👋 Happy Friday. I know what you’re thinking: "Great. Another short, convenient and witty round up of recent med news. Just what I needed 🙄" - Your British sarcasm won't discourage me from doing my job!
Here’s what we got:
⏰⚡ Back To The Future… of Blood Pressure Medication
🛌 💤 Lying to a Sedated Patient: Turns Out, It Matters
🧠 #TheMoreYouKnow: Other Top Stories of The Week
If you want to read any previous editions of The Handover, you can on our website.
RESEARCH UPDATE
⏰⚡ Back To The Future… of Blood Pressure Medication
I really am committed to delivering you the top medical research. And to prove it, I rented a time-travelling DeLorean, zipped one day into the future, and grabbed this Lancet paper before it’s officially published tomorrow – the 30th August.
P.S. I also peeked at tomorrow’s Wordle. It’s ‘yeast’. Don’t ask how I know. Just enjoy the win.
Let me ask you this: How much does Ramipril 10 mg reduce systolic BP by on average(mm Hg)?
Currently, BP management is a peculiar trial-and-error process.
Assess blood pressure. Give ACE or ARB.
Doesn’t work? Titrate up.
Doesn’t work? Give another drug.
Doesn’t work? And another.
But we never think, how much is this medication actually going to affect blood pressure. Like, what’s the expected drop in mm Hg if we add this drug, or that one?
Which is especially funny, because when it comes to statins, we do think like that. Statins are characterised by how much they lower cholesterol(10%, 30%, 50%) and we use that to guide treatment. But not with antihypertensives…
In this systematic review and meta-analysis, researchers analysed 484 trials pooling over 100,000 participants to quantify the blood pressure-lowering efficacy of the five major antihypertensive drug classes.
That's ACE inhibitors, ARBs, Beta-Blockers, CCB’s and Diuretics.
For extra credit, they also aimed to develop and validate a model calculator capable of predicting blood pressure reduction for any combination of drugs and doses. Very cool.
Inclusion criteria were randomised, double-blind, placebo controlled trials, which had antihypertensive treatment for ≥4 weeks before blood pressure assessment. Follow-up duration 4-26 weeks, standardised mean baseline BP was 154/100 mm Hg.
The results per medication and combination are beautifully detailed by this table:
The other key findings were:
Monotherapy: The average BP drop was 8.7mmHg, making them low intensity. Interestingly, when titrating up, a double dose of any medication led to a modest decrease in BP by 1.5mmHg on average.
Combination: Combining two drugs was the way to go. Dual combination therapy led to a reduction on average of 14.9mmHg. That's 4x titrating up alone.
Efficacy Calculator: It would seem their calculator dream worked out. This tool, which was validated on external trials (r=0.76, p<0.0001), allows clinicians to choose a regimen that will, on average, have the desired blood pressure-lowering effect.
One of the more striking takeaways is just how ineffective titration really is. If a patient’s BP is way off target, is it worth waiting a month after nudging the dose up, only to find a tiny 1.5 mmHg improvement?
Maybe it’s time to rethink the ladder…
By the way, I’ve got the DeLorean rented until next Tuesday.
If you’d like to go back and warn your 16 year old self against medicine, I’m charging £5000 a round trip.
Maybe whisper “Private Equity” as an alternative career choice 🤝
RESEARCH UPDATE
🛌 Lying to a Sedated Patient: Turns Out, It Matters
Between Anki and placement, medical school was a bit of a blur.
But I can vividly remember my first anaesthetics seminar in my first semester of my fourth year.
A slender, silver haired-man sauntered into the lecture theatre. With a compelling swagger that only an anaesthetist could have. He waited for the room to die down. Then announced a quote I won’t forget:
“The work of an anaesthetist is like that of a pilot. The real focus, the real pressure is in the take-off and the landing.The beginning and the end. For the most part, the flight is smooth sailing.”
Well if that is true, this study in the BMJ suggests we’ve been flying with a pigeon caught in the turbine this whole time. And no one noticed.
So let me ask you this: What’s the best way to lie to a sedated patient?
On their back? On their side? Fetus? Starfish? Yearner?
Forced to be a solider, born to be a yearner
In this multi centre randomised control trial, researchers aimed to investigate what this optimum position might be… and its role in hypoxaemia in sedated patients.
They took 2159 sedated adults from 14 hospitals in China. Then assigned them 1:1 to either receive standard supine positioning or lateral positioning. They measured the incidence of hypoxaemia (SpO2 ≤90%) within the first 10 mins after being positioned. Then as a bonus they measured some secondary outcomes like incidence of severe hypoxaemia (SpO2 ≤85%) and airway rescue interventions.
And they found…
Incidence of hypoxaemia was lower in the lateral group compared to the supine group. Way lower. 5.4% and 15.0% respectively (adjusted risk ratio 0.36, 95% CI 0.27 to 0.49; P<0.001).
Unsurprisingly, airway rescue interventions(increased oxygen flow and jaw thrusts) were also significantly lower in the lateral v supine group. 6.3% v 13.8% (adjusted risk ratio 0.46, 95% CI 0.34 to 0.61; P<0.001) - The study does note no adjuncts were needed.
Also the incidence of severe hypoxaemia was also significantly lower in the lateral group 0.7% v 4.8% (adjusted risk ratio 0.16, 95% CI 0.07 to 0.33; P<0.001).
Of course not all scenarios can actually call for a lateral position– I think open heart surgery would be pretty difficult if the patient were on their side.
Plus, the observation time was only the first 10 minutes. This meant that longer term outcomes(such as pulmonary complications) couldn’t be assessed.
But I quite like breathing. I couldn’t imagine living without it. The study shows there are pretty simple and low cost ways to mitigate respiratory compromise in someone out cold.
Protect Your Time. Protect Your Sanity. Try Kenhub
Learning anatomy is painful…Really painful.
There are how many muscles in the forearm?
I have to know all the origins and insertions??
What even is the brachial plexus???
Kenhub makes it all weirdly manageable.
Clear videos, readable articles, and quizzes that actually help stuff stick. It’s used by over 6 million medics who’d rather not cry on the pages of Grey’s Anatomy.
Leaving you more time for doing… literally anything else.
Start the new term on the right foot and check out Kenhub today.
And to unlock the full experience, use this link for 10% off a premium subscription.
QUICKBITS: OTHER NEWS YOU SHOULD KNOW
Chickenpox Party No More. Vaccine Rollout OTW - From January 2026 the chickenpox vaccine will be available on the NHS. This will mark the death of everyone's favourite neighbourhood get together — the chicken pox party . No need to put those little tikes in a room to play, fight and bite until they all have varicella-zoster 😢. The UK was kinda slow on this one…Germany, Canada, USA and Australia have been giving out the vaccine for years. No surprise though, we’re pretty slow with everything.
Mounjaro Shipments Paused To UK - The superior diabetes-turned-weight loss drug Tirzepatide(as per this study I famously wrote about) is being gate kept from the UK! This comes as result of the incoming 170% price hike in Mounjaro price starting September 1st. Some savvy pharmacies and wholesalers are trying to mass buy and stock up on Mounjaro before the price hike. This behaviour has led a pause for everyone. Hate when the whole class gets punished for one naughty kid.
Surely We Can Come To An Arrangement? - Wes Streeting has once again displayed negotiation skills on par with a three year old after failing to come an agreement with big Pharma for drug prices. This means that major cancer medications and more could see a price rise…But hey BMA, no need to feel bad anymore — he’s like this with everyone.
First New UTI Medication in Almost 30 Years! - Trimethoprim and nitrofurantoin, step aside. There’s a new UTI med on the block, by the name of Gepotidacin. It’s been proposed as a medication for women who suffer recurrent infections. It’s supposed to be just as effective as nitrofurantoin. It’s just been approved by the Regulatory Agency, but needs to be evaluated for cost-effectiveness before being distributed on the NHS. With all the other news this week? Lets see how they find the budget.
Handover Over 🫡
If you liked it, tell your mates**.
If you hated it, tell your enemies.
What did you think about todays handover?
**How about we sweeten the deal 😏 … The top referrer for the Handover in the 30 days gets a free pair of Figs scrubs. And the threshold for success is pretty low. The most anyone has referred so far is 3 people total!
Just use your personal referral link below. Each week I’ll announce who’s top of the list, and how many referral they made.
N.B. Referral gotta be nhs.net, doctors.net or university email address. Referral requires double opt in verification, so tell your mates to check their email after they sign up!
Good luck
Hello! If you haven’t already, would you mind letting me know your role. Just one tap is all it takes. You’re so helpful.