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CMJ1106-Rao.qxd 11/17/11 8:54 PM Page 628 LETTERS TO THE EDITOR References ‘The tubercular diabetic’ 1 Editor – We read with great interest the article by Bailey and colleagues (Clin Med August 2011 pp 344–7). Treatment of people with tuberculosis (TB) and diabetes is indeed complicated. Not only does rifampicin potentially adversely alter the pharmacokinetics of gliclazide,1 glipizide,2 pioglitazone,3 nateglinide4 and repaglinide,5 but like isoniazid, it may increase insulin requirements.6 Liver and nerve toxicity from anti-TB drugs may be difficult to distinguish from diabetes-associated non-alcoholic fatty liver disease and peripheral neuropathy respectively and for those with co-morbid HIV infection with access to treatment, there is the added complication of antiretroviral-associated insulin resistance.7 TB itself may precipitate hyperglycaemia by a stress hormone response and there is some evidence of glucose intolerance in TB patients reverting to normal in up to 75% of patients after three months of TB treatment.8 We wholeheartedly endorse Bailey and Grant’s conclusion that TB and diabetes demand increased attention from clinicians and academics if we are to ensure that future patients receive optimal management of both conditions. Webbe D, Dhillon S, Roberts CM. Improving junior doctor prescribing – the positive impact of a pharmacist intervention. Pharm J 2007;278:136–9. Ende J. Feedback in clinical medical education. JAMA 1983;250:777–81. 2 In response We thank Quantrill and Webbe for their response, and agree completely both that an important role of pharmacists is to educate, and that better systems are needed for providing feedback to prescribers about any errors made. We believe that feedback is complementary to pharmacist attendance on consultant ward rounds, and that both approaches are required. Pharmacists attending ward rounds are likely to be more aware of patients’ current priority medical problems, and are able to discuss drug therapy with senior members of the medical team; , resulting in the higher intervention rate demonstrated in our paper. Separately, better feedback on prescribing errors, particularly to junior doctors, is also needed, to facilitate learning. Several studies have shown that junior doctors get little or no feedback on their prescribing errors at present. We recently completed some exploratory work with junior doctors and pharmacists to explore these issues, and found a key barrier to be pharmacists unable to ascertain the identity of the prescriber. We are therefore considering piloting the use of name stamps, and are designing a controlled study to explore the impact of providing feedback to our junior doctors. We would encourage Quantrill and Webbe to publish their findings in more detail so that others can build on them further. HEMANTHA CHANDRASEKARA Specialty registrar in endocrinology and diabetes, Royal Liverpool University Hospital KEVIN HARDY 2 BRYONY DEAN FRANKLIN Director, 3 ANN JACKLIN Chief of service pharmacy and therapies, 4 628 8 In response We read with appreciation the comments of Chandrasekara and Hardy. The management of concomitant tuberculosis and diabetes mellitus remains challenging and highlights two important factors. Firstly, that our level of clinical suspicion of dual pathology here in the UK needs to be raised so that management can be optimised, including appropriate adjustment and monitoring of medication. Secondly, that as diabetes progresses in low-income countries we need to consider collectively how best to manage this chronic disease in resource-limited settings and indeed this is a focus of our ongoing research. Whiston Hospital, PAUL GRANT Prescot, Merseyside Specialist registrar in diabetes References GAVIN MILLER Imperial College Healthcare NHS Trust, London 7 and endocrinology, Lead pharmacist, clinical services, Centre for Medication Safety and Service Quality 6 Consultant in endocrinology and diabetes, 1 Pharmacy Department 5 pharmacokinetics and pharmacodynamics of nateglinide in healthy subjects. Br J Clin Pharmacol 2003;56:427–32. Hatorp V, Hansen KT, Thomsen MS. Influence of drugs interacting with CYP3A4 on the pharmacokinetics, pharmacodynamics, and safety of the prandial glucose regulator repaglinide. J Clin Pharmacol 2003;43:649–60. Atkin SL, Masson EA, Bodmer CW, Walker BA, White MC. Increased insulin requirement in a patient with type 1 diabetes on rifampicin. Diabet Med 1993;10:392. Tebas P. Insulin resistance and diabetes mellitus associated with antiretroviral use in HIV-infected patients: pathogenesis, prevention, and treatment options. J Acquir Immune Defic Syndr 2008;49 (Suppl 2):S86–92. Oluboyo PO, Erasmus RT. The significance of glucose intolerance in pulmonary tuberculosis. Tubercle 1990;71:135–8. Park JY, Kim KA, Park PW, Park CW, Shin JG. Effect of rifampin on the pharmacokinetics and pharmacodynamics of gliclazide. Clin Pharmacol Ther 2003;74:334–40. Niemi M, Backman JT, Neuvonen M, Neuvonen PJ, Kivisto KT. Effects of rifampin on the pharmacokinetics and pharmacodynamics of glyburide and glipizide. Clin Pharmacol Ther 2001;69:400–6. Jaakkola T, Backman JT, Neuvonen M, Laitila J, Neuvonen PJ. Effect of rifampicin on the pharmacokinetics of pioglitazone. Br J Clin Pharmacol 2006;61:70–8. Niemi M, Backman JT, Neuvonen M, Neuvonen PJ. Effect of rifampicin on the King’s College Hospital, London SARAH LOU BAILEY Clinical lecturer in infectious diseases and global health, Brighton and Sussex Medical School Oxygen therapy in acute coronary syndrome: current NICE recommendations Editor – I read with great interest the concise guidance by O’Driscoll and colleague (Clin Med August 2011, pp 372–5) on emergency oxygen use in adult patients. Oxygen therapy © Royal College of Physicians, 2011. All rights reserved.