FDA approved Inhaled Insulin Afrezza

Damion Edwards for Mannkind

The Food and Drug Administration (FDA) of America had just approved the new inhaled insulin Afrezza for patients with both types of diabetes. It can replace the short acting insulins but not the long acting ones, so patients with type 1 diabetes would still need to inject the basal insulin, but would then just need to inhale before meal times, effectively saving themselves 3 injections.

Afrezza, or technosphere insulin, has a short time to maximum blood concentration of 14 minutes, resulting in improved control of postprandial (after meal) blood sugars, less weight gain and lower risk of hypoglycemia (blood sugar level too low). Side effects include transient cough, and a small reversible reduction in forced expiratory volume in 1 second (FEV1) (a measure of a person’s ability to blow) by 37ml. An expected FEV1 calculated for a Chinese man measuring 174cm and 72kg was about 4 litres, making this a drop of less than 1%.

However, bronchospasm (airway narrowing) had occurred in patients with previous asthma and chronic lung disease, so Afrezza is contraindicated in those patients. FDA had also mandated post-marketing studies of the drug.

This is great news for patients who are currently injecting insulin multiple times a day, as inhaled insulin was much more acceptable to patients with type 2 diabetes.  This means that more patients with poorly controlled diabetes would be willing to be started on insulin, which no longer requires painful injections.

Nonetheless, the previous inhaled insulin Exubera had been withdrawn from the market before because of poor sales. The high price, and the huge size of the inhaler were cited as reasons of its failure.

Provided this is not priced too high, the fact that this inhaler is palm-sized should help Afrezza escape the fate of Exubera. Hopefully it will arrive in Singapore soon.

A New Class of Diabetes Medication Arrives in Singapore

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Despite current treatment including insulin, only 40% of patients in Indonesia35% of patients in Singapore and 22% of patients in Malaysia have good diabetes control.

A new class of medication called the SGLT2 inhibitor has been approved in Singapore, the first one being Invokana (canagliflozin). It has a unique mode of action for the treatment of type 2 diabetes mellitus.

In the kidneys when blood is pushed through a glomerulus (the smallest operating unit in the kidney), glomerular filtrate (earliest urine) is formed. It contains glucose (sugar), different ions, water and waste products. The good stuff is retained through reabsorption. Glucose is reabsorbed through the SGLT2 channels.

SGLT2 inhibitors block the action of the SGLT2 channels, so glucose is lost in urine. Thus the blood glucose drops and diabetes control improves. Patients also lose weight as they are losing energy in the urine. The glucose in the urine also drags water with it and thus patients’ blood pressure drops.

The most important benefit is that it is not dependent on insulin secretion, so the risk of a dangerously low blood sugar (hypoglycemia) is prevented. With this extra class of oral medication, patients may be able to delay their use of insulin.

There are side effects though. First, the sugar in the urine increases the risk of a urine tract infection and fungal infection around the urethra. Second, patients can get dehydrated unless they replenish their fluids with an extra glass of water.

I am very glad that we now have another weapon in the treatment of diabetes.

Saturated Fat Found Not Related to Heart Disease

Stuart Miles/freedigitalphotos.net

Stuart Miles/freedigitalphotos.net

A recent article from the Annals of Internal Medicine had found that saturated fat was not related to heart disease. That was after a BMJ article said roughly the same thing.

Almost all guidelines around the world still ask everyone to avoid saturated fat. Amazingly, even after all the recent data, the British Heart Foundation had no plans to alter the guidelines as yet.

This is a huge study looking at the relationship between both self-reported saturated fat and measured saturated fat, and risk of heart disease and stroke. No relationship was found.

A few other important observations of the study:

1. Omega-3 fatty acids (fat from fish) are good for you.

2. Trans-fatty acid (fat from margarine, biscuits and other baked products) are bad for you.

3. Fat from dairy products are good for you.

4. Arachidonic acid (omega-6 fatty acids from chicken, eggs and beef) are good for you.

The points about fish and trans-fat are probably not surprising to most of us. However, for too long we had been advising patients to avoid milk and egg. Those food are turning out to be really good for us!

What I usually advise my patients is to eat a Mediterranean diet, with lots of non-starchy vegetables, fish, nuts and olive oil. Milk and eggs are alright. Avoid sugar and refined white starch such as white bread and white rice.

But in view of the latest evidence, I would not say no to the chicken and the beef. Bon appetit!

Universal Screening of Gestational Diabetes Proposed

Pregnancy

Photo credit:  Stuart Miles/freedigitalphotos.net

The U.S. Preventive Services Task Force (USPSTF) has just recommended that all pregnant women be screened for gestational diabetes. For health care professionals, the document is here.

In pregnancy, the baby and the placenta induces a higher of sugar level in the mother, to ensure that the baby will have enough sugar for use and growth. Normally, the mother’s pancreas will work harder to overcome this by making more insulin. However, sometimes that fails and blood sugar starts to rise, causing gestational diabetes. The main problem of gestational diabetes is that the baby has too much sugar and so grows to too big a size, sometimes more than 4kg. This may make giving birth difficult.

Gestational Diabetes was last reported in Singapore to affect 13.8% of all pregnant mothers in 1988.

Fortunately, the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial cleared showed that proper treatment to normalize the blood sugar helps to prevent complications . For healthcare professionals, the paper is here.

Because effective treatment protects the mother and baby, all women in the US are now encouraged to have an oral glucose tolerance test (OGTT). In Singapore, women who are high risk are encouraged to have the OGTT. These risk factors are: obesity, family history of diabetes, previous gestational diabetes, and previous birth to a baby heavier than 4kg.

In pregnancy, diet and exercise is key to control the blood sugar. A lot of pregnant women can control their blood sugar with simple changes to their diet by decreasing refined carbohydrates such as white sugar, white rice, rice-based noodles (bee-hoon) and white bread.

However, in severe cases insulin will be needed. Oral medication are generally not advised for pregnant mothers.

To know more, here is a video shot by Leonny Atmadja from Our Channel.

The Hidden Danger of Taking Supplements

herbal pills

Photo credit:  cjansuebsri / freedigitalphotos.net

My patients often ask me whether they can take herbal supplements to help their liver or kidneys. I must say that I am increasingly becoming skeptical of the quality of the supplements. A group of Canadian researchers had recently found that many herbal supplements do not contain any of the plants that they are supposed to.

Worse still, in some circumstances, some people develop severe liver failure requiring transplant. There has been a spike in reports of liver failure caused by supplements. Some of the cases were caused by high-dose green tea extracts for weight loss, and others from undeclared steroids in the supplements.

In Singapore, the Health Science Authority had banned a few supplements that damaged livers: kava-kava from Germany/Switzerland, OxyElite Pro from America, and black cohosh supplements.

Adulterated pills from ‘traditional medicine’ herbs had been found to be adulterated with corticosteroids resulting in Cushing’s Syndrome: weight gain, decreased immunity and other side effects. Indeed similar ingredients had been found with Malay traditional treatment as well (Pili Ajaib).

I would therefore advise staying away from most of these supplements until the regulations are changed to proactively monitor them.

8 Causes of Dry Skin & Solutions

Hands

Photo credit:  photostock/freedigitalphotos.net

Amazingly, medical journals only look at skin diseases, but have always overlooked the humble dry skin. It is however an extremely common problem that patients have. I was so happy when I found this article written by Dr Anneke Andriessen, a Consultant at UMC, St Radboud Nijmegen, Netherlands at the British Journal of Nursing, published in January 2013. That is an extremely comprehensive article, unfortunately not for public assess. So here are the causes:

1. Dry weather.

2. Central heating and air-conditioning.

3. Tight clothing.

4. Detergents, deodorant, soaps (especially anti-bacterial ones) that strip away the lipids and water from the skin.

5. Sun exposure.

6. Aging.

7. Zinc, essential fatty acid and vitamin D deficiency.

8. Diseases such as hypothyroidism (low thyroid levels), kidney failure, diabetes, HIV, skin diseases and nerve problems that decrease sweating.

Here are the solutions:

1. Consider an air humidifier indoor.

2. Use gentle washers such as those that are suitable for babies.

3. Use moisturizers generously.

4. Take a healthy and balanced diet. Zinc is available in many food. Essential fatty acids are the omega-3 and omega-6 that are rich in fish, nuts and oil olive, amongst others. A study done last year found that low vitamin D levels is associated with dry skin, and using a moisturizer enriched with vitamin D improves the situation. Milk and salmon are rich sources of vitamin D, and we can also make our own under sunlight. However, lack of vitamin D is common, 90% in winter in Switzerland (expected), but is actually worse in Singapore, a country in the equator. Singaporeans mostly work indoor and avoid the hot sun whenever possible.

Flu Vaccines Proven to Prevent the flu, especially serious ones

Child receiving Vaccine

 

Image courtesy of  David Castillo Dominici / FreeDigitalPhotos.net

The influenza vaccine has been shown in a major study involving many countries to prevent 59% of influenza infections, and 74% of serious ones.

This was published in the New England Journal of Medicine, involving 5220 children in 15 medical centers across the world. Notably it was a randomized-controlled trial, with half the children getting a sham injection, and the others the real thing.

The flu jab also decreased fever, doctor visits, school absence, and parent absence from work. There were also no difference in the serious side effects in both groups.

Vaccines work by tricking our immune system to form immunity to them. The vaccines contain the same coating as the real virus, but without sickness-causing ability. So they are like decoys. It has helped eradicate smallpox, and much decreased polio in large parts of the world. The flu virus, however, changes its coat every season, thus requiring yearly vaccination against the new strains.

New York City has now decreed mandatory flu vaccination for its preschool and day care centers. This should greatly reduce the sickness caused by the flu virus.