Many patients and their doctors will be concerned about the adverse publicity surrounding the diabetes drug rosiglitazone (Avandia). The concern is justified by the current prevailing view in the scientific community that the drug should never have been licensed in the first place. In this respect we should all ask ourselves why did we need to prescribe a new drug for diabetes when we had well-established alternatives such as metformin, sulphonylureas and insulin.

The answer to the above is clearly because rosiglitazone improves diabetes control. This is not, however, the most relevant point in diabetes management. When dealing with patients over a long period of time the most important point on this issue relates to whether people actually have better lives in the long-term on rosiglitazone. This translates specifically to whether people on rosiglitazone live longer or develop heart disease more readily. It appears from monitoring studies that heart disease is indeed more likely in people taking rosiglitazone and this of course is the very thing we are trying to prevent.

Rosiglitazone was authorised for use in Europe by the European Medicines Agency in July 2000 and it has been a particularly popular and profitable drug. Why was rosiglitazone included into our diabetes armoury without a demonstration that cardiovascular health also improves? These and other delicate questions are now being raised by scientists and the medical press in heated debates concerning the behaviour of the drug company GlaxoSmithKline and the procedures, which kept rosiglitazone on the market for over 10 years.

Rosiglitazone represents one of two available medicines in a particular class of drugs known to improve insulin sensitivity. They are called the glitazones. The other drug, pioglitazone (actos), has largely escaped the current controversy about cardiovascular safety as data analysis focuses on some of the searching questions regarding the flawed design of the post marketing surveillance and cardiac safety data relating to rosiglitazone. These now suggest that the risks of continuing to take this drug exceed the benefits of improving diabetes control. For this reason it has been recommended that prescriptions for rosiglitazone should be discontinued.

But what is the alternative? The easy answer is to switch to pioglitazone which is what many people are doing. The relative lack of similar damming evidence against pioglitazone is reassuring and so the choice is a reasonable one.

One note of caution, however, there is now an even more urgent requirement to determine the safety of pioglitazone and it cannot be assumed that pioglitazone will turn out to be safer than rosiglitazone.

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