doi:10.1371/journal.pmed. 0040191).

Analysis of patient registers in the Wandsworth Prospective Diabetes Study showed a significant increase in the proportions of patients reaching targets for blood pressure, HbA_1c and total cholesterol since the introduction of the new contract. However, compared with white patients, black Caribbean patients were less likely to reach the HbA_1c and blood pressure targets.

There were also overall increases in prescribing of oral hypoglycaemic agents and insulin, ACE inhibitors, and lipid‐lowering drugs, but some large differences between ethnic groups remained.

Head‐to‐head comparisons of statins suffer from inadequate blinding, lack of allocation concealment, poor follow‐up and lack of intention‐to‐treat analysis, say US researchers (PLoS Med online:2007;doi:10.1371/ journal.pmed.0040184).

Their analysis of 192 randomised controlled trials comparing a statin with another statin or lipid‐lowering drug found that results tended to favour the trial sponsor's product whereas trials with adequate blinding were less likely to do so. The authors say this bias should be considered when using this evidence to inform treatment decisions.

Tools to estimate cardiovascular and coronary risk are not reliable in patients with type 2 diabetes, say Oxford researchers (Diabetes Care 2007;30:1292‐4).

They compared actual event rates in the UKPDS study with rates predicted by the Framingham, SCORE and DECODE calculators. For fatal cardiovascular events, the UKPDS 10‐year rate was 7.4 per cent; the figures predicted by the calculators were 5, 8.7 and 6.6 per cent. Only DECODE, which takes glucose tolerance into account, was within 95 per cent confidence limits of the actual figure, though SCORE was accurate for men. SCORE, but not Framingham, was acceptably accurate for fatal coronary events.

The DoH has accepted in principle a recommendation by the Joint Committee on Vaccination and Immunisation that all girls aged 12 and 13 years should be vaccinated against human papilloma virus; the vaccination programme could begin in Autumn 2008.

The British Society for Rheumatology and British Health Professionals in Rheumatology Standards, Guidelines and Audit Working Group have published new guidance on the management of gout (Rheumatology online: 23 May 2007; doi:10.1093/ rheumatology/kem056a).

Symbicort (budesonide/formoterol) is now licensed for symptom relief in patients with asthma who are already using the combination for maintenance: SMART (Symbicort Maintenance and Reliever Therapy) reduces exacerbations compared with using a short‐acting beta‐agonist as rescue medication.

The risk of heart failure with trastuzumab (Herceptin) does not increase over time, say US researchers. Data presented at the American Society of Clinical Oncology in Chicago showed that the incidence of heart failure was 4.1 per cent after two years and 3.8 per cent after five years.

A rapid increase in prescribing of new antiepileptic drugs (AEDs) for children is not supported by evidence of their safety, UK researchers believe (Br J Clin Pharmacol 2007;63:689‐97).

Their analysis of the UK General Practice Research Database revealed a five‐fold increase in prescribing of new AEDs for children and adolescents between 1993 and 2005. Lamotrigine accounted for 65 per cent of prescriptions for new AEDs and topiramate (Topamax) and levetiracetam (Keppra) for most of the remainder. The authors point out that the long‐term safety of newer AEDs has not been established in children.

School students who unexpectedly drop a grade between mock and final exams are more likely to have been suffering hay fever symptoms than those whose results matched expectations, UK investigators say (J Allergy Clin Immunol 7 June 2007; Epub ahead of print).

Their case‐control study of 1834 15‐17 year olds showed that those who performed under par were 40 per cent more likely to have symptoms, 40 per cent more likely to have taken an antiallergy medication and 70 per cent more likely to have taken a sedating antihistamine.

The 48th clinical guideline (MI: Secondary Prevention. Secondary Prevention in Primary and Secondary Care for Patients Following a Myocardial Infarction) from the National Institute for Heath and Clinical Excellence (NICE) updates both its 2001 guidance on post‐myocardial infarction (MI) prophylaxis and the National Service Framework (NSF) on coronary heart disease. Tools to support implementation can be downloaded from the NICE website ( www.nice.org.uk/cg048).

As with other recent guidelines, NICE first emphasises the importance of effective communication and establishes that care should be patient centred, involving and supporting patients, their families and carers to share decisions about management. This focus is carried through to the delivery of advice and education, which NICE states should be appropriate to and include all sub‐groups of patients for whom access may be difficult due to age, sex, geography, ethnicity, co‐morbidity or socioeconomic status.

The guideline is divided into three main sections (see Table 1) covering lifestyle change, cardiac rehabilitation and drug treatment (see Table 2). It is extensively cross‐referenced with previous guidance on smoking cessation, obesity management, anxiety, depression, dyspepsia, hypertension, use of statins and particularly heart failure. Patients with left ventricular (LV) systolic dysfunction should be considered for an implanted cardioverter defibrillator in line with guidance on the management of arrhythmias, and all patients should be assessed for coronary revascularisation.

Several aspects of treatment depend on a diagnosis of heart failure and LV systolic dysfunction. Patients with a past MI (defined as occurring more than one year ago), heart failure and LV systolic dysfunction should be treated in line with NICE's clinical guideline on heart failure, and take an ACE inhibitor (or angiotensin‐II antagonist) and a beta‐blocker whether they are symptomatic or not. Those with no heart failure and preserved LV function should be offered an ACE inhibitor but, unless there are other indications or an increased risk of further cardiovascular events, not a beta‐blocker. In patients with heart failure, the calcium‐channel blocker of choice to treat hypertension and/or angina is amlodipine; verapamil, diltiazem and short‐acting dihydropyridines should be avoided. An aldosterone antagonist is recommended for patients with acute or past MI who have heart failure and LV systolic dysfunction.

Several therapeutic issues are highlighted for further research: the optimum duration of treatment with aspirin plus clopidogrel (Plavix); the clinical and cost‐effectiveness of long‐term secondary prevention with an ACE inhibitor; the relative efficacy of spironolactone and eplerenone (Inspra); uptake of and adherence to comprehensive cardiac rehabilitation; and the clinical and cost‐effectiveness of omega‐3 fatty acid ethyl esters in all patients post‐MI. Copyright © 2007 Wiley Interface Ltd